Taking a flexible, evidence-based approach to caring for infants born substance-exposed
Bangor has seen the impact of opioid use disorder in the neonatal intensive care unit (NICU) at Northern Light Eastern Maine Medical Center since 2003-4, long before the opioid epidemic reached a crisis level in Maine. Mark S Brown, MD MSPH came to EMMC in 2006 and took on the development of a comprehensive program to care for these infants with Neonatal Abstinence Syndrome (NAS) and their families. He explains that we usually refer to NAS as a group of problems that occur in a newborn who was exposed to opiate drugs while in the mother's womb.
“Opioid use cuts across all socioeconomic lines and creates a separate set of challenges for women during child-bearing years,” says Dr. Brown, who is the Chief of Pediatrics at Northern Light Eastern Maine Medical Center. The goal of treating babies with NAS is to evaluate and treat the baby without medication whenever possible as well as support their mothers in their recovery.
“Substance use disorder is very difficult for a person to walk away from,” Dr. Brown says. “It requires a lot of personal work and support from others to move into long-term recovery.”
Dr. Brown initiated data collection in 2007 at the NICU, with the help of Dr. Barbara Sorondo of Clinical Research Center at EMMC, to track the babies who had been exposed to opioids or other substances during pregnancy, treated or not. The NICU has honed its approach to treating NAS babies based on the data tracked over the past 12 years, and the application of leading pediatric research they have done and feedback from families. Medication-assisted treatment should be supported whenever possible, Dr. Brown says.
Evaluation of the babies of mothers who are dealing with substance use disorders includes frequent assessment around feedings, usually about every 4 hours, on the baby’s ability to eat, sleep, and be comforted. The initial treatment focuses on comfort care, such as keeping mothers and their babies together as much as possible, supporting breastfeeding opportunities, minimizing environmental stimulation, and swaddling or bundling babies in blankets.
If comfort care alone does not alleviate symptoms, babies with NAS also can be treated four or more times in 24 hours with an opiate replacement medication without starting a longer-term program of medication-assisted treatment. These babies receive a neonatal form of methadone or a small dose of morphine to ease their withdrawal symptoms.
“Individual patients have customized expressions of withdrawal that makes it difficult to have a one-size-fits-all approach,” Dr. Brown says. One example of the many factors that affect withdrawal is genetic differences that make some patients more receptive to opioids, heightening their dependency level, he adds.
Because of these factors, even with an approach focused on comfort care, there is always likely to be a small group of babies who need weeks of medication-assisted treatment to treat their NAS. Keeping babies in a hospital for this treatment has corrosive effects on the babies, their mothers in recovery and their families, Dr. Brown says.
In 2014, Dr. Brown at Northern Light Eastern Maine Medical Center and Dr. Adrienne Carmack at Penobscot Community Health Care partnered to launch an outpatient Collaborative Home Alternative Medication Program (CHAMP). CHAMP guides mothers, babies, and families through the process of weaning babies safely off opiate replacement medication at home and has served nearly 100 patients over the past five years.
The landscape in Maine for babies experiencing NAS has improved dramatically over the last 13 years “There’s a state-wide effort now to care for babies with NAS,” he says. “I’m very encouraged.”
Photo: Mark S Brown, MD MSPH Northern Light Eastern Maine Medical Center
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