Infants with Prenatal Substance Exposure: Yale New Haven Children’s Hospital’s Approach

Infants with Prenatal Substance Exposure: Yale New Haven Children’s Hospital’s Approach


Dr. Nancy Young: Hi, everyone. This is Nancy Young. I’m the director of the National Center on
Substance Abuse and Child Welfare. We’re delighted to be able to present this
webinar today. The National Center on Substance Abuse and
Child Welfare is in its 16th year. There are many resources on this topic and
other topics related to substance abuse, child welfare, courts, and collaborative practice
on our website see our website link there. We would encourage you, if you have not visited
the National Center website for resources, to please do that. We are sponsored by the Substance Mental Health
Services Administration, and the Children’s Bureau, which is part of the administration
for children, youth, and families. Thank you again, and we appreciate the sponsorship
of being able to present the webinar today. We’ll have a fairly short agenda, but hopefully
much rich information. We’re delighted to have Dr. Matthew Grossman
present with us today to talk about the work that they have completed and still have underway
in addressing the issues of infants with prenatal substance exposure, specifically infants that
are maintained on medication assisted treatments and their efforts in their hospital. Dr. Grossman is a graduate of the State University
of New York at Stony Brook School of Medicine. He completed his pediatric residency at Yale
New Haven Children’s Hospital. He’s an assistant professor of pediatrics
at the School of Medicine at Yale and a pediatric hospitalist. He’s been the quality and safety officer for
Yale New Haven Children’s Hospital since 2013. His team was awarded the 2015 National Pediatric
Quality Award from the Children’s Hospital Association. We will hear from Dr. Grossman and then have
time for questions and answers. Please do submit those questions through your
chat box. We have staff who are monitoring those so
that we can get to as many of those questions as we can. If we’re not able to get to your question,
we will have that submitted and if you’d like to then email us also to make sure that we’re
able to respond to those questions, we’d be happy to be able to do that. With that, let me turn things over to Dr.
Grossman. Welcome, and thank you for sharing your expertise,
knowledge, and your time with us today. Dr. Matthew Grossman: Thank you so much for
having me. It’s great to be here with everybody. I’m going to talk to you a little bit about
our experience in taking care of these substance exposed babies and their parents on the pediatric
unit at Yale and how our way of looking at this and the way of managing it has really
changed quite dramatically over the last six or seven years or so. Just as a background, which I’m sure everybody
knows. You’re all here. We all know that this is kind of a big problem,
opioids in the United States. Where it affects pediatricians, at least in
the hospital, is with what we call Neonatal Abstinence Syndrome or Neonatal Opioid Withdrawal
Syndrome. We’ve seen the prescriptions grow fourfold
for folks over the last decade. At least in the state of Connecticut, the
leading cause of death has always been car accidents. In the last year there were three times as
many deaths from opioids overdose as car accidents and car accidents haven’t gone down at all. Of course, there were enough opioids in 2012,
enough prescriptions, for everyone to get one. It’s been a big problem for someone from the
medical community. Along with the rates of opioid use in the
adult world, the rates of Neonatal Abstinence Syndrome have gone up dramatically since 2000. It increased fivefold from 2000 to 2013. We don’t have the best numbers yet, but our
senses it that it continued to go up over the last five years as well. We’ve seen it spread into areas of the country
where it was not quite as big of a problem. We’ve seen it. The big areas are West Virginia, Kentucky,
Tennessee, and then in New England it’s been a big issue as well. When these babies are born and I’ll go through
a little bit of what they go through but they’re mostly managed in neonatal intensive care
units. An estimate in 2012 was that four to five
percent of neonatal intensive care unit or NICU beds were filled with babies going through
Neonatal Abstinence Syndrome. In a lot of community hospitals, that percentage
is closer to 50 percent. These babies will stay a long time. Their average length of stay for these kids
is somewhere around three weeks, which is down a bit since it has become a bigger problem. Three weeks is the longest length of stay
of anything in pediatrics outside of prematurity. The super premature babies will stay a long
time, but outside of that the really sick kids who have pneumonia and chest tubes, they
don’t stay as long as these babies. This is number one. What happens to the babies? The baby is born to a mom who’s been using
some sort of opioid. Consistently, it is fairly certain to go through
some kind of withdrawal. That’s because when they’re in utero they’re
being exposed to this opioid all the time. Their brain adjusts to that. Often down regulating effect of these opioids
causes them to make a lot more receptors. Once they’re born and they’re no longer getting
the opioid, they have this overload. It’s usually things like dopamine and norepinephrine
that get overloaded. They get this hyper stimulated response. The withdrawal signs are not that different
from what we see in adults. They’ve been well categorized by this tool,
which if anyone on the line is taking care of these kids. This is a very familiar tool to use. This is what’s used almost universally to
help manage these kids. This is called the Finnegan tool. This was developed in the mid ’70s when there
was a heroin epidemic in Philadelphia. Neonatologists there were seeing lots and
lots of babies going through this. They just studied these babies and figured
out was what going on with them and what kinds of signs they were having. There’s 21 items on here. They split them into four basic categories. One was central nervous system disturbances. On there are things like high pitched cry,
difficulty sleeping, having this hyperactive Moro reflex. That’s the startle reflex that all babies
have. If you ever want to show it to somebody, if
you show a baby going through this, it’s very easy to see. It’s very dramatic. These babies will tend to have tremors. They’ll be shaking a little bit. That can be when they’re just untouched or
whether you disturb them for it. They’ll have this increased muscle tone. Normally, if you try to pick a newborn baby
up by the arms, the head will lag quite a bit because the head is much heavier than
the rest of the body. They don’t have much neck control at that
point. A baby going through this withdrawal will
come out almost stiff as a board. That’s an almost universal finding you’ll
see with withdrawal. You’ll see excoriations, which is basically
bad diaper rashes. You’ll see these kinds of jerks. They’re called myoclonic jerks. Seizures have been reported. The next category is vasomotor or respiratory
disturbances. Basically, everything speeds up. They’re sweating. They have fevers. They’ll sneeze. They’ll yawn. They’ll have some stuffiness. They’ll breathe faster. Then there’s gastrointestinal issues. Again, everything speeding up. They’ll be sucking a lot. They won’t feed well often because they just
can’t get it together to feed. They’re too disorganized. They’ll throw up. They’ll often have loose and watery stools. That’s generally what the babies experience. It’s a pretty miserable baby that you’re faced
with. It’s hard to go through this. It can happen anywhere from right after birth
to several days into birth particularly if you’re on a longer acting opioid like methadone. It can stay in the baby’s system for a while. They won’t start to experience withdrawal
until you get a little bit further. This is pretty standard. All those items are given a score. That was done by the folks in 1975. The things that seemed worse got a higher
score. There wasn’t anything more scientific than
that. In terms of monitoring and managing these
babies, they would add up the scores. They decided that a score of eight being the
magic number. If you’re above eight for a couple of scores
in a row, then you started medication on these babies. The standard approach to care for these kids
has been not a ton of variation since this scoring tool came out in 1975. The idea is babies will be born. They would mostly go to the neonatal intensive
care unit. Sometimes in other areas, but mostly in neonatal
intensive care units. They would be scored somewhere between every
two and six hours with this Finnegan tool. If they got three scores of eight in a row,
you would start them on medication. Now, you were supposed to do things like regular
baby things. Things we would call non pharmacologic care
where you’re holding the baby, feeding them when they’re hungry, those kinds of things. What was thought of as the key to treatment
was the medication you gave them. A lot of the research over the years has been
trying to figure out what the right medication or the right combination of medications are
that are going to have the best outcomes for these kids. Usually, what was considered to be the best
outcomes were shortening the length of stay in the hospital, because again, these were
the longest lengths of stay of anything we have in pediatric, or lowering the time that
you were treating them with these medications, which aren’t necessarily entirely safe. That’s mostly what we were looking at. Our experience at Yale, we had the benefit
of going through most of these medications. In the ’70s, we were using something called
Paregoric, which was my favorite one because it looks like something that no one should
ever take. It’s got all this stuff in it. It’s 30 percent alcohol, it’s got these little
things floating in it. It’s got camphor, other carcinogenics in it. I’m not sure why we landed on that one early
on, but we eventually moved to something called, “Tincture of opium,” which is just a plain
