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Tue May 6, 2014
Caring For Newborns In Withdrawal, Researchers Ask What's Best
More Rhode Island babies are being born dependent on the opioid drugs (including OxyContin and heroin) their pregnant mothers were taking. Many of these babies need hospital stays and powerful medication to help them through the painful withdrawal. Now, researchers at Women & Infants Hospital are trying to pin down what treatments work best, and what the long-term impacts are. Part one of our two-part series on newborns in withdrawal.
A rough entry into the world
(Sound: subtle whirring of the nursery)
Hear that? No? That’s a good thing. It’s quiet in the nursery at Women & Infants Hospital in Providence. Because these babies are sleeping. Finally.
“So you can see that we try and keep the lights down. And we try and keep the noise down..."
Meet Dr. Marcia VanVleet, head of the nursery’s medical team. She’s gazing down at the only two newborns in this quiet, dark room. They’re each sound asleep in their own electric rockers, which look more like softly glowing space cocoons.
"They don’t go forward and back, which is a motion that can be disturbing to babies that have been exposed in utero. They go sideways, much like a mother swaying or rocking her baby would go.”
By “babies exposed in utero,” she means babies like these two, who were born dependent on opioids. Opioids are a class of drugs that include prescription painkillers like OxyContin, but also heroin, and even the medication a woman might be taking to treat an addiction to those drugs, like methadone.
The babies are in withdrawal, and the technical term for their condition is “neonatal abstinence syndrome” or NAS. NAS is really a collection of symptoms – excessive, high pitched crying, tremors, trouble feeding, diarrhea, stiff limbs. Symptoms any newborn could have one or two at a time, says VanVleet.
"But when we start seeing it in a constellation of symptoms, and we know there’s an exposure," says VanVleet, "then we put them together and start looking at the symptoms and saying, ok, once you’ve met a threshold, then we usually start pharmacological treatment.”
The threshold is a score of eight or more on a scale developed to help doctors quantify the symptoms of NAS and decide when to start medications. Excessive, high pitched crying, for example, gets a 3. So does projectile vomiting. Severe tremors rate a 4. And so on. These babies scored high enough to need one of the two most common medications to help ease their symptoms: morphine or methadone. VanVleet says they’re essentially giving babies a bit of what they were exposed to in the womb so they don’t go into full-blown withdrawal. She says they give them enough to calm their symptoms. And then doctors can withdraw them from those medications slowly, with control.
Making babies comfortable
But which is better – morphine or methadone? That’s what VanVleet and her colleague Dr. Barry Lester, a psychiatrist and head of the center for the Study of Children at Risk at Brown University, are aiming to discover.
“The two drugs have never been compared as to their efficacy up until discharge," notes Lester. "And then there hasn’t really been a follow up where these two treatments have been compared. There are some follow up studies of heroin-exposed babies on methadone. But they’re very small studies.”
Lester and VanVleet have gotten funding from the National Institute on Drug Abuse to conduct clinical trials in newborns with neonatal abstinence syndrome at six different sites, including Women & Infants. The babies will be randomly assigned to receive either morphine or methadone. What’s more, researchers will follow up two years later to see how the babies are doing. Lester says the early evidence is that NAS babies do recover. But he says what they’re exposed to when they come home from the hospital matters just as much as what they were exposed to in the womb.
“If a baby is exposed to a drug and brought up in a good child-rearing environment, those babies pretty much recover," Lester says. "If a baby is brought up in a poor care-giving environment, that tends to exacerbate the drug effect, and it’s a double whammy.”
More NAS babies
The study could provide some clarity for health care providers who are seeing an increasing number of babies with neonatal abstinence syndrome, or NAS. That number? Well, until recently, we haven’t had good national or statewide statistics. A 2012 study in the Journal of the American Medical Association quantified the uptick for the first time: between 2000 and 2009, the incidence of NAS nearly tripled, to an estimated 13,500 babies a year. (Rhode Island just released statewide statistics on Monday, May 5, 2014.)
But, back in the nursery, Women and Infants pediatrician Marcia VanVleet says the hospital has started keeping its own tally.
“Last year, and I don’t have full numbers for the year, we ended in October, but we had already treated 41 babies and had seen 120-ish that had exposure," says VanVleet. "So that was only for three quarters of the year. So we’re looking at at least a two-to-three fold increase. And that’s what we’ve been seeing across the nation as well.”
Often a consequence of addiction
VanVleet says it’s partly a consequence of Rhode Island’s growing addiction to prescription painkillers and heroin. But some pregnant women are taking painkillers they’ve been prescribed, or they’re taking methadone to help treat an addiction to heroin. The latest evidence says these medications are safe for pregnant women and their babies in the short term. Whether that’s true for the long term as well isn’t as clear. But what is clear is that stopping cold turkey could harm a fetus more, says VanVleet.
“Because there is a risk of in utero seizure death and fetal loss. So if anything, we tell them, follow more closely with your provider, make sure your cravings are controlled." The bottom line, says VanVleet: "This is not a time to go through withdrawal yourself.”
The result? Safer pregnancies, but a painful entry into the world for a newborn, and a tough time for caregivers.
Discomfort for baby, guilt for mom
"These babies are really difficult to care for. They cry a lot, they don’t feed well. When you do get them to feed, they throw it all up or they have poop all over the place," VanVleet says. "So it’s a lot of extra work for the nurses and I truly take my hat off to them because they do put in that extra effort.”
The extra effort has paid off, at least for the time being, for the two little ones sleeping in this quiet nursery.
“So one of them is about 20 days old and is almost off the morphine," VanVleet explains. "The other baby is two days old. And the baby started having symptoms within 24 hours of life. But since starting medicines has had a great response.”
They might be sleeping peacefully now, but they’ll be up in a couple of hours, looking for comfort, needing to be swaddled and held. When the mothers visit, they need some comfort, too.
“This was not what they anticipated for their delivery or pregnancy outcome," says VanVleet. "They expected to go home with their babies. They expected their baby to be nice and calm and sit there in their arms. They didn’t expect to go home or have a baby crying 24/7. Then they go through anger, and they’re upset because they took this medicine, and they hadn’t maybe been told that this was going to happen. Or they had been told but maybe they didn’t realize this was what it was going to look like.”
Meet a mom - and her newborn son - in recovery
For 26-year-old Ellen, it looks like her newborn, Jonathan, has come through the worst symptoms. But with mom in recovery from heroin addiction and baby beginning life in withdrawal, there’s still a long road ahead for both of them. Their story comes next in our two-part series, airing during Morning Edition and again on All Things Considered on Wednesday, May 7.