Besides specialized care, babies with neonatal abstinence syndrome need to connect with their parents.
Tara Sundem, RN, NNP-BC, MS, admits she used to judge parents when newborns in her neonatal ICU were going through withdrawal. She, like many of her nurse colleagues, thought the best place for these babies after discharge was not with the parents. Sundem now says she was wrong after studying opiate use disorder and says the best place for these newborns almost always is with the parents, even if those parents are not yet drug free. But these families need help. [caption id="attachment_76248" align="alignleft" width="225"]
Tara Sundem, RN[/caption] "Studies are showing the importance of the biological mom's and dad's presence to help with baby's brain development," she said. So Sundem and Kelly Woody, RN, NNP-BC, also a neonatal nurse practitioner, started the nonprofit Hushabye Nursery in Gilbert, Ariz. The nursery is a recovery center for infants with neonatal abstinence syndrome. The infants' stay lasts until they no longer need NICU care. Parents can stay in rooms with their babies -- each room has a bed, crib and rocking chair. The approach is that staff embrace substance-exposed babies and their caregivers with compassionate, evidence-based care. According to Hushabye's website, this type of care can change the course of families' lives, sparing newborns from following similarly troubled paths. Through hard work and securing donations, the NP duo plans to open a new building dedicated to their mission Sept. 30, 2020. The new facility will have 12 inpatient private rooms. On the outpatient side, the facility will have a counseling area and outpatient programming such as prenatal and parenting classes. The new clinic will require a staff of 25 to 30, including up to 10 nurses.
Neonatal abstinence syndrome cases climb
The journey started when Sundem was working in a hospital NICU and noticed growing numbers of babies in withdrawal. The opioid epidemic was affecting the most vulnerable at an alarming rate. "We shouldn't have been surprised, but we were," she said. Nationwide, neonatal abstinence syndrome diagnoses have increased 235% since 2008, and these newborns spend an average of 19 days in the NICU.
Sundem and her NICU colleagues tried to help the babies, but the traditional NICU environment -- with bright lights and noise -- isn't conducive to soothing a baby in withdrawal.
Out of frustration, Sundem educated herself about neonatal abstinence syndrome and learned about adverse childhood experiences, or ACEs. She hadn't learned about ACEs in nursing school and said it still isn't taught in most programs today, but it should be. ACEs' impact on children's lives are widely researched. In a study of more than 17,000 people who received physical exams and completed confidential surveys about their childhood experiences and current health status and behaviors, researchers found a dose-response relationship between the number of ACEs in a person's life and negative health and well-being outcomes such as mental health issues and chronic diseases. Babies in withdrawal often are born with two or three ACEs, such as a mom's substance use, which might suggest mental illness and depression. Poverty is common. Sometimes, one or both parents have been in jail.
"Just by being born, our babies have two or three ACEs," Sundem said. "And if you take a baby away from their biological family, even to foster care for a little bit, you have set up that baby (for worse outcomes in life)."
Those negative outcomes include higher risks for substance abuse, hypertension, diabetes and much more, as well as significantly shorter life expectancies, according to Sundem. "When I started reading that data, I changed my thinking from 'We have to save the babies,' to 'We have to save the families,'" Sundem said.
Troubled mothers can still play a role
Sarah Benham, LCSW, a social worker for women and infants at The Hospital of Central Connecticut, New Britain, Conn., agreed the mother's role is important. "The proper way to care for newborns exposed to the addiction that a mother is currently experiencing is to allow the mother the ability to safely participate in care of the newborn," Benham said. "It is important for the mother to feel included and be informed when making medical decisions and understand her own limits to being present to care for her baby." It's not so easy to convince healthcare providers who are set in their ways, according to Sundem. "When they say babies should not go home with their moms because they have opiate use disorder or because they're on medication-assisted treatment, aka methadone, etc., I say you really need to look at the data," she said. "The data supports wrapping our arms around these families and figuring out how do we give them the resources, so that it is safe for them to take their babies home. I can tell you from the moms and dads that I'm working with, a lot of times this pregnancy is the catalyst to their recovery and their motivation." Although child services may determine the baby is cannot safely go home with the parent or parents, Sundem believes it's important for some kind of biologic connection to happen with mom in the first days or possibly the first months or first year.