form of opium. The recommendations for this are, “Give back
a like medication.” If you’re withdrawing from an opioid like
heroin or methadone, then you give back literally an opioid. The study listed at the bottom was from Germany,
where they compared giving this tincture of opium to phenobarbital and found…which is
usually a seizure medication and tends to sedate kids. It was not treating withdrawal, but would
sedate children. They found that they had better outcomes when
they used the tincture of opium. Next, we actually moved on to morphine in
the ’90s. That was just a change by our pharmacy. There were some studies, one from Scotland,
comparing morphine to tincture of opium, which found out similar results, which would be
expected. What you will find a lot of places will do
is they’ll use something like morphine or tincture of opium most places are using morphine
now and then they’ll add phenobarbital if things aren’t going that well. They have to go to high doses of morphine,
they’ll add phenobarbital. There are still some places that will use
phenobarbital as a first line treatment, but not that many. This is a study from Brown in Rhode Island. What they did is they gave some kids tincture
of opium, and they gave some other kids tincture of opium plus phenobarbital. What they found is the kids who got the phenobarbital
from the start had half the length of stay of the kids who just had tincture of opium. It’s a powerful study and a lot of reviews
that looked at all the studies found this was the most powerful one, this is probably
what we should be doing. That was in 2002. The other thing that’s come up a lot lately,
and there’s a big study going on, or just finished, that compared giving morphine to
methadone. This is a study from Maine, which you don’t
get to say all that often because there’s not a lot of people in Maine, but those who
are there have NAS apparently. They compared methadone to morphine, and found
that the kids treated with methadone did a little bit better than the kids treated with
morphine. One of the things that we were interested
in one of too many was a study that came from Johns Hopkins, where they gave clonidine,
which is sometimes used in adults for withdrawal. They were giving that along with their morphine. That’s just supposed to blunt the signs of
withdrawal, and they found that when they gave the kids tincture of opium and clonidine,
they did a little bit better. Had a shorter length of stay than the kids
who just got tincture of opium. That’s a crash course in what the medications
look like, and that’s just trying to figure out maybe there’s one better than the other,
or maybe a combination will work well. That was the standard approach. The standard approach, again to go over it,
was medic. Even though you’re supposed to do the non
pharmacologic stuff of holding the babies, but if you had a baby like in this picture,
you were giving them medication. That was usually morphine, but methadone’s
getting a little more popular. They were mostly managed in neonatal intensive
care units or NICUs. They would be managed using that Finnegan
tool, which makes it much easier. You just follow the scores and it tells you
exactly what to do. There’s not a lot of decision making going
on. Once you’ve started the medication, when you
started to lower it, you would do it very slowly. You usually go down by about 10 percent, every
day or every other day, so it would be a pretty slow wean that would take usually weeks. You would only go down if the kid had all
their scores below eight. Then, in the NICU, if anyone’s been in a NICU
setting, the staff own these babies, which was to the benefit of the babies a lot of
times. It’s the staff caring for the babies, not
so much the parents in most of the models, and there is a real ownership. There was a resident, there was a new doctor,
who worked in the NICU. There was one time I examined a baby without
getting permission from the nurse, and that was the one and only time I did that. I would never do that again, so help me God. It’s an intimidating group, and they own their
babies. That’s the deal. This is pretty much what we were doing at
Yale. One of the only difference is when these babies
were born, they would go directly from the delivery room to the NICU, and they’d be monitored
using the Finnegan score. The one thing is our NICU was a little bit
small at that time. After about a week or 10 days, when the NICU
felt as though they’d stabilized their dose of morphine, they would transfer them up to
the General Inpatient Unit, which is where I worked. I’m not a neonatologist. I take care of just general sick kids in the
hospital. They would transfer them up to me at about
7 to 10 days. That’s how I got involved taking care of these
kids. This was not a population I was interested
in, it was a population that I got stuck with. There was another hospitalist in our group,
and he had one year of seniority over me. He got to pick the floor where these babies
didn’t go, and that was the main reason he did that. They were easy to take care of. We would sit, and when we rounded on them,
the residents would just read off the Finnegan scores and we would say to up or down the
medication. Their average length of stay when I started
was about 28 days, which was not so far out of the norm around that time. One of the things that we did as a hospital
is we tend to try to get patients out of the hospital. What I did was I fudged the part where we
would go down on the medication slowly. We used to go down every other day, if they
had good scores. I used to say, “Just fudge that and go down
every day.” What happened was, somebody took a look at
our data and found that from before I started, per length of stay was 28 days. Then just by fudging things a little bit,
we went to 22 and a half days, which was almost right at the national average, at the time. Again, there’s always been a population that,
“We had a protocol, we followed it.” There wasn’t much to think about. In fact, one of my predecessors used to take
the Finnegan scores at the end of the week and play the Lottery for the residents, to
try to keep it interesting. There wasn’t a lot of thinking to go on. We didn’t see the parents very much. When we did, there were usually difficult
interactions. We looked forward to the fact that they wouldn’t
be there very often. At the end of the hospitalization, we would
hand the baby over to the parents and say, “OK, you’re ready to go home tomorrow.” Oftentimes we would hear, “Oh my gosh, we’re
not ready to go yet. We need another day, we don’t have a crib,
we need, you know, we’re not ready.” Which always blew us away, because you’ve
been here for four weeks, and we didn’t see much of the parents but they weren’t ready
to go. At any rate, we had lowered our length of
stay. What happened was one of our local hospitals,
Middlesex Hospital, which is about 45 minutes away from us, they noticed that we had reduced
our length of stay. I think they had a length of stay of about
six weeks at the time. They wanted me to come and give them a talk
about how we had been so successful in reducing our length of stay. I said, OK, but I only had about 90 seconds
of material. I had our protocol and I had the thing about
the lottery. That’s about all I had to tell, so I had to
go and do all this reading. Which was a real bummer, but it was reasonable. As I read all these studies, one thing came
to light. If I line up all the studies that I mentioned
earlier, there’s an interesting thing that comes up. DTO is the diluted tincture of opium. It’s a little hard to make out now, but if
you line up all these different studies which are all the same types of patient, same exposures,
and their supposed to be these same protocols, if you can follow it through, the kids who
got morphine, the length of stay ranged in these studies from eight days. There was one that was 8 days, one that was
24 days, and one that was 30 days. If you look for the tincture of opium, it
was actually 17 days versus 27 days versus 79 days. That’s a spread that you just don’t see in
any other disease process. That’s crazy. The idea that you have the same protocols
and in one place it would be a length of stay of 17 days and the other it would be 79 days
makes no sense. That is crazy. I thought, “Well, why is that? Why is that happening?” Of course, I didn’t know, but the first thing
that came to mind for me is, “Well, maybe it’s really not about the medications.” As I mentioned, the first line of treatment
is supposed to be this non pharmacologic care where you hold the baby, you feed them when
they’re hungry, and that kind of stuff. If you go and you look at the AP guidelines,
they list that stuff first. They spend 52 words on that. Then they spend 1,600 and 56 words on the
medication parts. If you think about what goes on in a neo intensive
care unit, they’re taking care of kids who are born like three or four months early. They’re putting tubes in these impossibly
small babies and saving their lives. The idea that putting a pacifier in and bouncing
a baby is real medical care is probably a little bit of a tough sell. It was something that was just given lip service
to. In fact, when I went back and looked at all
of those studies, most of them mention that non pharmacologic care as a first line treatment
and then don’t say anything else about it. They don’t say if they delivered it or how
often, where the parents there, were they not there. If you tried to do that the other way, tried
to do a study where you wanted to look at swaddling and see if that had an effect, and
you just said, “Oh, you know, some of these kids got morphine. I don’t know which ones or for how long, but
it’s fine.” Everyone would laugh at you if you tried to
publish that, but it was fine because it’s non pharmacologic care and that’s not real. What we did is we started saying something
very noncontroversial and just saying, “Well, what about if we just treat non pharmacologic
care as if it’s a real thing? Just treat it like it was.” We looked at how often we were giving kids
morphine. The data I’m going to show you is for kids
exposed to methadone. We did the same approach to all of our kids. About 80 percent of our kids are methadone
