Dartmouth study offers hope for babies exposed to drugs in womb
By SHAWNE K. WICKHAM New Hampshire Sunday News
ALISON VOLPE HOLMES
LEBANON — One in 10 babies born at Dartmouth-Hitchcock Medical Center last year had been exposed to drugs in their mothers’ wombs.
These are the littlest victims of the state’s opioid addiction crisis.
Their mothers depend on maintenance medications, such as buprenorphine, during pregnancy to prevent withdrawal symptoms that can be dangerous to a fetus.
So the babies often are born with withdrawal symptoms themselves, and have to be treated with morphine and other medications to ease their pain and other symptoms.
Now a new study out of Dartmouth offers hope that many of these babies can be treated without drugs.
Dr. Alison Volpe Holmes is associate professor of pediatrics at Geisel School of Medicine and an attending pediatrician at Children’s Hospital at Dartmouth-Hitchcock.
She is the lead author of a three-year study, just published in the journal Pediatrics, that found that having babies with neonatal abstinence syndrome (NAS) stay with their mothers instead of in neonatal intensive care units reduced use of medications, hospital stays and costs.
Rooming-in, she said, teaches parents to learn their babies’ cues. “So the parents are really the main treatment for the babies instead of medication being the main treatment,” Holmes said.
Holmes became interested in improving care of these babies as she saw the numbers rising. In 2015, 10 percent of the approximately 1,400 babies born at DHMC were drug-exposed, she said.
And about half of those babies will have “significant” withdrawal symptoms, she said.
Statewide, Holmes said the rate of drug-exposed newborns is about 6 percent, but she said that data lags a few years and she expects it will rise as well.
Before the study, Holmes said, babies typically would stay with their mothers unless they developed symptoms of NAS. If they did, babies would be transferred to the neonatal intensive care unit.
“But the babies would be transferred based on symptoms and not necessarily what was good for the holistic care of the family,” she said.
Perusing the literature on caring for these infants, Holmes found wide variations in lengths of stay. One thing stood out: “If the babies stayed with their mothers and families, that fairly consistently decreased the need for medication and length of stay,” she said.
The goal of her study, she said, was “to try to get all the babies to what we call a rooming-in model, where they stay with their mothers and families.”
The team started working with moms and other family members even before the babies were born, educating them about what to expect. They connected families with the DHMC Perinatal Addiction Treatment Program, which provides mental health services as part of pre-natal care.
And once the babies were born, Holmes said, “We focused on a calm, stark environment with limited handling.”
The team encouraged lots of skin-to-skin contact with moms and dads. “We know that calms down babies, lowers their heart rate, lowers their breathing rate,” she explained.
They encouraged on-demand feeding, swaddling and white noise.
When a baby did show symptoms of NAS, the team first increased “environmental” measures, such as minimizing visitors, turning off the TV and lights, and feeding. “If those things didn’t work, we would of course use medication.”
The American Academy of Pediatrics recommends that such measures should be the first and primary mode of care for NAS babies, Holmes said. “It’s just that not too many people before this really tried this systematically, to maximize the environmental measures of care.”
The results were startling. At the start of the three-year study, 46 percent of infants born at risk for NAS at DHMC were treated with morphine. By 2015, that had decreased to 27 percent.
Use of another drug, phenobarbital, also decreased during the same period, from 13 to 2 percent.
The length of stay also dropped, from about 17 days to 12 days; average hospital costs per treated infant decreased from $19,737 to $8,755; and the costs per at-risk infant dropped from $11,000 to $5,300.
The study’s authors reported no adverse events.
Holmes said she hopes the program will be replicated at other hospitals in New Hampshire and elsewhere.
DHMC is part of a regional collaborative as well as a national network of neonatologists and neonatal ICUs working to improve medical care for these families, Holmes said.
All drug-exposed babies at Dartmouth-Hitchcock are kept in the hospital for four days for monitoring. And Holmes said, “They have to look absolutely perfect to go home on day four.”
“If they do anything even a little bit off, we wait longer.”