The Innocent Victims

By Carla Saunders, NNP-BC
Advance Practice Coordinator, Pediatrix Medical Group
East Tennesse Children’s Hospital

To many reading this it is no surprise that the prescription drug abuse problem in our country has reached epidemic proportions. What may surprise many is how this raging epidemic is affecting our most innocent of citizens, newborns.

The Journal of American Medical Association recently released a study revealing maternal opioid use increased five fold and the incidence of newborns experiencing Neonatal Abstinence Syndrome (NAS) tripled from 2000-2009. They estimate that “in 2009 there was approximately one infant born per hour in the U.S. with signs of drug withdrawal.”

According to the American Academy of Pediatrics (AAP), 55 percent to 94 percent of neonates exposed to opioids in utero experience withdrawal or NAS. This means that for these precious babies their first experience in this world will be one of significant suffering. Their first days, weeks, or even months will be wrought with uncontrollable tremors, inconsolable crying, stomach cramps, vomiting, diarrhea, blistered and bleeding bottoms, fevers, sweating, rapid breathing, uncoordinated and ineffective sucking, poor feeding, and tight muscles. The very act of comforting these newborns can cause them discomfort over stimulation which can further exacerbate their symptoms.

A 2009 National Survey on Drug Use and Health revealed 4.5 percent of pregnant women aged 15 to 44 used illicit drugs in the past month. According to the 2009 CDC Key Birth Statistics there were 4,130,665 births in U.S. This translates to approximately 186,000 babies born to mothers who used illicit drugs in past month. The AAP recognizes that “reported rates of illicit drug use … underestimate true rates.”

At East Tennessee Children’s Hospital (ETCH) we have felt this epidemic. ETCH is a 152 bed, free standing, not-for-profit Children’s Hospital with a 60-bed Level III Neonatal Intensive Care Unit (NICU). We are a regional referral center for 16 surrounding counties with an average of 700 NICU admissions annually. Over the past three years the number of admissions for NAS has more than tripled, from 45 in 2009 to 135 in 2011, with a projected 285 for 2012. The average daily census of NAS patients in our NICU for the first quarter of 2011 was eight; by first quarter of 2012 it was 26. Now it is holding steady at 29. Nearly 30 percent of our admissions are now for NAS averaging nearly one admission per day.

In response to the rise in numbers we formed a multi-disciplinary task force to develop a standardized treatment protocol. Oral morphine is used to treat physical withdrawal symptoms along with Tylenol for fevers and discomfort. A holistic approach is used with special attention to non-pharmacologic interventions including diet, environment and physical comfort measures to decrease the amount of opiate needed to treat symptoms.

Since November 2010 we have treated nearly 400 babies for NAS. The overall average length of stay (LOS) is 37 days with a range from 7-155 days. Approximately 85 percent of the babies have an average LOS of 30 days while 15 percent are very difficult to wean and may require up to three medications to control their symptoms; this group has an average LOS of 81 days. We hypothesize that this later group may be consistent with a genetic predisposition to addictive behavior.

What we don’t know are the long-term side effects. The effect of exposure to opiates on the developing brain and DNA is unknown. We do know the NAS baby is at increased risk for behavior disorders, sleep disorders and impulse control issues. As adolescents and adults they will be at increased risk for addiction.

The importance of this problem on our future as a society cannot be underestimated. The immediate cost with an average of $40,000 per NAS infant hospitalization is just the beginning. There is the cost to our legal system with custody hearings, foster placements, often inadequate government resources in our Department of Children’s Services. There is the cost to our educational system with children who cannot function within the classroom. Teachers are distracted with disruptive and often violent behaviors affecting both their ability to teach and other’s abilities to learn. If these children cannot succeed through the educational system their chances of becoming productive members of society dwindle. With poor impulse control mechanisms and potential for addictive behaviors there is high risk for antisocial behaviors and violent crime.

The birth of a newborn is sacred. It brings hope and new chances. These innocent babies are our future. They are starting life with an uphill battle. One they did not choose and could have been prevented.

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