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As the time came near to have her baby, Rebecca Dowds was terrified the newborn would be snatched away by child welfare authorities.
Dowds was dependent on prescription opioids.
It was October 2015, but since 2013, she had been taking Percocet, a narcotic pain reliever containing a combination of oxycodone and acetaminophen, to treat spinal pain and sciatica. With the help of her obstetrician, she had weaned herself from six to three pills a day. “I got stuck at the three-pill point,” she says.
Newborns born to mothers who are dependent on opioids may go through withdrawal almost as soon as they are born. While the mother is carrying the baby, opioids pass through the placenta from mother to baby, leaving the baby dependent. At birth, opioids are no longer passing from the mother to the child, and withdrawal symptoms appear as the drugs are clearing from the baby’s system.
How to treat these babies — and their mothers — is of increasing concern for hospitals. More than 1,800 newborns were born with “neonatal abstinence syndrome” in 2016-17, a 27 per cent increase compared to five years earlier, according to the Canadian Institute for Health Information. That’s about one in every 200 babies born in Canada.
When Dowds was pregnant, she feared her own efforts to stop using opioids would be judged and found wanting by those in the health care system.
That fear was well founded. Until recently, many hospitals have separated mothers who used opioids from their newborns at birth, placing the babies in the neonatal intensive care unit where they could received around-the-clock care.
But a growing pile of evidence suggests that keeping mothers and babies together is better for both. It reduces NICU admissions, shortens hospital stays and reduces the need to prescribe drugs for babies going through withdrawal. Rooming-in even reduces the involvement of child welfare authorities.
And it gives mothers an opportunity to change their lives.
“Moms and dads are receptive to conversations. It can be life-changing. I have seen it. Now you are seeing a third party affected. It stimulates a lot of thought,” says Dr. Pradeep Merchant, site chief of neonatology at The Ottawa Hospital’s Civic Campus, where there are about 60 admissions of opioid-dependent mothers every year.
Learning she was pregnant was life-changing to Dowds.
“There was no one I needed to be accountable for. So I probably wouldn’t have changed for awhile.”
The Canadian Paediatric Society has recognized the importance of allowing mother and baby to remain together. “Weeks of separation can be harmful to early bonding and attachment, and risks making a bad situation worse for both mothers and their babies,”says Dr. Thierry Lacaze, chair of the society’s fetus and newborn committee, which released new guidelines in January, including endorsing rooming-in.
“These babies are very challenging. They need a lot of attention. They need skin-to-skin care. You need leadership to create a multi-disciplinary program,” he says. “The effect of being cuddled on the skin is very impressive. We tend to believe that we have to give drugs or medical procedures. But just cuddling has a huge impact. The effect is remarkable.”
Pregnancy can be a significant motivator for mothers who use opioids, says Lacaze. “They express a feeling of guilt and responsibility. They are asking to minimize the risks for their babies. If they come on illicit drugs, they are asking for a substitution. Many on prescription drugs ask a lot of questions and they’re being compliant.”
“Separating the mom and the baby is a disaster. It just continues the guilt and stigmatization.”
Rooming-in felt like behind at home with a very large family, says Dowds. Her daughter Sephira’s only withdrawal symptoms was sneezing, a common symptom of NAS. Most importantly, none of the staff made her feel like she was being judged, she says.
“Every move you make, you feel it. You feel smaller, less competent. Not feeling judged allows you to open up.”
Women who are pregnant are motivated to make positive changes and get healthy,” says Dr. Adam Newman, an attending physician at the Kingston General Hospital.
“If they don’t get proper treatment, they will keep on using drugs. When we routinely snatch babies away and put them in the NICU — even if we do it compassionately — we are physically separating them from their babies. They sense they are being judged. They feel amplified shame.”
Rooming-in allows bonding between mother and child, Newman says.
“It allows normal development. These mothers have real maternal feelings,” he says. “Women who do rooming-in get attention and positive feedback. They have the luxury of a safe and protected time together.”
Dowds had started using Percocet to treat back pain while she was working at a desk job for a landscaping company in Newmarket. She went to a pain specialist who slowly raised her dose of Percocet to six tablets a day. “I had a sit-down job at a desk and it was really hard to get through a day. At the time, it was a necessary evil. He just kept on prescribing the stuff.”
She moved to Kingston from Newmarket while she was pregnant because she has family nearby and was looking for more affordable housing and a fresh start. “I just wanted to start over. I just wanted better for her,” she says. “I wanted to make it as close to normal and perfect as could be.”
But Dowds had a hard time finding pain specialist in Kingston. She contemplated tapering off the Percocet with a substitute such as methadone or Suboxone, but knew other people who had difficulties transitioning. She switched to Suboxone a few months after Sephira’s birth, and lowered the dose last summer.
