Finding out last year that she was pregnant with her second child, Cailyn Morreale was overcome with fear and concern.
“I was very scared,” said Morreale, a resident of the small town of Mars Hill in western North Carolina. At the time, her joy at being pregnant was overshadowed by fear of having to stop taking buprenorphine, a medication used to treat opioid withdrawal that had helped counteract her addiction.
Morreale’s fear was compounded by the rigidity of the most common approach to treating babies born after being exposed in utero to opioids or some medications used to treat opioid addiction.
For decades during the opioid crisis, most doctors have relied on intensive medication regimens to treat babies born with neonatal opioid withdrawal syndrome. Those protocols often involved separating newborns from their mothers, placing them in neonatal intensive care units and giving them medications to treat their withdrawal.
But research has since indicated that in many, if not most, cases, such extreme measures are unnecessary. A newer, simpler approach that prioritizes keeping babies with their families, called Eat, Sleep, Console, is increasingly being adopted.
In recent years, doctors and researchers have found that keeping babies with their mothers and making sure they are comfortable often works better and gets them out of the hospital faster.
Despite his worst fears, Morreale was never separated from his son. She was able to start breastfeeding immediately. In fact, she was told that the trace of buprenorphine in her breast milk would help her son quit.
Her experience was different because she had found her way to Project CARA, a program based in Asheville, North Carolina, administered through the Mountain Area Health Education Center, which supports pregnant people and parents with disorders due to substance use. Morreale’s care team assured her that she did not need to stop buprenorphine and that her baby would be evaluated and monitored using the Eat, Sleep, Comfort method. The protocol considers it okay to send babies home as long as they are eating, sleeping, and are comforted when upset.
“By the grace of God, he was incredible,” Morreale said of his son.
David Baltierra, former director of the Rural Family Medicine Residency Program at West Virginia University, chair of the Department of Family Medicine – WVU Eastern Division and a family physician, suggests this protocol could simply be called “parenting.”
The method is increasingly used in place of the long-adopted approach to treating opioid-affected newborns called the Finnegan Neonatal Abstinence Scoring System. That tool includes a list of 21 questions (does the baby cry excessively, sweat, experience tremors, sneeze, etc.), the answers to which determine whether the newborn should receive medications to counteract withdrawal symptoms, which would then require a prolonged hospital stay. the hospital? a neonatal ICU.
Baltierra, however, has problems with the Finnegan method. For example, it often turns out that a deeply sleeping baby is awakened to receive a score. That didn’t make sense to Baltierra. If the baby is sleeping, he or she is probably fine.
Instead, health professionals should look for telltale signs that a baby is experiencing opioid withdrawal, he said. “Their body is tense, they have a high tone, they don’t calm down.”
Baltierra and her colleagues have been training residents to use the Eat, Sleep, Comfort approach for a decade, and progressively longer over the past six years. The results are persuading more health professionals to adopt the method.
A 2023 study found that babies treated this way were discharged from the hospital in almost half the time and were less likely to receive medication than those receiving care at Finnegan.
Matthew Grossman, an associate professor of pediatrics at Yale School of Medicine, calls the introduction of the treatment model he has helped pioneer “the least innovative enterprise” imaginable.
Research shows that optimal care for pregnant women who have experienced opioid use disorder includes treatment with buprenorphine or methadone, which carries the risk of their newborn having withdrawal symptoms. Grossman and his colleagues found that a non-drug approach works best.
He said the Finnegan tool is useful but often too rigid. Depending on your score, one too many sneezes could send a baby to the NICU for weeks.
Grossman said she observed that some babies who received medication did well for a few days, but began to worsen when their mothers were sent home without them. Those observations made him ask: “Did the child need more medicine or more mom?”
Research by Leila Elder and Madison Humerick, who did their residency in WVU’s rural program, found that the average length of stay for newborns at retreat dropped from 13 days in 2016 to three in 2020.
Elder said babies born at the 25-bed rural hospital where they delivered were given drugs to treat their withdrawal symptoms only when unrelated problems sent them to other hospitals for NICU care.
The simpler treatment also means that more babies born in rural communities can receive care closer to home and has reduced the likelihood that a mother will be discharged before her baby is cleared to return home.
Grossman suggested that rural hospitals are better suited to employ the Eat, Sleep, Comfort approach than larger city institutions, given the latter’s generally easier access to a NICU and their propensity to choose that option.
Sarah Peiffer remembers the first time, as a medical student, that she witnessed a nurse administer the Finnegan protocol and discuss it in clinical terms at the bedside of a new mother.
“And I remember being a little horrified,” she said. The process was clearly distressing for both mother and child. “I felt like there was almost a sense of punishment, like we were saying to this mom, ‘Look what you did to your baby.’”
Peiffer is now a Project CARA practitioner and family health physician at Blue Ridge Health in western North Carolina and a strong advocate for ESC and its approach to partnering with families. “If you look at all the non-pharmacological things you’re supposed to do, like keep the lights low in the room, keep the baby swaddled, have as much skin-to-skin contact as possible with the mom, and you really treat the mom like she’s a medicine .”
Research suggests that skin-to-skin contact immediately after birth offers “vital benefits” for short- and long-term health and bonding.
That contact, Elder said, “releases endorphins for the mom,” which helps reduce the risk of postpartum depression.
Grossman said developing the Eat, Sleep, Console protocol was simply a matter of pausing to reassess it.
The original intention of the Finnegan tool was not to make the process so rigid. But “everyone is excited to have a tool, and then this approach calcified,” he said.
Grossman said the goal of the simpler approach was to put the family at the center of care, and that shorter hospital stays for babies were simply a fortuitous result. The shift in focus fits into a broader movement toward nonjudgmental, family-centered care for those who have experienced addiction and their children.
Now, she said, after five days, mothers often say, ‘Can we go home? I think I understand this,'” and are treated “with the same respect as any other mother.”
Peiffer said she has witnessed how this mother-centered care counteracts “that sense of shame that people feel instead of families feeling empowered to care for their baby.” It represents “such an important shift in the way we think about neonatal abstinence, both medically and culturally.”
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