Carrie Johnson, DO, Candy Stockton, MD, and Susan Johnson, RN in the NICU at St. Joseph Hospital in Eureka, California
Experts in Humboldt County changed the style they treat newborns dependent on opioids. The babies spend less time in the neonatal unit and receive less medication. The team includes, left to right, Carrie Griffin, Do, Candy Stockton, MD, and Susan Johnson, RN. Photo: Shaun Walker

When babies are born dependent on opioids, typically they are whisked away from their mothers, put into the neonatal intensive intendance unit (NICU), dosed with morphine to get them through withdrawal, and gradually weaned off the drug—a process that can have weeks.

Research at present suggests that this long-established standard of care may exist the worst mode to care for a newborn with opioid dependency, or neonatal forbearance syndrome (NAS). The NICU is busy, noisy, and bright, filled with beeping machines, other crying babies, and bustling nurses. Infants are fed not when they're hungry but every 3 hours on a schedule. When they cry, there may be no ane to agree them if the nurses are busy attention to other babies. And when they finally can slumber, they may be awakened to be poked and prodded for medical tests and treatments.

A new initiative is turning NAS treatment on its head with a shockingly simple concept: care for the baby similar a babe and the mom similar a mom. Keep the baby and the female parent together. Go along the babe out of the NICU. And don't give the babe opioids unless admittedly necessary.

This approach is known as "Eat, Slumber, Console," meaning permit the babies consume and sleep when they want and panel them when they cry. With this protocol, hospitals treating members of Partnership HealthPlan of California — a Northern California Medi-Cal managed care organization — reduced the average hospitalization of babies with NAS from eighteen days to 11 days. Partnership said that in just the showtime 3 months of implementing the new approach, it saved $389,000. Studies at other institutions have shown newborns experience no adverse effects from this new protocol.

When the Standard of Care Is Incorrect

Exterior of St. Joseph Hospital
St. Joseph Hospital in Eureka, California, has adopted new protocols for treating newborns with opioid dependency. Photograph: Shaun Walker

To anyone who'due south taken care of an babe, Eat, Sleep, Console may audio obvious, but to physicians and nurses who treat babies with NAS, it'due south a revolutionary departure from decades of exercise recommended by experts.

"Taking these babies from their moms and putting them in a nursery where it'southward noisy and lights are on has always seemed a lilliputian counterintuitive to what'southward best for them," said Susan Johnson, RNC, the NICU clinical coordinator at St. Joseph Hospital in Eureka. "But it was what the standard was and what we were told to do."

Since the 1970s, the standard of intendance for NAS has been pharmacologic therapy — typically methadone or morphine — guided by the Finnegan Neonatal Abstinence Scoring Organisation. The Finnegan system tests for symptoms of opioid withdrawal, such equally shaking, fever, sweating, loftier-pitched crying, gastrointestinal problems, sneezing, and yawning. Babies are assessed every three hours, and if they score eight or more than on the Finnegan three times in a row, they are given medication. Once they're on the drug, it takes 3 to four weeks to wean them off, during which fourth dimension they must remain in the hospital.

The problem is, many of the signs of opioid withdrawal look like typical newborn behaviors. "It really pathologizes a lot of the symptoms that are normal in any given newborn," said Carrie Griffin, Do, a family medicine dr. in Humboldt County who specializes in perinatal substance use and treats moms and babies. "All babies yawn, all babies have some amount of a tremble response. And what happens is, when we know that there's been opioid exposure in utero, information technology's a unlike lens through which nosotros're looking at these babies."

Learning That Mom Is Medicine

Eat, Slumber, Console gets rid of the subjective Finnegan scoring system and only gives weight to a newborn's essential functions. Can the baby drinkable an ounce of milk? Sleep for an hour undisturbed? Be consoled inside 10 minutes? If the infant is performance normally, then regardless of opioid exposure in the womb, the withdrawal isn't severe enough to warrant handling with drugs.

The protocol was developed by Matthew Grossman, Physician, an assistant professor of pediatrics at Yale Schoolhouse of Medicine. While caring for babies with NAS, he noticed that the infant's environment — and particularly whether the infant was kept with its mother — had more bear upon on how quickly the baby was released from the hospital than the pharmacologic treatment did. So instead of automatically turning to opioids, Grossman decided that the first-line handling would be the mom.

It turns out that when the babies are given mom instead of morphine, they do ameliorate. With Eat, Sleep, Console, the average length of stay for infants born with NAS at Yale New Haven Children'southward Hospital dropped from 22 days to iv days. What's more, only 12% of newborns treated with Eat, Slumber, Console required opioids compared with 62% of babies scored using the Finnegan model. These changes cutting the cost of intendance per baby past more than than 70%.

Spotter this presentation near Consume, Sleep, Console by Yale pediatrician Matt Grossman, Md.

