Doctors will tell you it's normal for a newborn to cry. But when the tears are accompanied by shaking, shudders - even seizures - a mother might have passed on to her child something other than DNA: a drug addiction.
As prescription drug and heroin abuse rises in New Hampshire, doctors are facing a side effect of this trend: babies born addicted to opioids - drugs used to control pain, a condition known as Neonatal Abstinence Syndrome (NAS).
The state's reported incidents of addicted babies rose 600 percent in six years, from 2003 to 2009, according to Dr. William H. Edwards.
"It really is an epidemic," said Edwards, section chief of neonatology at the Children's Hospital at Dartmouth-Hitchcock (CHaD) in Lebanon. "It's an astounding problem, and it needs to be recognized."
"The numbers are truly alarming," said Patricia Tilley, chief of the state's Bureau of Population Health and Community Services.
Edwards said NAS is growing steadily in New Hampshire, and the high cost of treating babies for drug addictions puts a toll on the state's medical system.
"Our experience at Dartmouth-Hitchcock mirrors what we're seeing at the state level," said Edwards. "I think we've seen a real acceleration on issues related to substance abuse in general and opioid use in particular."
In 2009, NAS was diagnosed in 116 New Hampshire infants, more than five times as many as in 2000, according to a report released last fall by the New Hampshire Bureau of Drug and Alcohol Services and the New Hampshire Charitable Foundation.
In 2000, NAS was diagnosed in 22 infants. In 2006, the number jumped to 72 infants, and in 2008, it increased to 101.
A national problem
In 2011-12, 5.9 percent of pregnant women ages 15 to 44 in the United States said they were using illicit drugs, slightly up from 4.4 percent in 2009-10, according to the report.
Between 2000 and 2009, the number of NAS hospital births nearly tripled nationally, from 1.20 per 1,000 births to 3.39 per 1,000 births (about 4 million).
The rise in addicted mothers and babies coincides with rising incidents of prescription drug abuse and heroin use.
A 2010 national survey by the federal Substance Abuse and Mental Health Administration showed illicit drug use at 16.2 percent among pregnant teenagers and 7.4 percent among pregnant women ages 18 to 25.
Treating addicted babies
Babies who were exposed to drugs in utero can experience fever, diarrhea, seizures and problems sleeping, eating and gaining weight. The exact symptoms depend on the drug to which the baby was exposed.
For babies born into addiction, treatment options vary depending on the intensity of the infant's withdrawal symptoms. Babies with mild symptoms are typically sent home, said Edwards, while babies with severe withdrawal problems are cared for in neonatal intensive care units.
Four hospitals in New Hampshire treat newborns with withdrawal symptoms: Dartmouth-Hitchcock Medical Center in Lebanon, Elliot Hospital and Catholic Medical Center in Manchester, and Southern New Hampshire Medical Center in Nashua.
At Dartmouth-Hitchcock, Edwards said, addicted babies are treated in two areas of the hospital. Infants with mild withdrawal symptoms are placed in the hospital's pediatric patient ward, where they receive an ancient but effective treatment: being held by mothers and family members.
"Sometimes, the comfort that skin-to-skin contact can create is enough," said Edwards.
Dr. Bonny Whalen, newborn nursery medical director at CHaD, who works with Edwards on NAS, has been doing prenatal visits with women at the River Mill Addiction Treatment Program in Lebanon. "We've talked about comfort measures for babies, such as rooming-in, skin-to-skin, gentle rocking/swaying, swaddling and providing calm environments."
Babies with more severe addictions are treated in DHMC's neonatal intensive care unit, where they are given doses of liquid morphine.
"With morphine, babies are weaned off in the hospital, and then they can go home not requiring additional medication," said Edwards.
According to Edwards, the average hospital stay for infants receiving addiction treatment at Dartmouth-Hitchcock is two weeks, but some remain in the hospital for four weeks.
In a normal birth, mother and baby typically head home after a few days.
The financial toll
In addition to the health consequences, another issue associated with NAS is the often expensive medical bills racked up during a baby's withdrawal treatment.
Most of the hospital bills pertaining to these babies are paid by Medicaid.
According to a national study by the American Hospital Association, state Medicaid programs paid the hospital bills for about 78 percent of addicted newborns.
From 2008 to 2009, New Hampshire charged Medicaid $2 million to care for babies addicted to drugs.
The study also found the national cost of health care for these babies has nearly quadrupled from 2000 to 2009, rising from $190 million to $720 million, and that average hospital costs for NAS babies rose from $39,400 to $53,400 during that time.
"It's just a huge cost," Edwards said. "We've found that the majority of the increase in NAS, in New Hampshire and elsewhere, is in Medicaid populations, a marker of socioeconomic issues. It's not simply a medical problem, it's a societal problem."
Governor's task force
New Hampshire is taking steps to address NAS. A governor's task force called the Prenatal Substance Exposure Task Force was created in August to examine issues related to it. Edwards serves on the task force, which will submit a report to Gov. Maggie Hassan.
Edwards said the task force has focused on developing statewide procedures for hospitals to respond to NAS. He said the group has been busy addressing many issues, including creating more transparency between treatment programs and hospitals.
Legislators in some states have introduced bills allowing for drug-addicted mothers who deliver addicted babies to be prosecuted for assault or homicide.
Edwards said he didn't think New Hampshire officials would look to establish criminal penalties, opting instead to focus on the baby's health.
Ultimately, Edwards said, the answer is not treatment programs, but prevention, understanding what leads to addiction and how to avoid it.
"Over half of the women start off by taking drugs that are prescribed for legitimate medical issues yet continue to take it beyond needing it," said Edwards.
Fortunately, he says, most of the babies seen at CHaD are born to mothers enrolled in programs to treat their addiction. "The vast majority of these babies are withdrawing from methadone or suboxone or buprenorphine - drugs used to treat opioid addiction," said Edwards. "But there are other drugs that babies suffer withdrawal from, like street heroin, or nonprescribed prescription drugs like Vicodin or Percocet.
"We need to understand what is leading to this escalation not only in NAS, but in opioid abuse and addiction," said Edwards. "Getting involved in this has certainly opened my eyes to the broader scope. The cost of this epidemic is quite expensive, both in terms of dollars and human tragedy."