Healing Babies and Families in an Opioid Crisis

All babies need milk, rest and comfort to feel safe and cared for in their new homes-and those simple essentials can be a powerful antidote for many infants exposed to opioids while they were in the womb.

That's the thinking behind Eat, Sleep, Console (ESC), an approach being implemented at Cedars-SinaiGuerin Children's and a growing number of other hospitals to treat neonatal opioid withdrawal syndrome (NOWS). This condition covers a wide range of mild to severe reactions that can occur in infants after birth when they are cut off from opioids in their prenatal blood supply.

ESC marks a shift from traditional opioid withdrawal evaluation and care methods to a focus on holistically soothing a child during the tense withdrawal process. At its heart: close family involvement, with bonding time a top priority.

"At the end of the day, everyone wants the same goal-healthy babies and healthy families-regardless of what they might be going through," said Allison Henry, MD, Cedars-SinaiGuerin Children's director of newborn care.

As a deadly opioid crisis surged, so did the numbers of parents with opioid-related diagnoses, as well as babies born with NOWS. Federal figures showed rates of the syndrome climbed by 82% from 2010 to 2017. Roughly 60 infants are born with NOWS every day in the U.S.

Read: Addiction During COVID-19

What is NOWS?

Newborn opioid withdrawal can start immediately, over the hours and days following birth or even up to a week later. It depends on the substance, parental metabolism, and the amount and regularity of use. The process can be triggered by any opioid exposure, including prescribed and unprescribed pain medications or other drugs as well as certain treatments for substance use disorders taken by the birth parent.

Infants who have NOWS are often restless and fussy, just like a healthy baby, but don't eventually settle down, making their needs tough to decipher. Symptoms include:

• Jitters
• Tremors or seizures
• Intense irritability
• High-pitched crying
• Sweating
• Fevers and temperature fluctuations
• Poor sleep
• Stiff or tense muscles, restricting movement
• Abnormal rates of heartbeats and breaths
• Trouble feeding
• Gastrointestinal symptoms, such as nausea, vomiting and diarrhea

They are also susceptible to more severe conditions-such as low birthweight, poor weight gain, and dehydration and nutritional deficiencies-because of gut problems, according to the American Academy of Pediatrics. Researchers are investigating the impact of NOWS on childhood brain structure and developmental issues, including attention.

"Opioid withdrawal is distressing, both physically and psychologically," said Itai Danovitch, MD, chair of Cedars-Sinai's Department of Psychiatry and Behavioral Neurosciences. "An infant has no way to understand or soothe the source of their distress."

Parents and other caregivers might not know the cause of their baby's unease, or even if they do, how to manage their care.

"The initial days after birth are about learning how to read and interpret an infant's expressions and to learn how to respond to them as well as possible," said Danovitch, whether the issue is hunger or needing a blanket. "When an infant is dysregulated by opioid withdrawal, it becomes harder to interpret all of their other expressions and needs."

Read: Fentanyl: The New Talk Between Parents and Teens

Allison F. Henry, MD

Allison F. Henry, MD

A Dose of TLC

Many hospitals treat NOWS using the Finnegan Neonatal Abstinence Scoring Tool, a decades-old tally system that evaluates a baby on 21 withdrawal signs such as muscle tone, reflexes and sleep. Taken every few hours, the score is used to determine pharmaceutical treatment and gradually wean babies off opioids.

ESC, instead, focuses on nurturing. Medical teams monitor and support feeding, sleeping for longer stretches and skin-to-skin contact. Babies aren't poked and prodded every few hours. Infants are treated in quiet, dark or dimly lit areas that are less stimulating, with outside visitors limited. At Cedars-Sinai, they stay together with families or caregivers in a private Pediatrics room that is peaceful and conducive to healing.

"You make sure the baby's being held and rocked and loved," Henry said.

The goal is to calm them within 10 minutes. If they still can't be soothed, or coaxed to take sufficient amounts of milk or to sleep for at least an hour at a time, doctors introduce methadone or morphine management.

Studies show the method shortens hospital stays and vastly reduces total exposure to opioids-the overall amount of exposure during pregnancy and from medications used in the hospital.

"There's so much interconnectedness between the mind and body that treating anxiety and distress really has a big impact on their physiological needs as well," Danovitch said.

Read: Substance Abuse in Pregnancy Doubles Cardiovascular Risk

Support, Not Shame

Caregivers are taught about the syndrome and skills such as swaddling and consoling. Some also learn about the use of formula and breastfeeding techniques. The aim is to "empower them to care for their own child," Danovitch said.

Doctors can also guide families to longer-term follow-up care, including lactation consultation, mental health or substance use treatment, or social supports through the Community Connect Program.

Along with emphasizing the importance of getting care, experts urge parents and other caretakers not to blame themselves for a newborn's condition. Guilt and fear often plague families when their little one is sick, especially because of stigma around opioid use. That can keep caregivers away from the doctor's office, even though NOWS-as well as addiction-is treatable.

Being truthful in your prenatal consultation can open up the door for family-centered healing.

"We can't support you unless we know what your challenges and concerns are," Henry said.