Dr. Kimberly Dow, a neonatologist at Kingston General Hospital, says opioid-dependent mothers are a misunderstood group.
“They have turned their lives around. It’s very emotional to talk to them. It’s a very good feeling. They’re marginalized. They’re poor. They’re struggling socially and educationally. They don’t have a lot of the resources that other people have.”
A study by researchers at the Kingston General Hospital and Queen’s University has compared outcomes for infants with NAS before and after rooming-in was introduced. The results were significant — before rooming-in 20 out of the 24 babies needed pharmacologic treatment for NAS. After rooming in, it was only three out of 20 babies.
But the number of days spent in hospital was the most startling figure. Before rooming in, the median length of stay was 24 days. After rooming in it was only five days.
There are also economic benefits to the health-care system, Newman points out. “There are savings of hundreds of thousands of dollars at the Kingston General Hospital alone. Babies stay for a shorter period of time, and they stay in a less expensive place.”
Since birth, Dowds’ little girl, Sephira, has been with Better Beginnings, a program aimed at preventing children from low-income, high-risk circumstances from having poor developmental outcomes. Thanks to this program, and the Rooming-in program, Sephira is healthy and happy says her mother.
“She has three-, four-word sentences. She has huge words for her age. Like upside-down, or dinosaur, dragon. She knows all of her colours and some shapes.”
Dowds’ back pain is a chronic condition and she would like to try physiotherapy, but can’t afford it. She recently took a job working the night shift at Tim Hortons.
“It’s not going to be quick. There’s nothing specific they can do to fix it,” she says.
Newman says opioids have been used by pregnant women for hundreds of years, and there is no evidence of birth defects or neurological defects, although there may be a genetic susceptibility to addiction.
“I follow a few women. Their children looked like well-developed little kids.”
At a glance
What is neonatal abstinence syndrome? Known as NAS, it is a constellation of issues in newborns born to mothers exposed to opioids in pregnancy.
What are the symptoms of NAS? They include trembling, crying, tight muscle tone, seizures, yawning, stuffy nose and sneezing. Symptoms may take a few days to appear. Other effects, such as irritability, sleep disorders and feeding problems can last for four to six months. The intensity of withdrawal symptoms varies, depending on the type of opioid used, the frequency, dose and timing of last exposure, and the mother’s metabolism and use of other substances. “Some people will say these babies are born addicted. That’s a fallacy. They’re physically dependent,” says neonatologist Dr. Kimberly Dow.
What kind of opioids have these babies been exposed to? There are three types of possible exposure: illicit opioids, such as heroin (or synthetic drugs such as fentanyl); prescription opioids, such as oxycodone and, third, replacement opioids such as methadone.
What are the Canadian Paediatric Society recommendations for NAS? Keeping mothers and babies together is essential to both in the long and the short term, says the society in a guidance document. The society also recommends that newborns exposed to opioids be observed for at least 72 hours after delivery and assessed to determine whether additional monitoring and medication are needed. Breastfeeding should be encouraged because it can delay the onset and decrease the severity of withdrawal symptoms, as well as decrease the need for pharmacological treatment. Once newborns are ready for discharge from hospital, a well-coordinated plan involving a team of health-care professionals is essential to ensure that once they are home, the babies continue to sleep and eat well, gain weight and adapt to their environment, says the CPS. This includes community resources to support keeping infants and their mothers together long after they leave hospital.
What is the long-term prognosis for these babies? Good, it appears, although there have been few studies on long-term outcomes. Early in childhood, NAS babies may display minor learning difficulties, slower speech acquisition or behavioral issues. They also tend to have sleep disturbance for the first one to three months of life. However, there have been no reports of health or major neurodevelopmental issues. “The question is whether it is a response to the drug, or one of a myriad of social issues. We certainly believe that providing intensive supports and keeping mother and baby together helps to mitigate the effects. But we don’t have proof,” says pediatrician Dr. Thierry Lacaze. “When we send these babies home, they don’t have health issues. It’s a transient problem, most of the time.”
By the numbers
1,846: Babies born with neonatal abstinence syndrome in Canada in 2016-17, according to data the Canadian Institute for Health Information. This number does not include Quebec, and it is believed to be an underestimation of the actual number
988: Born in Ontario
27% – Canada-wide increase in NAS births between 2016-17 and 2012-2013
50 to 75%: Proportion of infants born to mothers who use opioids who need treatment for withdrawal symptoms
60: NAS admissions at The Ottawa Hospital in the past year, approximately
15 or fewer: Admissions in 2012
$190M: How much, in U.S. dollars, American hospitals spent in NAS expenditures in 2000, according to research reported in the Journal of the American Medical Association
$720M: How much was spent in 2012, in inflation-adjusted U.S. dollars
jlaucius@postmedia.com
查看原文...
Dowds was dependent on prescription opioids.