A Mother's Touch

Nicole Merschdorf was 1 of the first women to become through the new protocol with her daughter Penny Lou at Mad River Customs Hospital in Arcata, California. Merschdorf had been using intravenous drugs for v years, and she was on buprenorphine to treat her addiction when the baby was delivered. Buprenorphine is a first-line treatment for opioid addiction, and while it can lead to NAS in babies built-in to pregnant women taking the medication, the NAS is normally less severe. Buprenorphine helps the women maintain a more stable life without experiencing withdrawal and cravings while in treatment.

When Penny Lou was born, she showed signs of NAS, similar restlessness, jerkiness, sneezing, and overactive sucking. But Merschdorf said that as soon as she did skin-to-peel contact with her baby, "It was actually all the difference in the world," she said. "She'd be fussing in her bassinet, and equally soon as you picked her up and she felt a torso, she'd instantly be soothed."

Merschdorf and her daughter were able to stay in a individual room in the nursery for seven days before Penny Lou was deemed healthy enough to go home. The baby girl required only a unmarried dose of morphine on the second twenty-four hour period. The one-off treatment — another difference from the Finnegan model — was enough to get her through the worst of her withdrawal without requiring a full course of the drug. Now Penny Lou is a happy, healthy six-month-old baby.

"When the baby is born, there'due south a massive corporeality of guilt and regret," Merschdorf said. "Just the doctors and nurses are at that place to help you lot. And getting the best medical treatment for your kid is what'south going to be best for them in the long run."

Changing Clinicians' Minds

In rural Humboldt Canton along California'southward northern coast, more than than 10% of newborns are diagnosed with NAS, the second highest rate in the state. Griffin, the family medicine physician, has spearheaded the rollout of Eat, Slumber, Panel in several Humboldt hospitals, including St. Joseph Hospital and Mad River Community Hospital. Since the programme started, most of the babies have gone home afterward four days, and Penny Lou was the merely one who required pharmacologic treatment.

Most babies and children would rather be cuddled by their parents when they're feeling sick than have somebody sedate them and make them sleep through the symptoms.

—Candy Stockton, MD

Griffin said that while she is excited by their initial success, she's still working to get buy-in from all the care providers. "There's been a lot of resistance from pediatricians here considering they feel like the babies are suffering, and we're not doing anything to mitigate it," she said. "It is hard to unwind those years of preparation and assessing and clinical pattern development and reorient effectually the idea that this is a healthy baby. The baby is experiencing withdrawal from the substance, but if nosotros support them as we would want to support any newborn, they practise really well."

To help get more of the doctors and nurses on board, Griffin and Candy Stockton, Physician, a family md at the Humboldt Independent Practice Association and head of the county's perinatal substance use task force, accept been trying to reframe what the true source of suffering is for these children.

"Well-nigh babies and children would rather be cuddled by their parents when they're feeling sick than have somebody sedate them and make them sleep through the symptoms," Stockton said. "Putting the infant in a brightly lit, noisy, chaotic environment in the neonatal intensive care unit of measurement, separating them from their parents and caregivers to provide this care — all of those things are more traumatic to an infant who doesn't understand what's happening than it is for them to be a piddling shaky with a footling chip of nausea and some muscle aches."

Instruction Is Primal

This type of clinician teaching is critical as Partnership HealthPlan of California works to get more hospitals to gyre out Eat, Sleep, Console. The initiative began with a one-day briefing on maternal opioid use in October 2018, at which Grossman presented the protocol. His talk had a dramatic and firsthand upshot on many of the care providers at the 22 hospitals in Partnership's network. While the average reduction in length of stay was from 18 to eleven days, the hospitals that were most committed to Swallow, Slumber, Console got their boilerplate stay down to merely four days. As more hospitals adopt the program, the average length of stay is likely to go along dropping.

"Education is commonly not your strongest mode of making modify happen on a massive scale," said Robert Moore, MD, Partnership'south chief medical officer. "Merely the testify is so overwhelming that when doctors heard a single presentation [on Eat, Sleep, Panel], we saw this big alter."

Partnership is collaborating with the California Maternal Quality Care Collaborative to continue education effectually the new protocol, concentrating on four rural Northern California jurisdictions that take been specially difficult-hit by the opioid crunch: Humboldt, Lake, Mendocino, and Shasta Counties. Equally more providers learn about the treatment, Moore hopes hospitalization times and health intendance costs will keep to drop as this improved approach to neonatal abstinence syndrome takes concur.

"Keeping the knowledge out at that place is going to be actually of import," Moore said. "Ultimately, learning more on the ground — how are they thinking nigh these barriers, what are their plans to address the barriers — and keeping that dialog live is going to be helpful."

Dana Smith is a freelance wellness and science writer based in Oakland, California. She has written for many publications, including Scientific American, Pop Scientific discipline, Medium, the Atlantic, and the Guardian. Prior to pursuing a career in journalism, she earned a PhD in experimental psychology from the University of Cambridge. Her work can be found at danagsmith.com.