How hospitals wean drug-affected babies off opiates
Their cries are piercing. Their distress is visible.
For babies born to mothers using narcotics – even legal prescription painkillers – the first weeks of life can mean a wrenching withdrawal off drugs.
In California, the number of babies born affected by drugs has nearly doubled over seven years to more than 3,630 in 2015, according to state public health officials.
That rise is directly tied to the stubborn opioid epidemic of prescription painkillers and illegal street drugs such as heroin that have hooked increasing numbers of women, both in California and nationwide.
“It’s not the mom you expect anymore. It’s not just the mom who came in off the street,” said Dr. Kristin Hoffman, a neonatologist with the UC Davis Children’s Hospital. “We see moms in all socioeconomic classes,” such as those taking opiates like Oxycontin for chronic back pain or other ailments.
Weaning their babies off drugs can take weeks. Known as neonatal abstinence syndrome, the symptoms vary from a high-pitched cry to muscles so tight some babies can be as stiff as a board. They are often jittery, sweaty, easily agitated and unable to soothe themselves. They often have trouble sucking from a bottle or nipple, which means they struggle to gain weight. Many are troubled by diarrhea or spitting up.
At Sutter Medical Center’s neonatal center in midtown Sacramento, the number of babies hospitalized for withdrawal continues climbing.
“It’s a different kind of drug exposure we’re seeing. It’s a different demographic for babies going through pretty bad opiate withdrawal,” said Dr. Angela Vickers, a Sutter Health medical director and expert on drug-exposed infants. In the last decade, she said, about half of Sutter’s opiate-addicted babies are “born to moms who are working, living in an intact family, very much welcoming their baby, with good prenatal care.”
But their newborns’ experiences are no different. “We see moms in middle- or upper-middle class families whose babies will go through just as much withdrawal as babies whose mothers were on street drugs.”
Symptoms usually begin within a day or two after birth, but may take up to a week to appear.
Statewide, Sacramento County has the fourth-highest number of drug-impacted newborns: 189 babies in 2014, the most recent year for full county-by-county records. Sacramento ranks in the top five along with Los Angeles, Riverside, San Bernardino and San Diego counties, according to the state Office of Statewide Health Planning and Development. The drugs affecting these infants include cocaine, hallucinogenics, opiates or other “noxious” substances, which pass to the baby primarily in the womb but also through breast milk.
One of those new moms is Elana, a Sacramento resident who didn’t want her real name used. At 29, she’s been off heroin for about a year and, under a doctor’s care, now takes buprenorphine, a prescription medication used to eliminate cravings and help wean addicts off drugs. Elana said it’s been heartbreaking to see her tiny daughter, born April 12, go through the rigors of withdrawal because of her previous addiction. “It kills me to see my daughter in pain,” she said. “I hate to see her go through this.”
For the last five weeks, Elana has been visiting Sutter Roseville hospital up to eight hours a day, while her daughter is carefully monitored and slowly weaned off small doses of morphine and other drugs used to ease her withdrawal.
In recent years, opiate addiction among U.S. women has been growing faster than for men, fueled by the increase in prescription painkillers, according to the Centers for Disease Control and Prevention.
If they become pregnant, the potential risk to their baby is high. Between 2000 and 2012, the number of U.S. babies born with drug withdrawal syndrome grew five-fold, according to the National Institute on Drug Abuse. That translates into a baby born every 25 minutes suffering from opioid withdrawal.
And the costs go beyond the baby’s discomfort and distress. Compared with regular newborns, drug-impacted newborns stay eight times longer in the hospital and their care is exponentially more expensive, according to federal statistics.
The long-term impacts on this new generation of infants is unclear. In the 1980s, there were “dire predictions” that babies born to mothers using crack cocaine, so-called “crack babies,” would suffer lifelong deficits in intelligence and social skills, according to the National Institute on Drug Abuse. While those concerns were “grossly exaggerated,” cocaine exposure during fetal development can lead to “subtle, yet significant” effects in some children that are still worrisome, including behavior problems, difficulties with attention span and cognitive performance, the institute found.