Knowledge and compassion
The nursery offers prenatal and postpartum programs and will offer more services once the clinic opens later this year. "We go to the methadone clinics, the medication-assisted treatment clinics, and we offer prenatal and postpartum support groups," Sundem said. She and other staff connect families with resources that might help them, including housing. The aim is to get families into treatment and pave the way for families to turn around their lives, so they can safely care for their newborns. The clinic will provide an alternative to the NICU, so babies showing signs of withdrawal can be transferred to Hushabye's dark, quiet environment. Nurses trained in caring for babies with neonatal abstinence syndrome will care for the newborns one on one.
"One mom explained to me that withdrawal is like the worst flu and migraine times 100," Sundem said. "When I heard that, I thought, 'That is exactly what we see.' The babies are vomiting, they have diarrhea, they're miserable. It makes sense. When you have the flu, you want everybody to be quiet."
Hushabye isn't a treatment facility but the organization partners with facilities that can get the new moms and dads in right away. The goal, according to Sundem, is to have parents stay at Hushabye 24-7 to help care for their newborns. "My goal is that they learn to trust us and engage enough with us and will continue to come back," Sundem said. "We'll be that safe place where they're not going to be judged, and where they get their therapy." Women and families who are struggling often come with significant past trauma and fear of judgment, according to Benham. It is important for nurses to help decrease the stigma of opiate use disorder that prevent these families from seeking care unless it's a crisis situation, according to Sundem. "I say opiate use disorder, versus addiction, because addiction has such a negative connotation," she said. "They're not going to go where they get judged."
Messages to nurses in any setting
Nurses inside and outside the NICU can make a difference in these babies' and families' lives, she said. For example, nurses should encourage breastfeeding because studies suggest it is best for the baby. "Studies show these babies do better when they're with their moms in a quiet, dark environment and they breastfeed," Sundem said. Studies show it is safe for moms to breastfeed if they are taking medications for treatment, such as methadone or buprenorphine (Subutex), their drug screens are negative and the only positive is for the medication prescribed for opiate use disorder, according to Sundem. Breastfeeding guidelines for women in drug treatment have changed in recent years. "Prior to the mid-1990s, the American Academy of Pediatrics Policy Statement on the transfer of drugs into human milk stated that methadone doses above 20 mg/day were a contraindication to breastfeeding. However, in their most recent policy statements in 2001 and 2013, methadone at any dose is no longer listed as a breastfeeding contraindication," researchers reported in the journal Substance Abuse in 2015. The baby's safety is always at the heart of care, according to Benham. "In my experience, most women struggling with active drug use are unable to provide the level of care these infants need 24/7 like we would expect from a mother without a substance-use disorder," Benham said. "But we should not discourage any time spent between mother and infant as long as it is safe."
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Neonatal Abstinence Syndrome: Off to a Shaky Start (1 contact hr) Neonatal abstinence syndrome includes a spectrum of similar physiological signs and symptoms caused by drug withdrawal. It's characteristics include central nervous system hyperirritability, GI dysfunction, and autonomic dysfunction. These symptoms alter the normal transition of the infant to extrauterine life as they affect the most basic functions such as sleeping, feeding, and interaction with the environment and caregivers. Opioid Use Disorder and Pregnancy, Part 1: What Does Evidence-Based Care Look Like? (.5 contact hr) Emergency and maternity care staff can assist in perinatal opioid use cases by facilitating access to treatment and comprehensive care. What information is available for screening approaches for prenatal substance use? What kinds of treatment programs are available for pregnant women who struggle with opioid use disorders? Opioid Use Disorder and Pregnancy, Part 2: What Does Evidence-Based Care Look Like? (.5 contact hr) Perinatal opioid use is a serious public health challenge in the United States. What interventions promote safety of mother and baby? Join the conversation about the need for decreasing stigma and optimizing care for those affected by perinatal opioid use disorder.
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