exposed. The reason I singled them out is they tend
to have the worse withdrawal, which may come as a surprise to some. Heroin is not as bad on a baby as methadone
when it comes to withdrawal. These are the ones that we could be certain
are going to go through significant withdrawal. We looked at this from 2003 to 2010. It was about 150 kids at that time. We have far more of them now. 98 percent of them were treated with morphine. That means that 98 percent of them had three
Finnegan scores of greater than eight. I’m going to show you these a few times. These are called control charts. This is a way to follow your progress. I’m going to try to orient you to this a little
bit. The black lines are the balancing lines. Each one of those points is a patient and
their length of stay. This is the length of stay of these babies,
of the methadone exposed babies. That’s each one. The white line going across is the average
for us. That was 22 and a half days. The green line, of the recent studies, it’s
the lowest length of stay I could find in a big study and that was the Vermont Oxford
Network which was 199 hospitals that worked to reduce the length of stay and got it down
to 19 days. Then the red lines are what’s called control
limits. That’s three standard deviations from the
mean, which means that 99 percent of your value should fall within those red lines. When you’re trying to decrease the length
of stay and improve how you care for kids like this you want to see two things happen. You want to see that white line, which is
the average line go down and you also want to see the red line get a little bit tighter,
which means there’s less variation. There’s less space between the two red lines. Those are the things we were going for. This is 2008 to 2010. This is where we started, 22 and a half days,
quite a bit of variability. Pretty normal compared to other places. What we started to do when we went through
this is to think about why we were doing all the things we were doing, which is an unusual
thing in medicine. There’s a million papers published every month. It’s hard to keep up in everything. When you have protocols and you have guidelines,
usually you go with them. We started to just question why we were doing
things. Why were we using medications? Why were we doing all the standard things
we were doing? What we found as we looked into all of these
things, we found out that there was the same answer for every part of the treatment we
were doing. The reason we were doing the things we were
doing today was simply because that’s what we were doing yesterday. There was no other evidence behind it. It got a little disappointing as we delved
more and more into it, but it was a little bit freeing for us to try to think about a
different way to do this. Why were medications considered the treatment? In fact, lots of places don’t consider a baby
to have Neonatal Abstinence Syndrome unless you give them medication, which is a made
up definition and doesn’t make any sense. In other words, if you make improvements in
non pharmacologic care so that you don’t have to give them medication it doesn’t count in
your treatment of Neonatal Abstinence Syndrome. It’s nonsense. We thought, “Why are medications the first
line treatment even though everything you read says that it is?” We started to just say, “OK, we’re going to
really focus on non pharmacologic care.” There’s some data to support this, particularly
from Vancouver where instead of taking the babies… Now, if you’re listening to this stuff and
feeling like some of this stuff seems like common sense, I’m right there with you. I think of this as one of the least innovative
projects that you can find. If you take care of these kids, you think
it’s innovative. If you don’t take care of them in the hospital,
you think we’re all kind of a bunch of idiots. I think those people are probably right. What they did in Vancouver is they just kept
the babies and moms together and it turned out, hey, that went well, which should be
a giant surprise. We started to do that. We started to think about what it meant to
do non pharmacologic care. You have these kids who are hyper stimulated. Keeping them in a low stimulating environment
is important and trying not to mess with them too much. Anytime you change their diaper or give them
a bath that’s a big experience for them and usually that won’t go all that well. These babies need to be fed a lot. There’s a couple of reasons. One it’s a soothing thing for them and also,
they’re using a lot of energy. You remember I mentioned their sort of stiff
as a board and they’re doing all of these things. They’re using a ton of energy. They often need a lot more calories than babies
not going through this. What we would always say is we want to feed
them when they’re hungry, which does not seem that radical. We were good at feeding babies in the NICU
on demand as long as that demand was exactly every three hours. If you’ve ever been in a NICU it’s very regimented. You would hear all the time, “Well, he seems
hungry. It’s two hours and 30 minutes and he seems
hungry, but he’s due to eat yet. He’s not eating until he’s due to eat.” Which is not how babies work and was not a
good fit for these kids. Doing things like feeding them whenever they’re
hungry could mean every 45 minutes for periods of time. They may eat very frequently. They also might need to be held quite a bit,
which does not fit into a NICU environment. Also, one of the things that happens is they
start to get upset and they start to cry, a lot of the withdrawal signs can snowball
from that. If you can tend to them right away, then you
can short circuit a lot of these signs from snowballing. If you’re a nurse who has five babies, one
of them starts to cry, and you have to give medications to another two, it might be 20
minutes before you get to that crying baby. In which case, things have fallen apart at
that time. What we found is if you want to feed the kids
whenever they’re hungry, which can be frequently, and you want to be able to respond to them
within seconds there’s got to be somebody at their bedside all the time. That’s not going to be a staff member. That has to be a family member who’s going
to deliver this non pharmacologic care essentially. Now, we can control the lights and the noise
to some degree, but if we’re going to be able to do that we need a parent or a family member
at that bedside. We started to focus on that and just by doing
that we reduced our length of stay from 22 and a half days down to about 13 days. That is a dramatic decrease in length of stay. If that were a pill, then we would make sure
everybody got that pill. That’s how we started to think about it. We started to think about it like asthma. If you have an asthma attack they make you
take one of those inhalers. Those albuterol inhalers. You come to the hospital, that’s what we give
you. It would be crazy to think that we wouldn’t
give you that. That’s the treatment. We started to think of it in terms of, “OK,
let’s think of the mom as the albuterol for asthma. Just have that same mindset.” When we started to think about that we started
to say, “OK. Well, we’re bringing this kid to our NICU.” Which now we built a new NICU for parents
to room in, but prior to that we were in one of these NICUs that has 12 babies in a room,
which is the old standard model. Which most places are like that, with these
big rooms with lots of babies in them and no place for the families. If there’s no place for the family to stay,
then you can’t deliver that first line treatment. It would be like sticking an asthmatic in
a unit that doesn’t carry albuterol, which is crazy. You would never do that. We tried to think, “Well, why to these kids
go to the NICU? What’s the reason that we would keep them
in the NICU?” The NICUs are doing lifesaving things. It’s an intensive care unit. They’re putting tubes and lines in. These kids don’t need any of that. What was the reason that they were in the
NICU? The answer was, because that’s where they’ve
always been. There wasn’t any other great reason for it. One of the reason that was brought up is they
might have seizures. That comes from a study from the early ’70s. Actually, one of the authors from that works
in our system. We asked him about it and he said, “Yeah,
we weren’t really sure if those were seizures.” If you look at the follow up study, nobody
reported seizures. That’s not a concern for these kids. There’s no reason at all that these kids should
be in a neonatal intensive care unit other than we’ve always done it that way, which
is not a good reason. It ends up being, when you look at things
like this, what people call standard of care isn’t a standard of care. It’s a traditional care, which is very, very
different because it’s not backed by any evidence. We looked at our NICU. This is our website photo where everyone looks
happy. It’s bright. It’s bustling and there’s a lot of people
around. I snuck in and just took a cell phone photo
of it. You can see this is not a very welcoming place
for a family. There’s 12 babies in there. You can see there’s obviously no place for
a family to stay. It does not look very welcoming for any parent
to be there. You can see there’s a little curtain up there. That’s your privacy. Unwelcoming to families. A good laboratory of a place where you can
deliver almost no non pharmacologic care. You can swaddle a baby. They’re going to be fed every three hours. It’s bright, it’s bustling, it’s loud. They’re going to get no other care, and so
that’s why we saw the results we saw. If you go to the General Inpatient Unit, we
don’t have necessarily the nicest rooms, but you can…at least one person can sleep there,
there’s a refrigerator, you can control the environment entirely. It just has you and your baby in a room. A much better environment to be able to deliver
this non pharmacologic care. We said, “OK, why are these babies going to
the NICU? Let’s have them not go to the NICU.” We said, “Instead of them being born and going
right to the NICU, let’s have them stay with their moms in the nursery.” “Then, if the baby starts to have withdrawal