It was October 2015, but since 2013, she had been taking Percocet, a narcotic pain reliever containing a combination of oxycodone and acetaminophen, to treat spinal pain and sciatica. With the help of her obstetrician, she had weaned herself from six to three pills a day. “I got stuck at the three-pill point,” she says.
Newborns born to mothers who are dependent on opioids may go through withdrawal almost as soon as they are born. While the mother is carrying the baby, opioids pass through the placenta from mother to baby, leaving the baby dependent. At birth, opioids are no longer passing from the mother to the child, and withdrawal symptoms appear as the drugs are clearing from the baby’s system.
What does an opioid-dependent baby look like? Here’s neurologist Dr. Kimberly Dow:
How to treat these babies — and their mothers — is of increasing concern for hospitals. More than 1,800 newborns were born with “neonatal abstinence syndrome” in 2016-17, a 27 per cent increase compared to five years earlier, according to the Canadian Institute for Health Information. That’s about one in every 200 babies born in Canada.
When Dowds was pregnant, she feared her own efforts to stop using opioids would be judged and found wanting by those in the health care system.
Meet Rebecca Dowds:
That fear was well founded. Until recently, many hospitals have separated mothers who used opioids from their newborns at birth, placing the babies in the neonatal intensive care unit where they could received around-the-clock care.
But a growing pile of evidence suggests that keeping mothers and babies together is better for both. It reduces NICU admissions, shortens hospital stays and reduces the need to prescribe drugs for babies going through withdrawal. Rooming-in even reduces the involvement of child welfare authorities.
And it gives mothers an opportunity to change their lives.
“Moms and dads are receptive to conversations. It can be life-changing. I have seen it. Now you are seeing a third party affected. It stimulates a lot of thought,” says Dr. Pradeep Merchant, site chief of neonatology at The Ottawa Hospital’s Civic Campus, where there are about 60 admissions of opioid-dependent mothers every year.
Learning she was pregnant was life-changing to Dowds.
“There was no one I needed to be accountable for. So I probably wouldn’t have changed for awhile.”
The Canadian Paediatric Society has recognized the importance of allowing mother and baby to remain together. “Weeks of separation can be harmful to early bonding and attachment, and risks making a bad situation worse for both mothers and their babies,”says Dr. Thierry Lacaze, chair of the society’s fetus and newborn committee, which released new guidelines in January, including endorsing rooming-in.
“These babies are very challenging. They need a lot of attention. They need skin-to-skin care. You need leadership to create a multi-disciplinary program,” he says. “The effect of being cuddled on the skin is very impressive. We tend to believe that we have to give drugs or medical procedures. But just cuddling has a huge impact. The effect is remarkable.”
Pregnancy can be a significant motivator for mothers who use opioids, says Lacaze. “They express a feeling of guilt and responsibility. They are asking to minimize the risks for their babies. If they come on illicit drugs, they are asking for a substitution. Many on prescription drugs ask a lot of questions and they’re being compliant.”
“Separating the mom and the baby is a disaster. It just continues the guilt and stigmatization.”
What was rooming-in like for Rebecca Dowds?
Rooming-in felt like behind at home with a very large family, says Dowds. Her daughter Sephira’s only withdrawal symptoms was sneezing, a common symptom of NAS. Most importantly, none of the staff made her feel like she was being judged, she says.
“Every move you make, you feel it. You feel smaller, less competent. Not feeling judged allows you to open up.”
Women who are pregnant are motivated to make positive changes and get healthy,” says Dr. Adam Newman, an attending physician at the Kingston General Hospital.
“If they don’t get proper treatment, they will keep on using drugs. When we routinely snatch babies away and put them in the NICU — even if we do it compassionately — we are physically separating them from their babies. They sense they are being judged. They feel amplified shame.”
Rooming-in allows bonding between mother and child, Newman says.
“It allows normal development. These mothers have real maternal feelings,” he says. “Women who do rooming-in get attention and positive feedback. They have the luxury of a safe and protected time together.”
Dowds had started using Percocet to treat back pain while she was working at a desk job for a landscaping company in Newmarket. She went to a pain specialist who slowly raised her dose of Percocet to six tablets a day. “I had a sit-down job at a desk and it was really hard to get through a day. At the time, it was a necessary evil. He just kept on prescribing the stuff.”
She moved to Kingston from Newmarket while she was pregnant because she has family nearby and was looking for more affordable housing and a fresh start. “I just wanted to start over. I just wanted better for her,” she says. “I wanted to make it as close to normal and perfect as could be.”
But Dowds had a hard time finding pain specialist in Kingston. She contemplated tapering off the Percocet with a substitute such as methadone or Suboxone, but knew other people who had difficulties transitioning. She switched to Suboxone a few months after Sephira’s birth, and lowered the dose last summer.
Dr. Kimberly Dow, a neonatologist at Kingston General Hospital, says opioid-dependent mothers are a misunderstood group.
