Another Friday Visit to the Pediatric Ward: Newborn Abstinence Syndrome

I love Fridays they are the reward for the work I do earlier in the week. Fridays are my operating room day, and any surgeon will tell you that this is home where I practice my craft, where I am most relaxed, and where I am immersed in a culture in which I flourish.

Now, it may seem paradoxical how can he be relaxed when he is operating on someone? but the reality is that I love performing surgery so much that vocation and passion meld into one beautiful art form. Speaking more broadly, I love being in the hospital on Friday. Between surgeries, I am speaking with my patients, sharing information with colleagues, and entertaining the staff with my crazy antics and observational humor. One of favorite moments on Fridays is an end of the day trip to the Pediatrics ward sometimes to see a patient in consultation, sometimes to check on a post-op patient, and other times just to visit.

The Usual Challenge in the Pediatric Ward: Opiate Withdrawal

On a recent Friday, the visit was a typical one. After seeing one of my own patients, I went out to the nurses station and ask my usual question: Are there any babies?

One of the nurses was feeding a baby girl, so she showed her to me. Shes beautiful! Do you want to hold her? the nurse asked. I hesitated at first; in spite of the fact that, earlier in the week, I had cut a tongue-tie in a one-day-old boy to allow him to breast feed, the reality is that I am always intimated by the sheer frailty of a newborn (even my own kids). But I acquiesced, and carefully took the baby from her. Yes, shes beautiful. The baby was swaddled in a blanket and slept calmly in my arms, unaware of the transfer from the nurse to me. Then I look at the nurse and asked, How old is she?

Thirteen days.

I assume shes here for the usual.

Yup. Do you want to take her home?

Her comment was mostly in jest, but the fact is that some of the babies do go to foster care. I know of at least one instance in which one of the nurses adopted an NAS child she had cared for in the hospital. For a brief moment, I want to say yes, but I know that, at my age, the energy necessary and the vast undertaking involved with such an adoption would be very difficult for my wife and me. I reluctantly say no, and then hand the child back for her feeding.

You see, the usual to which I referred above is Newborn Abstinence Syndrome (NAS), or quite simply, opiate addiction. This thirteen-day-old was born to a mother addicted to opiates, and the child is here withdrawing. These are the tiniest victims of the opiate epidemic in the United States. (Opiates are natural derivatives of opium; opioids are synthetic, but the terms are often used interchangeably.) We usually have a few such infants on our pediatric floor at any given time in a community hospital of about 300 beds, with a pediatric unit of about 21 rooms.

We are in an urban community, but I still feel the numbers represent the growing trend throughout the country, not just in urban settings.

The Partnership for a Drug-Free America had a PSA in the 1980s that had a child saying, When I grow up, I wanna be a track star, after which an adult says, No one ever says, I want to be a junkie when I grow up. That PSA has always stuck in my head.

The Opioid Epidemic

What we often hear in personal stories about addiction is a slippery slope of drug use that leads to addiction. There are certainly those of us who have an addictive trait or addictive personality. That addiction can be drugs, alcohol, sex, food, or spending. Alcoholism and other drug addiction tend to run in families. Children of addicted parents are more at risk for alcoholism and other drug abuse than are other children, according to the National Association for Children of Alcoholics .1 Added to that now is the easy access to prescription opiate and opioid pain relievers. Providers are caught in a tug-of-war between fear of under-prescribing for the treatment of pain and fear of over-prescribing with the potential for abuse.

Take a look at the numbers. The U.S. Department of Health and Human Services provided a fact sheet update on June 2016 that notes the following:

On an average day in the U.S.:

• More than 650,000 opioid prescriptions dispensed
• 3,900 people initiate nonmedical use of prescription opioids
• 580 people initiate heroin use
• 78 people die from an opioid-related overdose (prescription and illicit drugs)

Lets also consider my thirteen-day-old friend. Based on the National Institute on Drug Abuse data for Neonatal Abstinence Syndrome (NAS):

• Every 25 minutes, a baby is born suffering from opioid withdrawal.
• The rate of babies born with NAS per 1,000 hospital births was 1.2 in 2000, 1.5 in 2003, 1.96 in 2006, 3.39 in 2009 and 5.8 in 2012.
• The rate of maternal opiate use per 1,000 hospital births was 1.19 in 2000, 1.26 in 2003, 2.52 in 2006, and 5.63 in 2009.
• In 2012, newborns with NAS stayed in the hospital an average of 16.9 days (compared to 2.1. days for other newborns)
• NAS led to hospital costs estimated at $1.5 billion in 2012. The majority of these charges (81%) were paid by state Medicaid programs, reflecting the greater tendency of opiate-abusing mothers to be from lower-income communities.

These numbers support the fact that we are in the midst of an opioid epidemic. The response has to be on multiple fronts.

We need to work with providers to address prescribing practices. We need to educate patients regarding pain management expectations, both with acute pain (such as postsurgical) and chronic pain (due to neuropathy, cancer, orthopedic disabilities, etc.). Alternatives to opioids need to be considered. Prescription monitoring programs must be utilized efficaciously. Naloxone needs to be readily available for first responders. The CDC has provided recommendations with respect to prescribing pain medications with respect to pregnancy2.

Medical societies, providers, government agencies, patient advocacy groups, and many others are actively engaged in attacking this epidemic utilizing these responses. These efforts are already paying dividends with Prescription Drug Monitoring Programs already resulting in a decrease in opioid overdose deaths . There is widespread recognition of the exponential rise in opioid use and the need for rapid action.

Outreach to addicted expectant mothers continues to be a problem. A concern among providers has been the covert use of opioids during pregnancy due to the expectant mothers fear of criminal charges. If prenatal opioid use occurs and the providers are unaware, a newborn may be born with undetected NAS. Since symptoms often occur 48 hours after delivery, the child may already be discharged from the hospital. This has been seen to result in failure to thrive and emergency room visits for seizures.

Hope for (NAS) Newborn Abstinence Syndrome

Ohios Childrens Hospital Neonatal Research Consortium addressed this issue by creating a treatment protocol for NAS that includes an emphasis on early detection. In 2013, hospitals in the Cincinnati area began universal drug testing on expectant mothers. Since Ohio law does not require notification of law enforcement if a maternal test is positive, unless there is suspicion of criminal behavior affecting the safety of the newborn, there has been increased compliance with prenatal drug testing. Dr. Scott Wexelblatt, a pediatrician at Cincinnatis Childrens Hospital, noted , "Prior to this program, one of four women using opioids went undetected. Today we are detecting nearly all."

We have seen many epidemics even in the last few decades AIDS, Ebola, and Zika, for example and we have shown great resolve in fighting these. My hope is that such resolve will lead to the successful defeat of the Opioid Epidemic. It's the same hope I feel when I hold my little thirteen-day-old friend.

My book, Do the Right Thing: A Surgeons Approach To Life is now available on Amazon ! Read an excerpt here .

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1 Kumpfer, K.L. (1999). Outcome measures of interventions in the study of children of substance-abusing parents. Pediatrics. Supplement. 103 (5): 1128-1144.

2 Ko JY, Patrick SW, Tong VT, Patel R, Lind JN, Barfield WD. Incidence of Neonatal Abstinence Syndrome 28 States, 1999-2013, MMWR Morb Mortal Wkly Rep 2016;65:799-802.

photo courtesy of pixabay

My book, Do the Right Thing: A Surgeons Approach To Life is now available on Amazon! Read an excerpt here .

You can also connect with me on Twitter , Facebook , G+ , Pinterest ,LinkedIn , and Goodreads .