signs, we’ll have them come to our General Inpatient Unit. If everything’s going well, and the mom gets
discharged since we don’t have a lot of room in our nursery they both can come down together.” The idea is we want to keep the mom and baby
together. This was not a popular move. Our nursery, who had not had to take care
of these babies and families, was not that eager, for the most part, to take part in
that. It took us 18 months of negotiating. It was the first five babies that were born
all had some other medical problem right away that caused them to be sent to NICU. That medical problem resolved within minutes
of being in the NICU, so it’s just a protest vote. That has changed so dramatically in that unit,
where they are the leaders in this now in our hospital. I’ll get back to that later. The change from this “going in unwillingly”
to being a leader has been amazing. We started to do that, and you can see that
white line keep going down further, and the average got down to 10.2 days. Now, you will notice that there seems to be
more outliers in that group and the red lines have spread out. What happened there is our census in our NICU
during that time was low, and so when they were getting these babies, they were keeping
them all the way through the hospitalization. They were having this long length of stay
because they were still doing the traditional model. They didn’t even know we were doing anything
at this point. We were just doing this quietly on our unit
and just experimenting and seeing what things would work better and having quite a bit of
success. We were on a roll, and we started considering
our Finnegan scores. We asked, “Why…is this is what everybody’s
using?” It felt like it’s the “Law of the Land.” There’s a couple issues with it. Here’s one of them. There’s a few problems, and if you look at
the things on this list, it’s a good description of what withdrawal looks like in a baby. Here’s the thing, I’ve seen about 500 kids
exposed to methadone, and every one of them has had withdrawal. I don’t need this tool to tell me they’re
going to have withdrawal. Is it helpful to count how often somebody
is yawning or sneezing in order to decide whether they need these powerful and potentially
dangerous medications? Medications like phenobarbital have been shown
to reduce IQ points. The more we study morphine in babies, not
surprisingly, the less safe it is. Increasing the time that they’re exposed and
the time they’re going to withdrawal, if you keep giving them that may not be a great idea. Some of it seems a little bit absurd when
you get a situation where, if we look at these scores and say, “OK, we’ve had a kid who’s
had two scores of eight.” Remember eight’s the magic number, so they
get above eight three times, they’re going to get medication. “They have two scores of eight, and their
score is seven, and they sneeze three times,” which of course is fine. “But if they sneeze a fourth time, in this
sort of indeterminate period of time, then they get another point and they go to eight.” They don’t just get a dose of morphine, because
remember, when you start medications, it’s not that you’re just giving a dose. You’re going through this very long weaning
process. You’re talking about at least a hundred doses
of morphine that you get for that one extra sneeze. Probably doesn’t make a lot of sense. I can tell you that we don’t treat any other
disease processes where we count yawns or sneezes, and decide if those need extensive
medical management. When you start to look into it, “Well, why
is eight the magic number?” I couldn’t find that. It took me a long time to dig it up. The original 1975 paper says, “And if it was
a score of seven, it was not treated with drugs for the Abstinence Syndrome, because
in our experience, he would recover rapidly with swaddling and man feeding. And if his score was eight or above, we’d
treat him pharmacologically.” If you ask anybody…no one knows why they
use eight, they just know that they use eight, and it comes from this paragraph. Never been studied further. No one knows if this is the right number or
what it means. It’s just what they picked in 1975, and that’s
what everyone’s been doing, and it’s now 2018. Another disappointing thing we discovered. [laughs]
A couple problems with using this tool. It’s a long length of stay and lots of medication,
so we know by using this score and using the system we’ve done we’ve created the longest
length of stay out of anything in pediatrics, and we used lots and lots of medication. The whole purpose of the treatment is to just
get the scores below eight. I don’t even need to see the baby as a physician. I just need to look at the scores and know
that they’re below eight. A couple of the other things. When you look at…you may have noticed with
this scoring tool that, if you’ve had a baby that, “Hey, my baby did some of these things.” That is definitely true. One of the pictures I showed in the beginning
was my kid, who was born around this time, who was helpful. [laughs]
I can look at it that way. He was a difficult baby, and he had a lot
of these signs. He was not going through withdrawal. He was just a miserable baby. He’s a very pleasant eight year old now. He’s a lovely guy now, but he was tough, at
that point. I thought about it then, as I’m pacing the
halls in the middle of the night, that if I went into the pediatrician and said, “Hey,
what dose of phenobarbital are you going to give him?” they would have made fun of me. But for a kid that we said it was withdrawal,
we would have loaded him up immediately. There are three things on that scoring tool
that are pretty specific to withdrawal. In other words, you don’t see those outside
withdrawal. One is that hypertonic thing, that “stiff”
thing. You don’t see that outside of it. That exaggerated Moro reflex, that startle
reflex that all babies have, you don’t see that as exaggerated as it is in withdrawal. Then the tremors or the shaking. You can see that sometimes in other disease
processes, but those are pretty specific to this, as well. How do you know if a baby has one of these
startle reflexes that’s exaggerated? The only way you can do it, and the only way
you can do the Finnegan score is to unwrap the baby and disturb them. You have to try to get them to withdraw. Even though the treatment is supposed to be
keeping them calm and quiet, in order to do the score, you have to mess with them and
see if you can get them to withdraw so you can write the scores down. How do you know if they’re going to have tremors
when they’re disturbed? You have to disturb them. Doing type of scoring tool is doing harm to
the baby. [laughs]
It doesn’t make any sense, and it’s giving you information that you don’t care about. Nobody cares about how often somebody sneezes. It can also be slow to respond. We would do these scores every four hours. You could have a baby who’s have a difficult
time and has a score of 10 at, say, noon. Then you come back at 4:00, and they’ve got
another score of 10. Then they’ve got a score of 10 at 8:00, because
they’re still miserable, and that’s when you can intervene. You don’t do anything for eight hours. That’s slow. It’s, of course, these powerful and potentially
harmful meds to treat a sneeze or a yawn, which is silly. It’s a good catalog of signs of withdrawal. I’m not sure it’s at all useful in the treatment. We started to think about it, and we said,
“We don’t want to do this.” We want to think about what do we care about? We know these babies are going through withdrawal. We want to make sure they do OK. We thought about, “Well, what’s the job description
of a baby at this age?” They don’t do very much. They can’t drive yet. [laughs]
They’re supposed to be able to eat, and they’re supposed to be able to sleep, and they’re
supposed to be able to poop, which usually isn’t a problem with these kids. You should be able to calm them down. If you had a colic y kid, it usually doesn’t
start right at birth. It usually goes a couple weeks into life before
that. You should be able to calm down a baby at
this age. We said, “If you can do that, though, we ask,
‘Can the baby eat? Can the baby sleep? And can the baby be consoled?'” Eat, sleep, and console. Which, suspiciously, is the things that we
focus on in any baby. We work in one of these health systems where
you can decide to change something, and two years later it changes. We took advantage of that this time. We decided to stop using the Finnegan score,
but our protocol said to keep doing it, and we had to through all the hoops to get it
removed. What we did is we stopped using it to manage
the babies, and started using the Eat, Sleep, Console approach. We were still getting the scores, so we could
compare what we were doing versus what would happen if we used that Finnegan score. We looked at 50 babies, and we still did the
Finnegan scores every four hours, and the FNA is the Finnegan Neonatal Abstinence Scoring
System. But we didn’t use them to guide management. We used the management decisions based on
the Eat, Sleep, Console or ESC model. What we looked for is, the number of kids
that we gave morphine to versus the number we would have had we used Finnegan. In other words, the number that had three
scores of eight. We looked at how often they disagreed, so
how often we didn’t give the kid morphine as Finnegan would have told us to and what
happened the following day when that happened. If we didn’t give morphine, and these kids
got much, much worse because we didn’t give them morphine, we wanted to know about that. Here’s what we found. We found that, of the 50 kids, only 6 of them
in this group got morphine. Whereas 62 percent, which is right around
what the national average is, would have gotten morphine if we’d used the Finnegan approach. That’s a big difference. That’s 25 kids who didn’t get morphine, who
would have been… Again, it’s not a dose of morphine. It would have been weeks of morphine. There were 78 days where we gave less morphine
than Finnegan told us to. On 70 percent of those days, the score was
better the next day, and it was better overall by an average of about a point. There were two cases where it went the other