Why are doctors like Dow so passionate about helping women addicted to opioids?
“They have turned their lives around. It’s very emotional to talk to them. It’s a very good feeling. They’re marginalized. They’re poor. They’re struggling socially and educationally. They don’t have a lot of the resources that other people have.”
A study by researchers at the Kingston General Hospital and Queen’s University has compared outcomes for infants with NAS before and after rooming-in was introduced. The results were significant — before rooming-in 20 out of the 24 babies needed pharmacologic treatment for NAS. After rooming in, it was only three out of 20 babies.
But the number of days spent in hospital was the most startling figure. Before rooming in, the median length of stay was 24 days. After rooming in it was only five days.
There are also economic benefits to the health-care system, Newman points out. “There are savings of hundreds of thousands of dollars at the Kingston General Hospital alone. Babies stay for a shorter period of time, and they stay in a less expensive place.”
Since birth, Dowds’ little girl, Sephira, has been with Better Beginnings, a program aimed at preventing children from low-income, high-risk circumstances from having poor developmental outcomes. Thanks to this program, and the Rooming-in program, Sephira is healthy and happy says her mother.
Is the rooming-in program successful?
“She has three-, four-word sentences. She has huge words for her age. Like upside-down, or dinosaur, dragon. She knows all of her colours and some shapes.”
Dowds’ back pain is a chronic condition and she would like to try physiotherapy, but can’t afford it. She recently took a job working the night shift at Tim Hortons.
“It’s not going to be quick. There’s nothing specific they can do to fix it,” she says.
Newman says opioids have been used by pregnant women for hundreds of years, and there is no evidence of birth defects or neurological defects, although there may be a genetic susceptibility to addiction.
“I follow a few women. Their children looked like well-developed little kids.”
At a glance
What is neonatal abstinence syndrome? Known as NAS, it is a constellation of issues in newborns born to mothers exposed to opioids in pregnancy.
What are the symptoms of NAS? They include trembling, crying, tight muscle tone, seizures, yawning, stuffy nose and sneezing. Symptoms may take a few days to appear. Other effects, such as irritability, sleep disorders and feeding problems can last for four to six months. The intensity of withdrawal symptoms varies, depending on the type of opioid used, the frequency, dose and timing of last exposure, and the mother’s metabolism and use of other substances. “Some people will say these babies are born addicted. That’s a fallacy. They’re physically dependent,” says neonatologist Dr. Kimberly Dow.
What kind of opioids have these babies been exposed to? There are three types of possible exposure: illicit opioids, such as heroin (or synthetic drugs such as fentanyl); prescription opioids, such as oxycodone and, third, replacement opioids such as methadone.
What are the Canadian Paediatric Society recommendations for NAS? Keeping mothers and babies together is essential to both in the long and the short term, says the society in a guidance document. The society also recommends that newborns exposed to opioids be observed for at least 72 hours after delivery and assessed to determine whether additional monitoring and medication are needed. Breastfeeding should be encouraged because it can delay the onset and decrease the severity of withdrawal symptoms, as well as decrease the need for pharmacological treatment. Once newborns are ready for discharge from hospital, a well-coordinated plan involving a team of health-care professionals is essential to ensure that once they are home, the babies continue to sleep and eat well, gain weight and adapt to their environment, says the CPS. This includes community resources to support keeping infants and their mothers together long after they leave hospital.
What is the long-term prognosis for these babies? Good, it appears, although there have been few studies on long-term outcomes. Early in childhood, NAS babies may display minor learning difficulties, slower speech acquisition or behavioral issues. They also tend to have sleep disturbance for the first one to three months of life. However, there have been no reports of health or major neurodevelopmental issues. “The question is whether it is a response to the drug, or one of a myriad of social issues. We certainly believe that providing intensive supports and keeping mother and baby together helps to mitigate the effects. But we don’t have proof,” says pediatrician Dr. Thierry Lacaze. “When we send these babies home, they don’t have health issues. It’s a transient problem, most of the time.”
By the numbers
1,846: Babies born with neonatal abstinence syndrome in Canada in 2016-17, according to data the Canadian Institute for Health Information. This number does not include Quebec, and it is believed to be an underestimation of the actual number
988: Born in Ontario
27% – Canada-wide increase in NAS births between 2016-17 and 2012-2013
50 to 75%: Proportion of infants born to mothers who use opioids who need treatment for withdrawal symptoms
60: NAS admissions at The Ottawa Hospital in the past year, approximately
15 or fewer: Admissions in 2012
$190M: How much, in U.S. dollars, American hospitals spent in NAS expenditures in 2000, according to research reported in the Journal of the American Medical Association
$720M: How much was spent in 2012, in inflation-adjusted U.S. dollars
jlaucius@postmedia.com
查看原文...
