Photos by Chad Ryan | The Journal Gazette St. Joseph Hospital nurses Angela Bennett, left, and Linda Coverset often work with babies who have been subjected to opioids through their mothers’ use of prescription or illegal drugs.
Dr. James Cameron, medical director of Lutheran Hospital’s NICU, says it’s dangerous to wean a mom off drugs during a pregnancy.
Sunday, August 21, 2016 10:25 pm
Fighting addiction from birth
Rebecca S. Green | The Journal Gazette
Tiny delicate baby feet, pedaling in the air. Round and round. Going nowhere.
St. Joseph Hospital Neonatal Intensive Care Unit nurse Linda Converset has seen it many times. It’s called "bicycling," and it is a symptom of neonatal abstinence syndrome, or NAS.
If a woman took opioids or other drugs when pregnant, there is a possibility her newborn baby is going to be dependent on the drugs.
Tied to mom with the umbilical cord and gaining sustenance through the placenta, the baby is taking in whatever mom takes in: drugs, caffeine, nicotine, anything.
Opioids, legal and illicit, are among the substances that can cause NAS. Others include nicotine and caffeine.
Symptoms might not show up for a day or two – even after the mother has taken the baby home – and the consequences for mother and baby can be dire.
It is important that pregnant mothers disclose if they are taking opioids, prescribed or otherwise, but many do not for fear of involving child protection authorities. For them, it can feel like a damned-if-you-do, damned-if-you-don’t conundrum.
"The problem with addiction is that there is an additional layer of shame, because you are pregnant," said Dr. Elaine Carroll, a longtime specialist in high-risk pregnancies, now with Parkview Physicians Group. "The goal is to get people to have care."
If the mother gets treatment, and the baby gets help, it is actually a win-win, for both.
And pregnancy tends to be a really good motivator for moms to get healthy, Carroll said.
Alerting doctors to addiction
While other substances can cause NAS, it is predominantly opioids, such as codeine, Fentanyl and heroin, that bring on the symptoms, usually within the first week after birth.
But the nature of opioid dependence is such that it is too dangerous to wean mom off the drugs before the baby is born. Doing so can cause pre-term labor or loss of the fetus, said Dr. James Cameron, a neonatologist and medical director of Lutheran Hospital’s NICU.
So doctors will continue to prescribe the drugs throughout the pregnancy, using the longer-acting drugs such as methadone or suboxone. And they plan for what might happen when the baby is delivered.
"These babies ideally are going to be watched in the hospital for four to five days, as opposed to two to three days for a healthy pregnancy," Cameron said.
When one of Carroll’s patients is presenting with opioid dependency, she works alongside pain management specialists.
"You don’t want to make things worse," she said.
Cameron said he has found that babies whose mothers are placed on methadone during pregnancy do not experience NAS as frequently as others.
"Typically their abstinence scores aren’t high enough to justify treatment," he said.
There are other potential complications for babies whose mothers are taking prescription painkillers or heroin during their pregnancies, including low birth weight and smaller head size. That can lead to mental deficiencies in the future, attention deficit or attention deficit-hyperactivity disorder, motor disabilities and other problems, Cameron said.
"You think the baby comes out and it is going to be healthy because the brain is not exposed anymore," he said.
But the brain has been developing in utero, and those children are going to have more risk as they get older, he said.
With the prevalence of addiction in northeast Indiana, Cameron said officials believe they should be seeing a greater number of babies with NAS shortly after birth.
The fact that those numbers don’t match projections is somewhat concerning; it could mean that those babies are being missed either pre- or post-delivery.
Since 2014, the Lutheran Health Network’s NICUs have treated 41 babies born with drug addictions from Allen and its dozen surrounding counties, according to a hospital spokeswoman.
If the mothers don’t disclose to their obstetricians that they are using opioids, even if they are prescribed, doctors and nurses cannot plan for the worst at delivery or after delivery. That can leave the mothers without resources – and without relief – when the symptoms start in earnest.
NAS babies can cry continuously when they go home. They often suffer from appetite loss, gastrointestinal problems, rigid muscle tone, jitteriness, hiccups and other problems.
It is a lot for a new mom to handle, particularly one struggling with addiction or dependence.
Doing right thing for health of baby
"They’re in sad shape," Converset, the St. Joseph Hospital nurse, said of babies suffering with NAS.
She and Angela Bennett, the nurse manager, see NAS babies frequently.
They are called in to "score" the infant in the brief time it is in the hospital after birth. Using a scale called the Finnegan Scoring Method, the nurses evaluate everything from how the baby cries to how it sleeps.
It can take more than 24 hours for NAS symptoms to appear.
"The sooner we know, the sooner we can start treating the baby and start teaching mom and dad how to soothe the baby, and the better that baby will be," Bennett said.
The best treatment for these babies is a combination of medicine and good old-fashioned TLC: swaddling, comforting, skin-to-skin contact. The nurses encourage the moms and dads to assist in their baby’s care while it is in the NICU.
"Caring for these babies going through NAS is difficult," Bennett said. "In reality, what we want is for you to be there. To learn the skills to help your baby."
Carroll makes sure the mothers know that the health care professionals taking care of her and her baby, want her to be involved in the process, from pregnancy through treatment in the NICU.
She wants her patients to let her know what they’re dealing with, "so that we can get them to the right place."
But if your baby is born testing positive for exposure to drugs while in utero, the Department of Child Services is going to get a call. That is the law.
DCS and state health officials are trying to work with the medical community to establish guidelines for physicians who manage women who are opioid dependent while pregnant, Cameron said.
While neonatal providers are required ethically and legally to report an infant who is positive, obstetricians treating the pregnant mother pre-delivery are not, Cameron said.
"If the obstetrician is required to report, the women will not seek care and put both themselves and the fetus and newborns at risk during the pregnancy," the doctor continued. "The goal is to identify the women at risk, get them help and treatment plans, and after delivery provide the safest environment for the newborn with every goal of an intact family. An intact family is most likely when there is a treatment plan in place."
It is a frightening prospect for a mother, looking at dealing with "the system" before she’s even given birth.
Any baby born with drugs in its system must be reported, according to the DCS. Such a baby is, legally, a child in need of services.
Once a report is made, it is up to the DCS family case managers, working with the baby’s medical team and others, to determine the best recommendation to the court system.
Allen County Health Commissioner Dr. Deborah McMahan sees the decision to be open and honest as critical for the mother.
"The climate isn’t, ‘Let’s get those babies away,’ " she said. "We just need to be honest. If this is really your first challenge as a mom, to see if you’re going to be unselfish enough to put your child first, then you’re going to do that the rest of your life."
It is hard to be a mom and an addict, McMahan said.
"You have to have all those neurons firing."
But there is never a better time for a woman to seek help than during pregnancy.
"The good news is that there is never a time when a woman is more willing to do the work of recovery than when she’s pregnant," McMahan said. "So what a great time for us, then, to be screening, to be able to help her, not only for her child’s sake, but also for her recovery."