direction, where we gave morphine, and the Finnegan said everything was fine, and the
following day even though we gave morphine the score increased by 1.7 points the next
day. It would work both ways, but obviously most
often it works that we get less. There were no readmissions, there were, of
course, no seizures, no ICU transfers. These kids all did well. This is, again, a NAS baby who again we would
look at and a lot of places would say, “Well, give that kid morphine.” We’d give that kid methadone. If we asked the question, “Well, what would
you do for this baby if it wasn’t a NAS baby?” The answer is pretty easy. You would probably pick this baby up. I told you this wasn’t going to be that complicated. What we said are guiding…we had a couple
guiding principles, and one of them was to pretend it’s a baby. What we had been doing is taking these miserable
babies, babies that were having a hard time, and separating them from their moms. These moms are going through a pretty tough
time, who have been either in a maintenance program or not in a maintenance program, but
dealing with these issues as well. We are separating the mom and baby, and the
baby is doing what’s happening in this picture. We are treating that with morphine, and leaving
them in the box. Our major mantra was, “Pretend it’s a baby. What would you do if it were a baby?” Not a NAS baby. It turns out, if you treat them like babies,
they respond like babies. We started to look even further in what we
were doing, and why were we going down on the medication every day, or every other day. What was it about the earth rotating once
on its axis that meant that’s when we go down on medication? It had nothing to do with how the medications
are treated by the body. It’s just what was done. Once again, it was one of these things where
we couldn’t find any reason, nor could anybody else. We said, “OK, what’s happening when we get
these babies, if they’ve been on medication and they come…” Because we still have some of the kids who
will go to the NICU because they had other medical problems, or they come from an outside
hospital. What would happen when they were coming to
our unit is we were greatly increasing the non pharmacologic care, which is the first
line treatment, and we were now treating with that kind of respect. Couldn’t we just go down on the morphine a
lot faster? It took us a long time to figure that out,
seems very obvious. Instead of going with weeks, we would be able
to get them off in a couple of days. Then we thought, “Well, why are we even doing
it that way?” Because we have this situation where you have
a baby who, say, at 3:00 in the afternoon is having a hard time, and we’re having difficulty
consoling the kid. The first thing we do is not to give medication,
but we go and see, “Hey, can we increase the non pharmacologic care? Is mom there?” No, mom stepped out. “Well, let’s get her back.” She comes back and everything’s fine. But in a situation where that’s not the case,
where the mom had to go out, she went to get her methadone. She’s not going to be back for a couple of
hours. We’ve done everything we can. We can’t console the baby. We would give a dose of morphine. Normally that would mean you’re giving morphine
again for 100 doses at least. We said, “OK, well, that’s at 3:00. Now at 6:00, mom’s back, baby’s calm, eating
well, sleeping well, consolable.” We don’t give any more medication. That’s a big deal. One dose was now one dose. We gave PRN’s as needed. We gave the morphine as needed, instead of
going through this long, made up weaning process, that would take weeks and keep the baby in
the hospital. Here’s what we saw in the end. Again, so that we can see it, the green line
stays at 19 days, the white line is now down to 7 days, which is much slower than you’ll
see…Our three standard deviations, all of our points, fall well below the national average. We weren’t done yet. This is important one. We looked at our model and how staff was caring
for the baby. We were still doing a lot of the work. There were more parents staying. At the beginning of the project, I can remember
couple of parents who stayed in the beginning of this project. We were getting more and more parents staying. I’d read this paper that came out of San Antonio. There’s been a few papers like this where
they interviewed the moms and their experiences going through this. It was pretty heartbreaking. I’m going to read a couple of the quotes to
you. How do mom’s feel? First of all, there were four themes. Addiction is misunderstood. I’m sure a lot of people on the call understand
addiction well. I certainly don’t. No one goes into pediatrics, because they’re
excited to a much less neonatal medicine. What I know from addiction is from watching
“The Wire” and “Trainspotting.” That’s about it. Folks in the NICU do not understand that at
all. The mindset is very much like, “I can’t believe
they made these decisions,” not understanding about, “This is a disease.” The moms feel guilty. They don’t need anyone to tell them that what
they were taking, even though it was prescribed, is having their baby go through this. They felt judged by the nursing staff. There have been a number of these studies,
too, where they interviewed nurses and their experience in taking care of these babies,
and the nurses said, “Yeah, we’re judging them.” It seemed to line up nicely. They felt that the moms didn’t trust the nurses
because they were being judged and felt like they were unwelcome. Here are some of the quotes. “His nurse was like, ‘His muscles are locking
up because of his junky mom.’ I didn’t want to visit. I would call before and if that nurse was
there, I wouldn’t even go.” Imagine having a newborn baby and not feeling
welcome, and not feeling comfortable visiting. The idea of visiting a newborn baby is crazy
to begin with. The idea that you weren’t welcome to. “Because we’re going to leave, he’s going
to cry, and they’re going to leave him crying because they’re going to be like, ‘You know
what? His parents are jerks.'” I’m going to read you one more longer one,
that’s, I think, pretty powerful. “So I would just tell the nurses to take it
easy on the mother. After being addicted, I realized that this
is a disease. There are some who abuse. But if you’re using while you’re pregnant,
you have a problem. A big problem.” “And you need help. You obviously don’t care about yourself, about
anything, except the drug. Make it a little bit easier on that mother
if she’s showing initiative. She’s taking her time to be there. She loves her child. You can see it, and you can feel it. If it’s obvious that she’s there for the baby,
then embrace it. Make it easier. You don’t know what her circumstances are.” “You don’t know what she’s been through or
how hard her life has been. You don’t know what she was feeling when she
was pregnant. If she was being abused, if she was poor,
whatever the reason she was using while she was pregnant, you just don’t know, so try
to make it easier for her.” We heard her. We said, “We do not want anyone feeling this
way in our hospital.” We thought about how we were talking about
Neonatal Abstinence Syndrome, we thought about how we were approaching the parents and discussing
with them, and we changed it. We made it a lot more positive. We looked at our role as…our job is to empower
the parents, and we’re…the medical management was quite minimal, and what we were doing
is being coaches and cheerleaders in all this. It turns out, we thought, what we thought
we were trying to do with this is trying to make this go better for the baby and the mom,
both in the hospital and when they went home. If you remember what we were doing in the
beginning is we were taking these babies and in 28 days and saying, “Hey, it’s time to
go home.” The parents were saying, “We’re not ready
to go home. We don’t know how to do this.” They hadn’t bonded with the baby, they hadn’t
been there. We’d been taking care of the baby, they’d
be doing whatever they’ve been doing. Now, we start pre natally, going over the
mom and the dad, if they’re there. I often say “mom,” but sometimes it’ been
a single dad, or it’s oftentimes mom and dad together. Or it can be a grandparent. It can be anything. You say, “Look, this is what your baby needs. You are the treatment for your baby.” We know that they’re going to feel guilty,
but what we’re able to tell them is, “You are the treatment for your baby,” not… Even some of the places that do this well
have messages saying, “The non pharmacologic care is important. If that doesn’t work, then we give medication.” We would never say that. We’d say, “No this is the first line of treatment. This is what works. You are the treatment for your baby. There are times where some of these babies
have a tougher reaction to it where you’ll be 90 percent of the treatment and we’ll need
to give medication for a short period of time, which will just help. But you’re still the key to treatment. It’s all about you.” You could see the parents stand up a little
straighter. We’d hear that, “Hey, yeah, I wanted to deliver
here because I heard you respect moms going through this.” We thought about what we were doing. I’ve heard other places who were starting
to change, saying, “Oh well, do you guys have a contract for the mom?” Our answer is, “Well, do you have a contract
for other moms?” The answer is, of course, “no,” so we certainly
don’t have one for these moms. We treat the babies like babies and we treat
the moms like moms. The main thrust of our treatment is, “Treat
the babies like babies, and respecting the moms, and respecting the folks going through
this.” What we’ve seen is, for the staff, these were
the hardest babies for the staff to take care of. When you look at some of those NICU nurse
interviews, they say, “They’re taking care of these impossibly small kids and they have
a lot of deaths in the NICUs,” they would list these babies as their toughest to take
care of because of the experience with the family. The same thing on the floor. You have these very difficult babies, family’s
not there very much. Suddenly, when the family’s there and doing
