Babies who have been exposed to opioids in the womb can have tough introductions to this world. As their bodies withdraw from drug exposure, they have difficulty feeding and sleeping. They’re jittery and have tight muscles. They cry and can be difficult to console.
The number of babies with neonatal abstinence syndrome (NAS) has rapidly increased over the past decade – faster than rates of fetal alcohol syndrome. This has become a challenge to both urban and rural communities, and affects all socio-economic classes. To better serve these babies, Atrium Health Levine Children’s created a specialized NAS program in 2012. Since that time, the program has adapted and grown, incorporating innovative, evidence-based treatments and building a multidisciplinary team. The result is a comprehensive program that gives these babies gentler transitions and offers their mothers active roles in their care. It begins before the baby’s born and supports the baby’s development into childhood.
First, however, doctors and nurses in the program would like to correct a common misconception. It’s a myth that most NAS babies are born to mothers who are actively using illicit drugs. The fact is that most mothers of NAS babies have been in treatment during pregnancy, already taking steps to do what’s best for their babies and themselves. One big lesson from the program, in fact, is that mothers can become doctors’ and nurses’ closest allies in babies’ treatments.
“We are very family-friendly,” says Mandy Hrobak, NP, a Levine Children’s neonatal nurse practitioner with the NAS program. “No matter what kind of treatment we’re using, I believe the mom is the most important part.”
One emerging treatment for NAS is Eat Sleep Console (ESC), in which newborns room with their moms in the hospital, instead of staying in the Neonatal Intensive Care Unit. Treatments include frequent cuddling and breastfeeding, with low or no doses of medicines. Volunteer snugglers even come to offer additional contact for the babies. This method has been tremendously successful, reducing hospital stays by half and medication use by 79 percent for NAS babies, while supporting early family bonding. Doctors evaluate patients to determine which are the best candidates to refer to Eat Sleep Console, which is available at three Atrium Health hospitals: Atrium Health Levine Children’s Jeff Gordon Children’s Center, Atrium Health Lincoln and Atrium Health Cleveland.
Comprehensive Care from a Multidisciplinary Team
Beyond the doctors, nurses and moms is a large, multidisciplinary team helping to ease symptoms of babies’ withdrawal. Recent research has highlighted the importance of non-pharmacologic NAS treatments, including swaddling, breastfeeding and relaxation baths. The range of specialists in the NAS team reflects the diversity of care given to these families. Social workers, nurse navigators, lactation experts, a pediatric pharmacist, and even a neonatal dietician provide well-rounded support. Physical therapists and music therapists play increasingly significant roles as well.
“The goal of physical therapy is to optimize ‘state regulation,’ which helps babies remain quiet yet alert, which helps them learn, eat and play,” says Elizabeth Rose, PT, DPT, NTMTC, a physical therapist at Levine Children’s who treats NAS babies. “It also helps them smoothly transition between different states, like asleep and awake, while avoiding becoming fussy and irritable. When babies are calm and relaxed, they are more accepting of being touched which helps improve bonding with their families and caregivers which is another crucial component to their growth and development.”
When in the hospital, moms and families learn skills to help manage their babies’ symptoms at home. Physical and occupational therapists provide and teach how to perform infant massage as well as other calming techniques, and train families how they can support their baby’s neurodevelopment progression. Infants with NAS may also need speech therapy for facilitating safe feeding and while providing family education. Board certified music therapists show how to use music as a calming tool, using specialized recorded lullabies to assist with effectively sucking on a pacifier. Families may also learn how to use their own voices and rhythmic body movements to help their babies calm.
"Families may play an active role in their baby's music therapy support, using their voice to encourage bonding and promote state regulation," Danae Merrick, MT-BC, music therapist at Levine Children’s. "Babies recognize familiar voices. The use of calming, soothing vocal techniques and body movements can be used by families both in the hospital and after going home; encouraging bonding opportunities and gently helping these babies learn about the world around them."
Beginning Treatment Before Birth
NAS care begins even before the baby is born. Abruptly stopping opioid use during pregnancy can put mother and baby at risk, so providers advise a supervised withdrawal/detoxification or an opioid replacement maintenance therapy. In addition, providers offer an in-depth education to future mothers about what to expect when a baby experiences withdrawal. This allows mothers to establish proper expectations for their babies that may include longer hospital stays, as well as pharmacologic and non-pharmacologic treatments that may be needed.
Providers also help mothers with other challenges. About 80 percent of people with opioid use disorders also have mental health disorders; many others have polysubstance use disorder, including tobacco, that can affect a baby’s development. Connecting pregnant moms with an array of healthcare resources can put them on the path to recovery before they give birth.
“Multiple studies show that comprehensive prenatal care – with maintenance therapy and/or detox – improves pregnancy and postnatal outcomes in this population,” says Rebecca Pollack, MD, who works in maternal fetal medicine with Atrium Health’s Women’s Institute. “We approach addiction and narcotic abuse as an illness, not a character flaw. Treating moms with respect is what they need. It’s empowering.”
Individualized and Long-term Care
After a baby with NAS is born at an Atrium Health hospital, an “order set” begins a protocol of consultations, bringing the entire team together to treat the baby and mom as needed, both immediately and in the long term. A social worker is assigned to the baby to connect the family with resources after they leave the hospital.
At three months old, babies usually come to the clinic at the Levine Children’s Hospital Neonatal Follow-Up Clinic.. There, they receive neurocognitive and medical assessments to track their development, and providers ensure that the babies are getting the appointments they need. Babies return to the clinic every six months for the next two to three years to ensure that they’re keeping up with their milestones, while parents learn to monitor their child’s development.
“Most parents are very engaged. We have an assessment called the Bayley Scales of Infant Development that allows us to evaluate how a child’s development is progressing by month and year,” says Laura McManus, NP, who specializes in neonatal-perinatal medicine at Atrium Health Levine Children’s. “Most parents really like these numbers, so that they can know, ‘Is my child doing what a three-month-old should be doing?’”
The clinic also coordinates with pediatric specialists, including behavioral, developmental and neurologic pediatricians. As the babies grow into school-age children, the clinic can transition the children to the care and specialists they’ll need.
“Long term, babies with NAS can experience neurodevelopmental delays and deficits,” says Rose who serves on the multidisciplinary NAS committee at Atrium Health. “They’re at risk for feeding troubles or increased muscle tone. They may have cognitive and behavioral difficulties, which could impact their education and schooling.”
Having a large, multidisciplinary team allows the NAS program to create treatment plans for these patients and their families that are unique as they are, according to James Jones, DO, who was instrumental in creating Levine Children’s NAS program. He has studied NAS since his medical school fellowship in the early 2000s, and he has seen the challenges and solutions evolve. Through it all, he believes that bringing different specialties together to treat these babies and their mothers is the key to an effective NAS program.
“Offering individualized care is a big deal here. We don’t offer a one-size-fits-all approach for these babies,” Dr. Jones says. “We find good candidates for different types of approaches, and having a multidisciplinary team is really important to effectively do that.”
To learn more about our Neonatal Follow-Up Clinic, please call 704-381-1450.
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