More mom, fewer drugs
Robert A. Lisak
For 40 years, virtually every hospital in the United States has treated babies born to mothers who are addicted to opioids and heroin the same way.
Newborns are sent straight to intensive care and given morphine, phenobarbital, or other medications to ease their withdrawal symptoms. A children’s ward is the next stop, where doctors and nurses continue administering medication to slowly wean babies from drugs they were exposed to in utero. The painstaking process typically takes three to four weeks, sometimes stretching to more than two months.
Matthew R. Grossman, M.D., HS ’06, assistant professor of pediatrics and a hospitalist at Yale New Haven Hospital (YNHH), has found a better way. Most of the withdrawing infants he treats skip intensive care. Only 24 percent receive morphine or other drugs, compared to 70-80 percent at most hospitals. When they do, it’s often only a few doses. Virtually all are drug-free and home in a week or less, more than three times faster than the best results from current methods.
Grossman’s breakthrough therapy? More mom, fewer drugs.
“The babies need love, really,” the 41-year-old physician said. “It’s only slightly more complicated than that.”
About 2009, Grossman and other staff at YNHH’s pediatric care unit noticed that the more time that the mothers spent with their withdrawing babies, the better the infants did. The hospital began encouraging the moms to stay on the ward longer, and the average withdrawal time fell from 28 to 22 days. When physicians at a nearby hospital heard about Grossman’s success, they asked him to give a talk. To prepare, he reviewed the medical literature on treating opioid addiction in newborns.
“I saw some strange things when I went through the studies,” he said.
Virtually all hospitals then and now use a tool called the Finnegan Neonatal Abstinence Scoring System to manage infant opioid withdrawal. The system, developed in the early 1970s by a doctor in Philadelphia, requires hospital personnel to record 29 symptoms ranging from sneezing to tremors to digestive distress. The data yield a score that dictates when to administer morphine and how much.
“You would sit around a table and read off their scores, and decide whether you went up on their morphine or down on their morphine,” said Grossman, who, like all hospitalists, used the system. “It would take about 30 seconds.”
What surprised Grossman when he began reading studies was their almost singular focus on identifying the best combination of drugs to manage withdrawal. None of the researchers and physicians were scrutinizing Finnegan scoring or looking at alternatives. “None of them really talk about non-pharmacologic care,” Grossman said. “If they do, they just say, ’We tried to do that, but they don’t control for it.’ ”
Grossman already had data indicating that increased contact between mothers and their newborns shortened the withdrawal process. What if moms were with their babies even more? He decided to find out.
“That was where the hard work began,” he said. “Let’s try to standardize this non-pharmacologic care and treat it like a real treatment, like we would if it were a medication.”
Grossman and his staff began by trying to cut out the intensive care stage. Noisy ICU units with their bright lights and harried staff were the last place for already agitated and hyper-stimulated infants, he reasoned. The wards’ restricted visiting hours also limit mother-infant contact, which appeared to speed the babies’ withdrawal. The goal became to get the babies onto the pediatric ward immediately, if possible.
Once on the ward, mothers were encouraged to spend as much time as possible with their infants. Private rooms with cots, bathrooms, and TVs allowed them to stay indefinitely. Instead of nurses—babies can sense strangers—mothers fed, comforted, and swaddled the infants.
“We talked to the moms and said, ’You are the treatment for this child,’ ” Grossman said. “You have to be here because you are what your child needs.”
Grossman also came to question the Finnegan scoring system. Its rigid protocols for administering medication all but guarantee a hospital stay of at least three weeks, he said. Why should staff give morphine, he asked, after the baby sneezes three times in a given time period versus twice? Grossman replaced the system’s 29 measurements with three: Is the baby eating, is it sleeping, and can it be calmed when upset? Even if the scores were bad, Grossman tried to avoid medication.
“The first thing we say is, ’Is mom here?’ ” he said. “Let’s call and get her back.”
The results have been dramatic. In addition to the average hospital stay falling more than two-thirds, Grossman said, only about 30 percent of babies spend any time in the ICU—most of them for non-withdrawal issues. Among the babies who avoid the ICU, just 6 percent receive morphine or other drugs to manage withdrawal. “The more time they [mothers] spend with their babies, the better the kid does, basically,” Grossman said. “When you give them drugs, you end up prolonging the withdrawal.”
Assistant Nurse Manager Camisha Taylor said the treatment is the most dramatic change she has seen in her 13 years as a pediatric nurse at YNHH. But it did not come without challenges, Taylor said. The biggest was cultural. The babies’ mothers typically feel guilty and judged, feelings hospital staff encouraged, she said.
“We helped foster that guilt,” Taylor said. “It was very, ‘You stay over there; you did this to your child. We’ll take care of them.’ ”
At first, some staff resisted having mothers so involved, Taylor said. That evaporated after about a year, when the treatment’s success became clear. Mothers embraced the new culture as well, she said. “For them to feel like they were helping their infant was the biggest difference,” Taylor said. “We washed the guilt away.”
Grossman’s new treatment is well timed, given skyrocketing opioid abuse rates. In the mid-2000s, when Grossman was a resident, 10 to 20 babies a year were born to opioid-addicted mothers at YNHH. That number is now about 75, an approximately fourfold increase mirrored nationwide, especially in New England, Grossman said.
In spite of its success, Grossman’s new protocol is so far confined to YNHH and Dartmouth-Hitchcock Medical Center in New Hampshire, he said. He hopes that will change once his paper on the subject, which is under peer review, is published.
“Our goal is to see this everywhere because we can really have an impact on these babies,” Grossman said.