all the care, this becomes one of the easier patients for the staff to take care of. The parents are doing all the work. It’s our job to support the family. We used to see things like, “Hey, you know,
the mom’s really sleepy, so I’m going to call child protective services,” or “Can you believe
that mom, the baby was crying and she couldn’t wake up?” Yeah, she’s on methadone and her dose is about
30 percent higher than she’s used to. Plus, she’s a new mom. She has lots of reasons to be extra sleepy. What would we do if she wasn’t on methadone? We would probably figure out ways to support
her. That’s what we started to do. Instead of saying, “Oh, well, she didn’t wake
up.” Saying, “Listen, we know you’re doing such
a great job. You need your rest, too. Usually a baby wakes up at about two to feed. Why don’t I take that feed? You can sleep. Then we’ll get you up for the next one.” Just thinking of ways we can support people
just like they were moms and taking the judgment out of it. Because we took it to heart with what that
one mom said. We don’t know what they’re going through,
but we know that it’s not going to help that we’re judging or not being supportive. We want to give them their best chance and
that comes from us partnering. Frankly, it makes our lives a lot better,
as well. There are situations where the moms aren’t
there. The family’s not there. There’s ones where there’s no interest from
the family. They’re going to be giving the baby up, or
where they just can’t be there. They’ve tried everything. They have three other kids at home. They have no other resource. We’ve tried the best we can to help. What we’ve found is that doesn’t change what
the baby needs. Babies need to be loved. They need to be treated like babies. We have an army of folks who can fill in where
necessary. We look at it as it takes a village. I always assign the medical students to those
cases. I watch Sports Center during lunch and sit
with the baby. Our nurse manager has an office where she
can turn the lights out and keep the baby, if necessary. We figure out how to do the best we can if
the parent can’t be there. We know that’s what the baby needs. The sooner we can get them to somebody who’s
going to love them, team them up with a foster family, that’s what this baby needs. Just to summarize what we went through. I’ll go over the data a little bit more. With the old protocol, the whole purpose was
to suppress withdrawal signs. I had to examine the baby, but I didn’t need
to. It didn’t make any difference. I didn’t need to talk to the families. We were just trying to get those withdrawal
signs down. Now, the goal is to have the baby be a baby,
do what babies do. We know they’re going to have withdrawal. If we can manage it OK, then we have success. The old model you had a NICU where the mom
would visit. Here, we manage the mother and child together. That’s our way we do it. There’s different ways we do it in the different
hospitals in our system. Our main hospital, we may be able to change
it a little bit even though I don’t want to. We could have these kids go to the NICU because
you can room in now. We’ve done such a good job of changing the
culture on the floor, we’re probably not going to do that. We have another hospital where we have deliveries
just about mile away. When these babies are born there, if the mom
and baby can stay together and they have one room, after the mom is discharged where they
can stay. If they can go in that room, great. If not, they transfer them over to us, so
we can keep the mom and baby together. That’s the crux of it. Each hospital may have different challenges,
but that’s what you have to end up with. That’s the starting point. How do you keep the mother and child together. If you can’t, then you probably can’t manage
these babies in your hospital. This is surmountable. You can figure this out. Finnegan scores, it was all about treating
the number again. You just looked at the number and followed. It was very easy. Here, it’s Eat, Sleep, Console. With the Finnegan score approach, you didn’t
have to ask how the infant was doing. In Eat, Sleep, Console, the first question
to the mom is how’s the baby doing? What was interesting, I went to Dartmouth. Dartmouth does an amazing job. Their non pharmacologic care, how they support
their moms is laudable. Their infrastructure is better than ours with
that. They brought a panel of moms who’ve gone through
this, and there were five moms speaking for an hour. All they spoke about for the whole hour was
the Finnegan score. About how they knew that this nurse on at
night tended to score high. They knew if they got one more score of eight,
that they were going to start meds and that they were going to be here for another two
weeks. The baby would sneeze and they’d be focused. “Did anyone see that? I hope they don’t get that to their scoring
on it.” Even though they were doing all this stuff,
the focus was on these Finnegan scores. It was so fraught because if you tripped over,
it wasn’t that you got a dose of morphine, it was that you got 100 doses minimum. With Eat, Sleep, Console, you get to treat
the infant. It’s not such a big deal if you need to use
the morphine because you’re using one dose at a time. The last three kids that we gave morphine
to got a total of 8 doses combined, as opposed to what would have been at least 300. Everybody does supportive care. Everybody’s protocol says non pharmacologic
care first according to the AP guidelines, but we do it for real. In upper case letters, we’re zealous about
it,it’s the treatment. If it were a pill, everyone would use it. There would be no questions about it. Feeding on demand, again, this is surprisingly
tricky in a hospital. This has always been our trickiest thing. We just took out our feeding schedule. It’s feed the baby. That’s worked much better. Morphine was the key to our treatment in the
beginning. Now that shows up somewhere on page three
of our protocol. It’s not the feature of our treatment. It’s used just as an extra helper occasionally. It used to often be a surprise to families
when they would come in that this was going to happen with their baby. It was an uncomfortable conversation to have. Often OBs wouldn’t have them. Now, we’re meeting with the families beforehand
as much as possible and going over what the expectations are, what their baby’s probably
going to go through, and how they’re going to help through that. The staff used to take care of the infant. Now the staff coaches the parents. This is a big one. The culture change with our staff has been
remarkable. We are partners in this now. Here’s what we saw. This is up through the summer. I have to get our latest data. I glanced at it. It hasn’t changed. We went from an average of 22 and a half days. If I bring that back even further, we started
at 28 days. Our average length of stay is now 5.9 days
over the last two and a half years. The average length of stay nationwide is 19
days, using versions of the traditional approach. This is a dramatic change. This is a disruptive approach to this. It seems very intuitive. It’s a very common sense approach. We’ve had three babies stay longer than 12
days, two at 12 days and one at 13 days. Those are kids that just had trouble eating. They were a little sleepy when they were eating. We got that fixed. That’s it. If you look over from 2003, we were up over
30 days for a while. Then down below six days. If we look at the percent that were treated…we
were treating 98 percent of these kids. The percent we’re treating now is 100 percent,
aggressively from birth not with medications. We are treating them non pharmacologically
with swaddling, with holding, with feeding them on demand, with doing all of that, treating
them like a baby aggressively. Not separating them from their mom, but keeping
them with their mom from birth. That means we’re not giving a whole lot of
morphine. The percent treated with morphine is down
below 10 percent now. If we look, in 2016, for the kids who were
able to skip the NICU…eventually we got the NICU to get on board. When they thought about starting morphine,
they would just transfer the kids a little more quickly. In 2016, the kids that came straight to the
unit, we didn’t use morphine at all. When we do use morphine, we haven’t gone up
on our dose of morphine in about five years on the floor. People ask me how we go off. The answer I don’t know anymore. I have to try to figure it out whenever it
comes up. We find if we just give some, it’s at 10 percent
support. We can be aggressive about our non pharmacologic
care, doesn’t have to go above that. Breastfeeding rate, we were at nothing when
we started. We’re about 50 percent now. We have some rules about active use and not
discouraging it. We probably have a little bit of room for
improvement here, but not a whole lot. We’re pretty happy that we want to keep that
going. Our average cost of care, the hospital likes
this one, about 95 percent Medicaid, which is not a great reimburser in Connecticut. We’ve cut our costs by about a quarter, which
has saved about $2.5 million a year in our hospital. The suits like it. We published our first paper on this in June
of last year. We’ve seen a lot of people interested in it. Boston Medical Center had been using the traditional
Finnegan approach. They started to use just elements of Finnegan
for about six months. Then they started using the Eat, Sleep, Console
approach as a scoring tool. They’ve been doing that for over a year now. We didn’t create a scoring tool for this because
it seemed silly. It’s the stuff that you look at for babies. It’s just regular baby care. For some people, it makes it a little bit
easier. They found their use of morphine went down
from 82 percent to 40 percent. Their length of stay went from 18 days to
10 days. They weren’t satisfied with this. A couple of months ago, they came to visit
us. They brought a team down and wanted to see
what we were doing exactly to bring it back because they thought they could do even better
than what they were doing. They had no readmissions during their time
as well. This is informal. People have reached out to me and said they
are starting to do this RN, since the summer, around these states and a couple of spots
