When Ashley had her first baby three years ago, he was whisked away to a neonatal intensive care unit for a month of medication-controlled withdrawal. He was given oral morphine to control his tremors, stop his inconsolable crying and to help him to eat and grow.
His mother ceded her urge to care for him to the nursing staff. The beeps and buzzes of the unit’s monitors, the tiny preterm infants in the next cribs on ventilators — they were too much for Ashley.
{mosads}She felt tremendous guilt for his condition and felt judged by the medical team for causing his suffering as a consequence of her substance use disorder. She went back to using heroin and lost custody of her child.
Finding herself pregnant again and wanting the best for her next child, Ashley again disclosed her drug use to her obstetrician. She took methadone to control her withdrawal and maintain a healthy pregnancy. She abstained from illicit drugs with the support of a comprehensive treatment program for pregnant women.
Ashley found a care team that congratulated her on her success, and informed her that her baby girl would fare best by “rooming in” with her in a calm, quiet environment. As she had been compliant with substance abuse treatment, breastfeeding was recommended, and helped curb her newborn’s withdrawal symptoms even more.
Medications were not needed this time. After four days of successfully caring for her newborn 24/7 with the support of hospital staff, Ashley took her baby home with confidence.
The outcomes of these two pregnancies are wildly discrepant and so are the cost differences. The first baby incurred hospital costs of close to $150,000.
For the second baby, care much preferred by the family cost under $6,000. Ninety percent of newborns at risk for opioid withdrawal have public insurance, usually Medicaid.
But most of these babies are still cared for in neonatal ICUs. The public is paying a large bill for care that families do not want them and care that has worse outcomes.
At the hospital where I practice as a pediatrician, one out of 10 newborns is at risk for opioid withdrawal.
Thanks to excellent work by my obstetric colleagues, most mothers in our region are on maintenance medications like methadone; they are in opioid recovery by the time of delivery. We stopped sending withdrawing newborns to our ICU in 2014, and have completely transformed our approach.
There is a growing body of evidence to support this change. We have knowledgeable teams of professionals caring for families that feel supported in their recovery journeys.
Mothers and families are empowered, knowing that holding and comforting their newborns is the best medicine. The subset of babies with more severe withdrawal still receives medications, but medication use has dramatically declined, and when used, babies remain rooming in with their families.
And yet, rooming in for opioid-exposed newborns remains an exception. Though it is standard for healthy newborns, newborns at risk for opioid withdrawal benefit even more from rooming in.
However, hospitals and pediatricians have been reluctant to change established practices. If being held, comforted, and breastfed is the first-line “medicine” for newborn withdrawal, why deny it to those who need it?
Rooming-in for opioid exposure leads to shorter hospital stays and is more acceptable to families, but let’s keep in mind that neonatal ICUs are hospital profit centers.
Rooming-in brings value to families, to communities, and to taxpayers, but full neonatal ICUs keep hospitals afloat.
Newborns suffering from withdrawal in expensive neonatal ICUs exemplify overtreatment — too much medicine that is harmful. This particular overtreatment harms our most vulnerable.
Certainly, my fellow pediatricians want what is best for babies. But they are beholden to the perverse incentives of hospital reimbursement. Changing practice within this economic set up can feel impossible, even when we want to change.
Additionally, we always need to assure the safety of newborns rooming in. If a mother is struggling with active opioid abuse and cannot focus on safe newborn care, other family members may step in to help.
In situations where families are unavailable, hospitals can establish “cuddler” programs of community members who volunteer to provide soothing and comfort.
Volunteers allow mothers to leave for other responsibilities, including attending their own medical appointments.
Some have criticized that rooming in forces parents to be “babysitters” for their newborns — something we would not require if the baby were being treated for another condition.
However, human contact is a proven treatment for newborn opioid withdrawal — not so for other ailments. If families are unable, the community should step in to care for its youngest.
Northern New England is a bellwether region for the opioid epidemic. Here, we changed our practices quickly, so our regional care systems for critically ill and preterm infants were not overwhelmed. With newborn opioid withdrawal syndrome spreading rapidly along with the opioid epidemic, our nurseries are in crisis nationwide.
If withdrawing babies are in a neonatal ICU at your local hospital, ask how you can support new mothers in their struggle to avoid drugs of abuse, so they can lovingly parent their children and avoid foster care. Volunteer as a newborn “cuddler”, or start a program if there is not one established.
We will not end the opioid epidemic with just prevention and treatment programs. We will only break the bondage of opioids with unconditional love, and with community. The best place to begin is with the innocent, with the littlest victims of the epidemic.
Alison Volpe Holmes, M.D., MPH is a Public Voices fellow and an associate professor of Ppediatrics at Geisel School of Medicine at Dartmouth