Born on drugs

Babies born in withdrawal are smallest victims of opiate dependency
October 15, 2013

Prone to diarrhea, tremors, vomiting and seizures, these newborns have a distinctive high-pitched wail. They can’t suckle or sleep; off to a slow start, weeks go by before they can be released after birth.

They are dependent on narcotic drugs, largely opiods including heroin, oxycodone, methadone and Vicodin and medical professionals across the peninsula say 2013 started with a boom in their births.

Swaddling, dimmed lighting and constant contact are important to soothe the most helpless victims of a swift rise in narcotics use after changes to the formulation and availability of prescription painkillers shifted the habits of drug abusers.

Instead of the typical two or three-day hospital stay after birth, neonatal teams attend to these infants for weeks, sometimes months before they are released.

In 2012, the number of infants suffering from a collection of withdrawal symptoms, known as Neonatal Abstinence Syndrome, was documented as nearly 12 percent of the entire newborn population at Beebe, Neonatal Nurse Practitioner Nancy Forsyth said. Unlike the "crack babies" born a generation ago, mostly contained to inner-cities, this is a suburban epidemic.

“Use of prescription medications to treat acute and non-acute pain has become more liberal in both pregnant and nonpregnant populations,” Forsyth wrote in an email. In 2009, newborns with NAS stayed in the hospital an average of 16.4 days compared to 3.3. days for other newborns.

The FDA classifies opiate drugs -- including painkiller medications such as Oxycontin, Vicodin and Percocet -- as a Category B pregnancy risk level, meaning there is no evidence of harm to humans from their usage evidenced in animal studies.

Mainly, withdrawal is the painful and problematic side effect of exposure that puts babies at higher risk for the slow growth, suffering, irritability and expense associated with NAS, she said.

Post-Millennial Epidemic

Dr. Leo Eschbach, an obstetrician who has delivered babies at Beebe since 2001 said he has seen the number of babies born to mothers on narcotics reach epidemic proportions since he came to the hospital. He estimated at least eight babies were born in January alone who suffered from NAS.

“What we have is an increasing population of mothers and babies who are addicted to narcotics and other street drugs,” he said. “These babies, they withdraw. They won’t eat, they won’t sleep. They cry and scream. Usually we use morphine to wean them off, and that can take weeks.”

This trend of prenatal opiate use is not isolated to the Cape Region. A study published by the American Medical Association in April, 2012 reported the number of mothers using opiates increased five-fold from 2000 to 2009 nationwide.

According to the study, published in the Journal of the American Medical Association, the number of babies born exhibiting symptoms of NAS nearly tripled from 4,682 in 2000 to an estimated 13,539 newborns in 2009 —equivalent to one new baby suffering from opiate withdrawal born every hour.

Just beyond the Cape Region in Delaware, Nancy Oyerly, director of obstetrics at Seaford's Nanticoke Memorial Hospital, confirmed there has been a dramatic rise in the number of babies delivered at her hospital suffering from opiate withdrawal.

The closest Neonatal Intensive Care Unit in Delaware is at Kent General Hospital in Dover, where representatives report these days, 25 to 30 percent of the NICU is typically occupied by NAS babies.

"The increase in drug use has become epidemic now, the population just continues to grow," Eschbach said.

Everyone Pays

Nationwide, 77.6 percent of health care costs associated NAS babies with  paid for by state Medicaid programs including Delaware Physicians Care and United Healthcare Community Plan, Forsyth wrote.

In order for these babies to be stabilized for a safe release from the hospital, drug-dependent infants must be weaned off opiates in a gradual process under medical supervision. This process averages 16.4 days in the hospital, as opposed to the average stay of nearly three days for other newborns at Beebe.

Beebe Medical Center has 12 mother-baby rooms, additional beds for observation and a hospital nursery, but with an increasing number of these beds occupied longer by babies being weaned off opiates, the nursery fills up, fast.

Outside of hospitals, at the community level, Dr. Voncelia Brown, professor of community health at Salisbury University said she sees many of these mothers in her work just over the state line. Many mothers who are addicted to narcotics do not seek prenatal care, Brown said, because they are fearful their addictions will be revealed and social services will be contacted.

This is the worst thing they can do, she said.

Different hospitals have varying protocols for neonatal drug screens, Brown said, but usually avoiding prenatal care is reason enough for hospitals to test.

“In the effort to avoid drug screens, moms are not getting prenatal care,” she said. “Not every Delaware hospital tests every mother. A savvy mom that’s got an addiction issue is not going to be prenatally tested.”

The best action, she said, is for mothers to seek intervention as soon as possible and get medical supervision to minimize the impact of drug use on her child.

“In the best of all worlds we want moms to get treatment as soon as they know they are pregnant,” Brown said.