in Canada. Also one in New Zealand, but I couldn’t fit
that on the map. These are the ones that I know of. There are others that are doing it as well. It has become fairly popular, and I hope we
will keep continuing to extend it. We think this is something that is just better
for moms and babies, and that’s treating them as they should. It’s treating the babies with love and treating
the parents with respect. What we’ve seen is certainly the parents are
treating the baby but also, at least in the short term, we are seeing the babies are in
some ways treating the parents as well. The information on long term outcomes, how
these babies do after they go home, how they do when they are six months old or 2 years
old or 5 or 10 or 15, is limited. There’s a lot of interest in starting to study
that a lot more. It doesn’t matter how we manage them. Is it better or worse if we do it our way? In the beginning, does it have any impact
at all? We don’t know. We just don’t know how these kids are as little
kids, as teenagers, and as adults, but there’s a lot more data to come on that. We’re looking forward to being a part of that
as well. To sum this up, it’s just hugs before drugs
for these kids. It’s empowering families. It’s keeping the parents and the babies together. Its rooming in. It’s using non pharmacologic care the first
sign treatment. We can think of it as family centered care. Not as a way to deliver treatment, but as
the treatment for these babies. Thinking about getting rid of the Eat, Sleep,
Console approach and using meds only if needed. It’s asking for the medical approach. It’s asking why and making sure you know why
you are doing all of the things you are doing, and oftentimes you’re not. Change is hard, but it’s worth it. It’s not as hard when the change you are asking
for carries a lot of intuitiveness, common sense, and evidence behind it. It’s been a big team. I only listed a few folks, but it’s been an
amazing team. A lot of the folks listed there are from our
nursery, which again, was so resistant in the beginning. One of the things that was amazing is they
were supposed to be transferring babies to us when the babies starting having withdrawal
signs. They were still doing Finnegan scores so when
the scores got above eight they were going to transfer them down. After a year we noticed that we weren’t getting
those babies anymore. We were never getting them without their moms. We went up to ask and they said “Well, look,
we noticed that you guys weren’t necessarily starting medication on these kids when we
sent them down. We saw how powerful it was having the mom
and baby together and we weren’t going to split that up.” This group that had been so resistant in the
beginning, had made these changes all on their own, without any push from us. It made their jobs harder. It meant that they were managing these babies
for longer, but they said they saw how powerful it was when they were empowering these moms. They weren’t going to mess with that either. That’s amazing. Now, about half of the care that we do, is
in the nursery. The other half is in the inpatient unit. They are doing most of it. We are finishing it up for them, but they
have become leaders in this. That’s been one of the more amazing things. I think we have time for questions and discussion. Dr. Young: Thank you so much, Dr. Grossman. We had a lot of questions come in. We will get to those. I want to run through a little bit of the
resources because some of the questions have been specific to child welfare practice. We will make sure that the participants in
today’s webinar get these resources and a PowerPoint distribution to them so that they
have these to follow up with because we’ve had a fair number about child welfare practice. We have some from Children’s Bureau and their
information and memos, and from the Substance Abuse and Mental Health Services Administration,
specific to the treatment of opioids. If you are not familiar that SAMSHA put out
just a few months ago the National Guidance for Management of Pregnant and Parenting Women
with Opioid Abuse Disorders and Their Infants, we will send that to you so you have a way
to get in touch with ordering that. We also have some guidelines that are specific
to the treatment of opioid use disorders in pregnancy that we want to make sure that participants
have. The National Sensor published this Comprehensive
Approach to Collaborative Practice with child welfare, hospitals, treatment agencies, and
courts. It’s based on a national work group that came
out almost coming up on two years ago. We want to make sure that participants have
that as well as the other National Center resources that have been published on this
population and child welfare, as well as the online tutorials. We had a couple of questions come in about
getting CE use, so we have a Web page that’s specific to basics of treatment for opioid
use disorder, as well as this special population with pregnant and parenting women. The online tutorials also relate to that,
which we CE use. With that, let me turn to some questions that
have come in. First, you spent some time talking about this
change that happened, the culture change in the unit, in some of your last comments, about
some change that was made based on the nurses and others in the NICU sending families on
to you even before controlling them. What do you think that big difference was? Was it the data that they saw about the change? What do you think and what would be your recommendations
for other hospitals or communities about how to begin that change? Dr. Grossman: That’s a question I get a lot. It’s interesting. The way that we did the changes probably isn’t
necessary. We did this over a lot of years as we were
trying to figure out each new thing to do, so it wasn’t as unified. We knew we were trying to get it better, but
we didn’t have a vision of exactly what this was going to look like at the end. What’s been valuable is I mentioned in the
beginning that this started when I went to a Middlesex hospital to give this talk. I had to do all of this reading, which was
back in 2009. Last year in November, those folks came back
to visit our hospital to find out what was going on and what we were doing. We went through all of our stuff, and we sat
with a patient with them and walked around and talked to the staff. On their 45 minute drive home, they entirely
changed their protocol starting that night. They said, “We’re not going to treat babies
or moms the way we’ve been doing it for another minute.” They started changing that night. Now, most places are more measured. They said it was a little bit tough over the
first couple of weeks, and then everyone came onboard. Look, change is hard and not everybody’s going
to be onboard. A lot of other places have done it much more
slowly and said, “OK. We’re going to do this, this one element in
June of 2019, and then we’ll see.” That’s probably too slow. If you’re waiting until you convince everybody
that this is a great idea, you’re never going to get there. I’m a proponent of the lone nut theory of
this, and there’s this three minute Ted talk about the lone nut and starting a movement. It’s this grainy video at…It looks like
a concert, and there’s this guy dancing like a lunatic on a hill. Everyone’s just sitting and watching the concert
and ignoring him. Then somebody joins him, and then somebody
else joins him. Within 30 seconds, the entire hill is dancing. The idea was not to go and convince every
person that they should get up and dance. It was just to start and get a couple of early
adopters. As more people add, you start to become the
minority when you’re not part of it. Not waiting until everyone’s convinced but
finding a group that’s going to do this. This just is better in every way. It’s better for the staff. It feels better. It removes the anger from this. It’s so much better for the families, and
that’s very easy to see. I would just find some people who are interested
and get started that way. Dr. Young: Sounds terrific. Great advice to all of us to get started and
bring them on as you can. We recognize the contributions from Dr. Finnegan
from so many years ago before Subutex was available, but have you worked with families
with moms that have been using Subutex, buprenorphine, during pregnancy? Do you see any differences in expression of
the NAS symptoms during that? What the difference is? Dr. Grossman: Yeah. This has been borne out for the most part
from the data. It seems to be generally less severe, not
on 100 percent of cases. The length of stays tend to be shorter. For us, it’s a little hard to tease it out,
but we certainly see kids who don’t appear to be going through withdrawal. I’m a little skeptical of a lot of the studies
because it’s unclear what kind of non pharmacologic care they’re doing, which we’ve shown is so
important, that it’s hard to make a lot of conclusions from those studies. My experience is certainly that it tends to
be less severe on the babies. Methadone, as I mentioned, is the hardest
and has the worst withdrawal. It’s about 80 percent of our patients and
about 15 percent are Subutex, and that’s been going up over the last two years. Dr. Young: Thanks for that. The article that came out almost a year ago,
you published specifically to mothers that were on methadone and during pregnancy. What’s been your experience with moms who
were not on medication assisted treatment but using illegal substances or non prescribed
opioids, perhaps the population that’s not engaged in treatment and potentially less
compliant? Dr. Grossman: Yeah. Our approach has been no different whatsoever. There is somebody’s job, which is usually
our child protective services, to judge that. That is not my job, and that is good. I know what’s best for the baby with this
is to be with their mom. As long as somebody thinks it’s not dangerous
at that time, then we are doing exactly the same thing. What we have heard from our child protective
services is that they have been taking fewer of our babies away from their families because
they’re seeing them with the baby. That is adding a little bit more information
for them. If they’re on the fence and not sure, that’s
