Crossville Chronicle, Crossville, TN

May 8, 2013

Drug-dependent babies face many challenges after birth

By Heather Mullinix
Assistant editor

CROSSVILLE — Almost 200 babies in Tennessee have been born this year with a dependence to drugs they were exposed to while in their mother's womb, with 22 reported from the Upper Cumberland region.

Those babies were diagnosed with neonatal abstinence syndrome after they exhibited signs of withdrawing from the drug they had received prior to birth.

"These babies are inconsolable," said Carla Saunders, MSN, NNP-BC, at East Tennessee Children's Hospital, which has developed treatment protocols for treating babies with neonatal abstinence syndrome. "They have a unique cry that's a higher pitch and they can't comfort themselves. They shake, even under wrappings, and in severe cases they have seizures."

The numbers of babies born dependent on drugs has continued to rise in the past decade and, according to Saunders, many of those seen at East Tennessee Children's Hospital are dependent on prescription pain medication. Nearly 30 percent of the admissions to ETCH are for NAS, babies that would not be at the hospital for any other cause but their drug dependancy.

"We're averaging almost one baby per day, but we've gotten seven admitted within a 16-hour period," Saunders said.

Once they're born, they begin exhibiting signs of drug withdrawal within a few days of birth. Those symptoms can include tremors and seizures, a high-pitched cry, inability to feed, muscle stiffness and rigidity, inability to self-soothe and inability to organize movement. They can suffer from vomiting and diarrhea. They will often be hyperactive, moving about in their beds to the point of rubbing sores on their skin.

Babies are born dependent on drugs their mothers obtained legally for pain management or for treatment of addiction, while others were illegally obtained. Saunders said opiate dependancy is the most common drug dependancy noted in NAS babies at the hospital.

Treating these infants is not only emotionally difficult, it's expensive, as well. The average cost of a baby receiving TennCare benefits born with neonatal abstinence syndrome in Tennessee was $40,931 in 2010. That compares with $7,258 for a baby receiving TennCAre benefits not born addicted that same year.

"It's preventable suffering, and it's a preventable health cost," Saunders said.

Then there's the long-term effects, many of which are not yet known. Patricia Zetterberg, MSN, C-PNP, at ETCH, works with babies that have been discharged from the NICU at ETCH until they are two years of age.

"There are success stories," Zetterberg said, "But these are babies with problems."

Those problems can include an increased risk of Sudden Infant Death Syndrome, issues with sleep regulation, neurological developmental delays and problems with behavior regulation.

"They have temper tantrums that are beyond normal," Zetterberg explained. "We often see this early. These children have short fuses."

Issues with sensory processing are also noted, leaving the child feeling bombarded by the sights, sounds, smells, noises and tastes of the world. There can be cognitive and learning disabilities, including increased incidence of attention deficit hyperactivity disorder, poor impulse control, decreased attention and decreased decision making ability.

There are also psychological implications, including trouble bonding with parents and a parent's guilt for having exposed their child to the drug. If the parents have not dealt with their own addiction, there is increased risk for maltreatment, especially because children with in-utero drug exposure are often more difficult to care for than their non-exposed peers. Those with parents with substance abuse problems are also more likely to have a parent die before they reach the age of three, which also leads to life-long emotional and psychological issues.

"We don't know what happens in adolescence," Zetterberg said. "There is no study, but we believe these children are at increased risk for substance abuse and addiction."

When ETCH first noted the increase in the number of NAS babies being admitted, they turned to methadone to ween the babies off the drugs and ease the symptoms of withdrawal. That didn't work very well, Saunders said, because the weening time was extended and many times, when the babies were sent home, treatment was not always continued.

"Our safety net was falling apart," Saunders said. "I ran from this and buried my head in the sand. I didn't know what to do."

But her nurses came to her and said something had to be done. The hospital worked to bring together a team to address the situation. Nurses wrote bedside protocols and a medication protocol was developed where none had existed before.

The goals of this new treatment plan were to reduce the withdrawal period and to ween the baby entirely before he or she was discharged. Babies were held and comforted in a dark, cool environment and a lactose free diet was often used to ease digestive discomfort. They also knew they'd need to collect data going forward to aid in scientific study.

Most babies can be weened using morphine in about 20 days and not require further treatment. About a third require additional therapy, with the longest ween time recorded at 155 days.

Because of the many health issues tied to NAS, the Tennessee Department of health has made NAS a reportable condition, effective Jan. 1, 2013. Health officials will be required to identify cases more quickly and accurately as part of an effort to reduce NAS births.

Despite the danger in-utero drug exposure can cause a child, mothers in Tennessee cannot be charged with assault or homicide for taking drugs while pregnant. Tennessee did have a law that allowed such prosecutions, but that changed July 1, 2012.

Now, Tennessee is considering the Safe Harbor Act that would provide treatment for pregnant women with substance abuse issues.

"If we can find women who are pregnant and using drugs, it's best to get them prenatal care and get them into a medically assisted rehabilitation program," Saunders said.

Cold turkey isn't an option in many cases because the mother's withdrawal can cause fetal distress, pre-term labor or even fetal death.

The Safe Harbor Act does not allow the Department of Children's Services to move for termination of parental rights just on the basis of use of prescription drugs during pregnancy. DCS could still be involved with a family if other factors cause concern. The legislation moves pregnant women to the top of the list for available treatment programs, as well.

Saunders said there was a question of how to treat the pregnant women, as there are not enough rehabilitation programs available to meet the need.

The American College of Obstetrics and Gynecology recommends pregnant women take part in a medically assisted rehabilitation program.

"This prevents mini-withdrawls for the baby," Saunders explained. It also helps to reduce other risky behaviors, such as IV drug use that can expose the mother and child to further danger.

Because such pregnancies are high risk, ACOG says prenatal care is vital and can be the difference between good and bad outcomes for mother and child. That's one reason many health care providers urged passage of the Safe Harbor legislation, encouraging women to seek treatment instead of running from care due to fear they would be prosecuted.

"There is never a better time to change your life then when you find you're bringing a life into the world," Saunders said.