Drug-induced maternity: Papers say common treatment for opioid-exposed babies is unnecessary

When Cailyn Morreale learned she was pregnant with her second child last year, she was overcome with fear and trepidation.

“I was really scared,” said Morreale, a resident of the small western North Carolina town of Mars Hill. At the time, her joy at being pregnant was overshadowed by her fear that she would have to stop taking buprenorphine, a drug used to treat opioid withdrawal that had helped counteract her addiction.

Morreale’s fear was compounded by the rigidity of the most common approach to treating babies born after being exposed in the womb to opioids or some medications used to treat opioid addiction.

For decades throughout the opioid crisis, most doctors have relied on drug-heavy regimens to treat babies born with neonatal opioid withdrawal syndrome. These protocols often meant separating newborns from their mothers, placing them in neonatal intensive care units, and giving them drugs to treat their withdrawal.

But research has since indicated that in many, if not most, cases such extreme measures are unnecessary. A newer, simpler approach that prioritizes keeping babies with their families called Eat, Sleep, Console is increasingly being adopted.

In recent years, doctors and researchers have found that keeping babies with their mothers and making sure they are comfortable often works better and gets them out of the hospital faster.

Despite her worst fears, Morreale was never separated from her son. She was able to start breastfeeding immediately. In fact, she was told, the trace amount of buprenorphine in her breast milk would help her child withdraw from it.

Her experience was different because she had found her way to Project CARA, a program based in Asheville, North Carolina, administered through the Mountain Area Health Education Center, that supports pregnant women and parents with disorders for substance use. Morreale’s care team assured her that she did not need to discontinue buprenorphine and that her baby would be evaluated and monitored using the Eat, Sleep, Console approach. The protocol considers babies fine to be sent home as long as they are eating, sleeping and being comforted when upset.

“By the grace of God, he was awesome,” Morreale said of her son.

David Baltierra, former director of the West Virginia University Rural Family Medicine Residency Program, chair of the WVU Department of Family Medicine – East Division, and a family physician, suggests that this protocol could simply be called “parenting.”

The method is increasingly being used instead of the long-held approach to treating opioid-affected newborns called the Finnegan Neonatal Abstinence Scoring System. This tool includes a list of 21 questions (whether the baby cries excessively, sweats, shakes, sneezes, etc.), the answers to which determine whether the newborn should be given medication to counteract withdrawal symptoms, which would require an extended stay in the house. a neonatal ICU.

Baltierra, however, has problems with the Finnegan method. For example, it often causes a deeply sleeping baby to wake up to be scored. This made no sense to Baltierra. If the baby is sleeping, he is probably fine.

Instead, health care professionals should look for the telltale signs of an infant suffering from opioid withdrawal syndrome, she said. “Their body is in tension, they have a high pitch, they don’t calm down.”

Baltierra and his colleagues have been training residents to use an Eat, Sleep, Console approach for a decade, progressively longer over the past six years. The results are convincing more health professionals to adopt the method.

A 2023 study found that babies treated this way were discharged from the hospital nearly half the time and were less likely to receive medication than those receiving Finnegan-based care.

Matthew Grossman, associate professor of pediatrics at Yale School of Medicine, refers to the introduction of the treatment model he helped pioneer as the “least innovative” undertaking imaginable.

Research shows that optimal care for pregnant women who have experienced opioid use disorder includes treatment with buprenorphine or methadone, which carries the risk of their newborn having withdrawal symptoms. Grossman and colleagues found that a non-pharmacological approach first works best.

He said the Finnegan tool is useful but often too rigid. Under his score, one too many sneezes could send a baby to the NICU for weeks.

Grossman said he observed that some babies who received the drugs did well for a few days, but began to decline when their mothers were sent home without them. These observations made him ask, “Did the child need more medicine or more mother?”

Research by Leila Elder and Madison Humerick, who did their residency in WVU’s rural program, found that average stays for newborns in retreat dropped from 13 days in 2016 to three in 2020.

Elder said babies born at the 25-bed rural hospital where they delivered were given medication to treat their withdrawal symptoms only when unrelated problems sent them to other hospitals for NICU care.

Easier treatment also means more babies born in rural communities can receive care closer to home and has reduced the likelihood that a mother will be released before her baby is cleared to return home.

Grossman suggested that rural hospitals are better suited to use the Eat, Sleep, Console approach than institutions in large cities, given that the latter generally have easier access to and propensity to choose an NICU. option

Sarah Peiffer remembers the first time, as a medical student, she witnessed a nurse administer the Finnegan protocol, discussing it in clinical terms at a mother’s bedside.

“And I remember being a little horrified,” she said. The process was clearly distressing for both mother and child. “I felt there was almost a sense of punishment, as if we were saying to this mother, ‘Look what you did to your baby.'”

Peiffer is now a Project CARA practitioner and family health physician at Blue Ridge Health in western North Carolina and a vocal advocate for ESC and its approach to partnering with families. “Look at all the non-drug things you’re supposed to do, like keep the lights low in the room, keep the baby swaddled, do as much skin-to-skin with mom as possible, and really treat mom like a medicine.”

Research suggests that immediate skin-to-skin contact after birth offers “vital benefits” for short- and long-term health and bonding.

This contact, Elder said, “releases endorphins for the mother,” which helps reduce the risk of postpartum depression.

Grossman said developing the Eat, Sleep, Console protocol was simply a matter of pausing to reevaluate it.

The original intent of the Finnegan tool was not to make the process so rigid. But “everyone is excited to have a tool, and then that approach calcified around it,” he said.

Grossman said the goal of the simpler approach was to put the family at the center of care, and that shorter hospital stays for babies were simply a fortuitous result. The shift in focus fits with a broader movement toward nonjudgmental, family-centered care for those who have experienced addiction and their children.

Now, she said, after five days, mothers often say “‘Can we go home? I think I got it,'” and are treated “with the same respect as any other mother.”

Peiffer said she has witnessed this mother-centered care counter “that sense of shame that people feel instead of families feeling empowered to care for their baby.” It represents “such a major shift in the way we think about neonatal abstinence both medically and culturally.”

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