With the new classes of opiates, “it’s not really well understood how the different (drug) exposures affect long-term development. But it’s certainly not an ideal way to start out your life,” said UC Davis’ Hoffman.
For many of these babies, going home to a loving family is critical. “Once they get through that first couple weeks or months, they seem to do OK. Moms can bond with them and take good care of them,” said Sutter Health’s Vickers. The babies she’s most concerned about are those returning home to households where drug use may be still be occurring.
State and federal efforts are trying to slow the increase of drug-affected infants. In 2015, the CDC launched its “Treating for Two: Safer Medication Use in Pregnancy” campaign to encourage more research and alert health providers and pregnant women to the potential risks of using medications while expecting. Women and their health care providers “don’t have enough information to make clear decisions,” the CDC said, noting that fewer than 10 percent of medications provide details on whether they’re safe to use during pregnancy.
Despite the potential risks, not every pregnant woman should immediately drop her allergy, depression or other medications.
“Many women need to take medication during pregnancy to appropriately manage their health conditions,” the CDC notes. In some cases, “avoiding or stopping” those medications “may be more harmful than taking (them).”
In 2014, California health officials launched the Prescription Drug Overdose Prevention Initiative, which encourages safe prescribing practices for doctors and pharmacists, more consumer education and better access to drug-withdrawal medications, such as buprenorphine.
Those efforts may be working, at least in prescribing. Opioid prescriptions written by California doctors have dropped 17 percent since 2013, according to recent data cited by the California Medical Association. The numbers show California tied with Hawaii for the lowest per-capita number of written opiate prescriptions.
Ideally, women using drugs or undergoing treatment should avoid getting pregnant. “Contraceptive counseling should be a routine part of substance use treatment among women of reproductive age to minimize the risk of unplanned pregnancy,” according to the American College of Obstetrics and Gynecology.
Treatment for drug-afffected babies follows a set protocol at hospitals such as UC Davis and Sutter Health. That means a combination of morphine and other medications to ease pain; a darkened, quiet environment; and swaddling and cuddling for soothing.
“It’s all those things together that get them through withdrawal with the least amount of discomfort possible,” said Christi Walsh, nurse director of the 61-bed neonatal intensive care unit at Sutter Medical Center in midtown Sacramento. “It takes a lot of patience, comfort and love.”
At Sutter, babies are nestled in their incubators beneath colorful, quilted hoods, designed to provide a quiet, darkened, womb-like environment. The babies are placed on morphine and other medications to ease their pain, then slowly weaned off as their symptoms improve. Dosages vary, depending on the type of drugs and how long and how much mom was using.
One of the biggest pieces of withdrawal care is as basic as babyhood: cuddling. Ideally, many of those babies benefit from being held as many as eight to 10 hours a day.
“The demands of caring for our babies don’t leave nurses a lot of extra time for that nurturing care these babies need, particularly those whose parents can’t be at the bedside because they’ve returned to work or don’t live here,” said Nicole Mank, child life specialist with UC Davis Children’s Hospital.
When parents or family members can’t be present, rotating shifts of “baby cuddlers” are scheduled for round-the-clock holding. Some are community volunteers, others are medical students who sometimes handle late-night shifts.
Being held, rocked and sung to allows these babies “to experience that nurturing touch that is essential to their development. We want them comfortable with positive touch,” Mank said, “as opposed to heel pricks, IV starts and temperature taking.”
For moms such as Elana, the agony is knowing that her prior drug history – even now that she’s clean – is the cause of her baby daughter’s distress. “If I hadn’t been using, I’d have a healthy baby at home now. … I just want her home.”
On Wednesday, that wish finally came true; after five weeks in the hospital, Elana’s daughter came home.