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Cuddling as the First Line of Treatment for Neonatal Abstinence Syndrome
When you hear the words "substance use disorder," (SUD) the image of a male immediately comes to mind for most people. That's understandable. In this country the SUD rate for males ages 12 and older is 10 percent versus 5.7 percent for females, according to Results from the 2014 National Survey on Drug Use and Health.
But there's another group of individuals dependent on opiates who are not initially counted. Newborns. The uptick in maternal opioid use has resulted in a dramatic increase in a drug withdrawal syndrome in newborns called neonatal abstinence syndrome, or NAS. The opiates pass through the placenta that connects the baby to the mother before birth. As a result, the baby becomes dependent on the drug as well. There has been a 5-fold increase in NAS since 2000, according to the National Institute of Drug Abuse. Every 25 minutes a baby is born suffering from opioid withdrawal.
"Symptoms occur within two to three days after birth," explained Elisha A. Wachman, M.D., a neonatologist at Boston Medical Center, home of the Grayken Center for Addiction. "All have manifestations of NAS, but not all require [medication] treatment." Symptoms are primarily neurological in nature. The baby may experience irritability, tremors, poor sleeping, difficulty eating, vomiting or diarrhea. The most recent available data suggest that twelve percent of all NAS babies in the state are cared for by BMC.
In many hospitals babies born with NAS are treated with methadone in the neonatal intensive care unit, but Wachman explains a different approach practiced at BMC. Parents are the primary caretakers. "Cuddling is the first line of treatment," she explained. "We make sure they are sleeping, eating and comfortable. We hold them a lot and keep the lights low." Babies born with NAS are making strides. Following a week of conservative treatment, only 30 percent of the infants require methadone because of continued symptoms of withdrawal. This plan of treatment also significantly decreases the cost of care.
In addition to caring for babies with NAS, BMC works to ensure a safe delivery for pregnant women with SUD, many of whom are initially treated in BMC’s Project RESPECT, an acronym for Recovery, Empowerment, Social Services, Prenatal care, Education, Community and Treatment. The program provides a combination of obstetric care and substance use disorder treatment for pregnant women and their newborns. The multi-disciplinary team includes obstetricians qualified to administer buprenorphine, which reduces symptoms of withdrawal, a psychiatrist specializing in mood disorders in pregnancy, an addiction psychiatry nurse practitioner and a licensed independent clinical social worker.
“Relapse prevention and engagement in recovery treatment are our biggest initial challenges,” explained Kelley A. Saia, M.D., director of Project RESPECT. “We mainly manage methadone, buprenorphine, benzodiazepines and other mood stabilizers.” Each patient is managed individually.
Patients face their share of challenges in addition to SUD. “These women are often overwhelmed by housing instability, food insecurity, safety issues and intimate partner violence,” explained Saia. “Our patients are often less able to handle illness.” Research suggests that substance use may effect women differently from men. Some women may experience heart and neurological problems. Others are more likely to have anxiety or depression or be victims of domestic violence. That is one of the reasons that the participants in RESPECT have a consult with the program’s addiction psychiatry nurse practitioner, explained Saia.
There is also an increased possibility of pregnancy-related complications. “Recent data … find alarming rates of maternal mortality due to substance use,” said Saia. They also have higher risks of hemorrhage, hypertension and pulmonary embolism. The challenges do not end with child birth. “Our biggest concern is how to help a new mother early in recovery to manage sobriety, motherhood, earn an income [and] provide for herself and her family,” Saia explained. The biggest risk is relapse and overdose.
Because of this concern Saia and her colleagues maintain close contact with the mothers the first four to six months after delivery. They are then transitioned to a primary care physician who has training in addiction. Planning is in the works to follow women for 12 months after delivery.
These services for pregnant women with SUD have met with great success. In Project RESPECT, medication stabilization has improved from 27 to 100 percent at four weeks according to the program’s last quality assessment review. This is an important step in treatment, as this phase establishes the minimum dose of medication required to avoid symptoms of withdrawal.
Project RESPECT, innovative treatments for NAS, and many other substance use programs at BMC are the backbone of the Grayken Center for Addiction, a leader in the treatment, prevention, research and training for substance use.
BMC Launches Center to Improve, Advance Pediatric Care for Urban FamiliesDecember 31, 1969
BMC Launches Center to Improve, Advance Pediatric Care for Urban Families
(Boston) – Nov. 3, 2017 – More than a quarter of children in Boston live in poverty. Children living in poverty bring a unique set of issues to their health care providers. These include housing instability, food insecurity and exposure to violence – all of which can have negative short and long-term health implications for children and families.
Providing excellent care for these families requires developing innovative clinical programs to ensure that families have access to the resources they need. It also requires going beyond the walls of the doctor’s office and into the community, and building partnerships between health care providers, educators and community organizations.
The department of pediatrics at Boston Medical Center (BMC) is seeking to revolutionize care for urban families, forming a center aimed at ensuring that all children and families – regardless of their zip code – have an equal opportunity to be healthy and successful. The Center for the Urban Child and Healthy Family aims to develop and test innovative models of care for vulnerable families, strengthen partnerships with community organizations focused on children and families, and disseminate best-practice, evidence-based care models to practitioners, policy makers and researchers across the country. The center, directed by Megan Bair-Merritt, MD and Melissa Gillooly, will focus on the following three areas: trauma informed care, bi-generational (parent-child) programming, and care of children with chronic conditions.
One of the first center-funded pilot programs, Supporting Our Families through Addiction and Recovery (SO FAR) is based in pediatric primary care and led by Eileen Costello, MD. The weekly clinic provides – in the same visit – care for mothers with substance use disorder and their newborn infants, providing continuity of care and ongoing support for families during the postpartum period. The clinic includes medical care, peer support counselors as well as psychosocial support services.
Another pilot program is a clinic for children with special needs who have individualized education plans. Families are seen by Soukaina Adolphe, MD, the pediatrician leading the clinic, and Ivys Fernandez-Pastrana, an attorney and family navigator. Together, they work with families and schools to ensure that children are receiving the necessary accommodations at their school to help them thrive.
Low-income children may be less prepared for school than their wealthier counterparts. To address this disparity, the SMART (Schools and Medicine Advancing Readiness Together) program will unite families, medical providers and educators to develop individualized success plans for pre-K students, integrating their medical, educational and social needs.
In addition, the center has created a two-year fellowship focused on teaching the next generation of pediatric leaders about advocacy, policy and program evaluation. The first fellow is Lucy Marcil, MD, MPH, who, in collaboration with Michael Hole, MD, MBA, developed StreetCred, a free tax preparation service that BMC patients and staff use to file their taxes for free to ensure that they receive the tax benefits and credits they are entitled to. Since its founding in 2015, StreetCred has returned more than $1M in tax refunds to patients, staff and their families.
“Past and present, pediatricians from BMC have developed innovative approaches that have helped revolutionize how we care for vulnerable patients,” said Bob Vinci, MD, chief of pediatrics. “This center will be a forum for innovation, allowing us to build and expand care advances so that more children and families can achieve better health outcomes.”
Programs like the Medical Legal Partnership, which brings legal assistance into the health care setting for families in need, was developed at BMC and is now in place at nearly 300 health care institutions in 41 states across the country and has served more than 75K families (2015). In addition, Reach Out and Read, founded at Boston City Hospital (now BMC), incorporates books into pediatric care to promote literacy, serving 4.7M children each year in all 50 states.
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