One Mother's Story

When a woman does find herself in the position of coping with an addiction and learning she is pregnant, early intervention is vital.

Pregnant with her second child and addicted to heroin, 32-year-old Barbara Ridgley has spent half her life chasing the dragon.

With a warm smile and friendly disposition, Ridgley said she tried heroin for the first time on her 16th birthday and was instantly drawn into its grips. She's been trying to quit ever since she was 20, checking into and out of as many as six different rehabilitation centers countless times with varying lengths of sobriety, including much of her first pregnancy, Ridgley said.

Off heroin from 2007 to 2011, the pregnant mother said eventually she got too confident in her sobriety and stopped taking the necessary steps to stay sober, which for her includes going to narcotics anonymous meetings. By 2011, friends looking for painkillers began calling her for heroin contacts and she relapsed, picking up her old drug of choice.

After her most recent relapse, Ridgley said she lost most everything she had worked for during her sobriety. She was addicted again and homeless, sleeping in her car behind crack houses in Belltown, she said.

When she got news of her pregnancy, Ridgley said she saw this as a last chance to turn her life around and immediately sought help.

Although she wants to clean up for good, Ridgley said she was referred to a methadone clinic by her doctors to regulate her intake and minimize the negative impacts of opiate withdrawal on her unborn child.

“The doctor at the methadone clinic advised me to be on it for five years because I have many years of being high,” she said. “I don’t really know if I want to be on it that long. But I think I’m just going to listen to the doctors instead of listening to myself because that never did me any good.”

Although her baby may still withdraw from methadone, another opiate drug, medical professionals say continuing a constant, regulated and clean flow of opiates is safer for her baby than the trauma of quitting cold turkey for a long-time addict like Ridgley.

“I want to be very clear, a mother who is addicted and goes on methadone is making the right choice for her baby,” Forsyth said in a telephone interview. “Attempting to detox during pregnancy carries significant risk for mother and fetus.”

A Helping Hand

As mothers with drug dependency problems are identified during prenatal screening, efforts are taken to moderate their dependence and resolve their addicitons.

Many heroin users are put on methadone to step down off a heroin addiction, but NAS symptoms are also associated with methadone.

Residential treatment programs may be the right choice for some mothers to get clean in a safe environment.

The Lighthouse program is a residential treatment program for pregnant addicts and mothers with up to two children, Forsyth said. This program requires authorization for enrollment, which comes from the Delaware Division of Substance Abuse and Mental Health. For more information call 302-424-8080.

After a newborn is identified as suffering from NAS or potentially being released to an unstable home, a referral is made to the Delaware Division of Family Services.

From that point, Child Development Watch Central Intake Supervisor Deborah Burton said state and private programs including Smart Start, Child Development Watch and Zero to Three, work in conjunction with parents and one another to provide help for families.

"Public health is only one resource that assists with these cases," Burton wrote in an email. "We work with numerous state and community partners in order to provide a healthy start for Delaware babies."

For more information and additional state resources, contact the Kent and Sussex County offices of the Delaware Division of Public Health in Milford 302-424-7307.

Widespread and far-reaching, the epidemic of opiate use and abuse is not going to be solved easily, Brown said.

“One of the key issues of addiction is denial and as a society, I think we are in denial,” she said. “This is not about a community. It’s not about Lewes or Rehoboth, it’s about where we are as an American society.”

Assessing babies who may be addicted

Beginning two hours after birth at Beebe, at-risk infants are scored using the Finnegan Neonatal Abstinence scoring tool to assess and quantify signs of withdrawal. Infants are then scored every four hours thereafter using this tool to asses signs of withdrawal, which may begin shortly after birth or take days to present themselves. Many babies who develop NAS have been exposed to multiple drugs in utero and treatment for poly-drug use requires special consideration.

Despite a slow start for opiate-dependent babies, their long-term prognosis is remarkably good thus far. Though studies are ongoing, follow-up data show most NAS infants meet developmental goals on par with their peers. The biggest indicator of future health and development is a stable family environment after they overcome initial delays that include:

- Poor feeding habits and slow weight gain.

- Greater risk of sudden infant death syndrome.

- Impaired mother-infant bonding.

- Frequent skin excorations and diaper dermatitis.

-Central nervous system symptoms: irritability, wakefulness, high-pitched cry, tremors, hyperactive deep tendon reflexes,increased muscle tone, seizures

-Gastro-intestinal symptoms: hyperphagia, uncoordinated suck, constant frantic sucking, vomiting, diarrhea,dehydration

-Autonomic symptoms: nasal stuffiness, sneezing, fever, mottling, yawning, apnea

Sources: CDC/Neonatal Nurse Practitioner Nancy Forsyth

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