tipping it over to often keeping them together. There are situations where if the mom’s using,
if she doesn’t have any interest in being involved, there’s nothing we’re going to do
about it. If she does, look, she may not get her baby
now. That doesn’t mean that’s forever, and so this
is a chance for them to bond and to have that experience going down. Then we know it’s going to be good for the
kids. We don’t do anything differently. Dr. Young: That’s great. That’s great news. One of the resources that we’ll include in
the email that comes out to the registrants is a new publication or a new technical assistance
tool from the National Center on Developing Plans of Safe Care. Many of the participants on the phone today,
I’m sure, are familiar with the changes in the Child Abuse Prevention and Treatment Act
and that notification that’s to happen from hospitals to child protective services when
an infant is identified as affected by substance abuse, withdrawal symptoms or fetal alcohol
spectrum disorder. I think that panning guide will be helpful
to many in the audience, and again, we’d encourage you to reach out to us if you’d like some
help with any of that. How do you decide when to encourage breastfeeding
and when not to? Dr. Grossman: [laughs] That’s a good and a
little bit complicated question. We encourage it in cases where mothers are
in medication assisted treatment and compliant. We always encourage it then. There’s no dose restriction or anything like
that. Then less so if they’re using illicitly or
street drugs. There’s some questions about what you’re supposed
to do with marijuana, and probably our protocols, which I didn’t have any involvement in, are
probably a little more restrictive than I would like them to be. We are generally encouraging it. That’s the words I would use. It’s not up to us once they go home. We would encourage it when we can. Then we would discourage it. One of the things we’ve tried to do is just
being totally honest about things. In terms of like moms on methadone are going
to be sleepier, and so we discuss that with them. Moms are going to breastfeed. We would say, “Yeah. It’s safe. If you start using other things again, it
might not be safe, so you should stop breastfeeding them.” Which is I think a reasonable thing to discuss. We’re just open about it and trying to remove
the stigma about discussing these things. There’s relapse rates with these things, so
it’s important to discuss. That’s how we look at it, and I think probably
most hospitals have some version of that. It should always be encouraged in folks in
compliance with their program. Dr. Young: Were there any changes with the
nurse patient ratios on the general floor when you began moving babies or not moving
them to NICU but putting them together with moms in the general floor? Did you change the nursing pattern? Dr. Grossman: No. The nursing pattern’s not been changed in
the nursery or on the floor. If anything, if anyone gets a extra baby,
it would be now an NAS baby, which is the opposite of what most people think about it. They are not more difficult than any other
patient, and in fact, they’re easier than most. The folks in the nursery who are doing couplet
care, they have not changed. Some of them say, “Well, it’s a little more
work, but it’s OK.” No, no changes. Dr. Young: A few different questions about
the guidelines from American Academy of Pediatrics on the length of time to monitor for NAS symptoms
to materialize, if you will, or manifest. It sounds like or some of the data looked
like you’re perhaps not monitoring in the hospital that length. Can you talk about how long you’re monitoring
babies before discharge, when you’re make that determination that those symptoms are
resolved and ready to go? I guess that’s two different questions. One on are…
[crosstalk] Dr. Young: …before the symptoms and then,
second, on making that determination about when to send home. Dr. Grossman: I don’t think we are ever sending
home a baby whose symptoms are resolved. That’s not our goal. Our goal is to make sure there’s going to
be a good outcome. There’s not a lot of evidence behind the guidelines,
and they all say four to seven days for the longer acting ones and two to three days for
shorter acting. I have not seen a kid not have withdrawal
signs and then start on day four or five. Our general for the longer acting ones is
to look at five days plus or minus a little bit. Our goal is not to see if they’re going to
have withdrawal. Again, all of the messes of kids exposed to
methadone are all having withdrawal at that point and with buprenorphine with rare exceptions
not having it. We’re trying to think about are the parents
ready, or they feel confident? Are they doing everything? That’s usually somewhere between four and
six days. If we have a situation where the mom can’t
be there, she’s in a program, and they won’t let her leave at night. The baby does great when mom’s there and not
as good when mom isn’t there, we’re going to discharge that baby sooner because mom’s
the treatment, and she’s not here. We are following those. We’re trying to figure out if that’s the right
amount of time. We’ve found for our purposes, it is maybe
for a slightly different reason than what they’re doing it. We feel like usually within that the moms
are ready. In some cases, it certainly could be shorter. For C section babies, they often go home with
the mom from the nursery on day four. Dr. Young: There was a comment/question about,
again, back to the involvement of child protective services that sometimes that particular hospital’s
from the questioner is that they’re holding babies for a longer period of time because
they don’t have a place for the baby and the mom to go or for the baby to go if there’s
going to be a placement. Have you run into that? How are you doing that? How are you making those determinations? The larger question with that is CPS involvement. Has that relationship changed? Have you had some specific efforts with child
protective services? You said they’re more likely to be keeping
babies with their moms. What’s that look like? Are there specific strategies that you put
in place related to CPS? Dr. Grossman: Not specifically to CPS. We certainly have a good relationship, and
they’ve loved what we’ve done. The Commissioner of our Department of Children
and Families loves our program. We haven’t done it specifically to affect
that. It wasn’t our goal but it had that impact. In terms of that, we definitely ran into issues
as we were starting where there would be this delay of several days where we would be ready
to discharge the baby before things would be figured out. We made us think about that years ago. It’s when they start the process. They wouldn’t start anything until we would
say the baby’s ready to go. We knew that. We’ve been able to work around that a little
bit so I think they’re ready to go. We don’t have delay. If we have a delay, it’s very rarely and it’s
for a day. That’s just working with them saying, “Look,
are you going to…” It’s the same amount of work just when you
start doing it. The treatment means babies are not going to
be with their families. They need to be with another family soon. They saw that and I said, “We can permit it.” There’s extra work for us when it starts. We were able to work with them and I think,
we all understood that. They’ve been a nice partner. Dr. Young: That’s something that we’re hearing
and encouraging from the National Center on Substance Abuse and Child Welfare. In fact, that monograph that we showed the
cover of the collaborative approach to the treatment with pregnant women with opioid
case disorders has a whole case study written from Burlington, Vermont and their charmed
collaborative which works closely with the prenatal clinic so that the plan can be determined
before the due date. A lot of the crisis that burdens the CPS is
responding to by getting the call here if an infant…We have to do a safety assessments. Often, there’s automatic hold placed on the
baby that there’s not going to be a discharge until there is investigation and a safety
plan developed by CPS. We’re mindful of the community that are working
on that very specifically. Again, we’d encourage participants to take
a look at that case study in that monograph about how Burlington, Vermont has changed
their practice in regard to that, making sure that there’s a plan prior to the mom’s due
date, which brings us some of that engagement with families in the prenatal period. Do you have a protocol that’s been developed
or who’s providing that education piece to parents and particularly, the engagements
of fathers? What does that look like in that prenatal
period on that education to families? Dr. Grossman: That’s a good question. The other place, they’re doing it better than
we are. In some places have done a pediatric consult. We will have either the neonatologist or hospitalist
will meet with the family and go over. We have a nurse practitioner who does it. We have a whole protocol and handout information
packet that goes to the families. Our efforts to engage the fathers prenatally,
I don’t think we haven’t done much of anything. That’s a good idea to try to figure how to
do that. I don’t know of anyone has a real focus on
that at this point but it’s probably a nice idea. We do all the stuff. Of course, there are families that we missed
and we haven’t given them the prenatal education or plan. I would just do as soon as we can and keep
reinforcing it. Dr. Young: What if the other service systems
or a collaborative partners that become important when there is a notification from Child Protected
Services and there’s the determination about the baby is not going to stay in the custody
of the birth mom? Are the dependency court judges for the juvenile
court judges…Have you had or is there anything that you could report back about any change
in the juvenile court system or their awareness or reach out to them specific to the court
processes for these infants? Dr. Grossman: I can’t speak intelligently
about that. What I don’t know of our changes around here. I haven’t heard anything about that. I apologize. Dr. Young: No, that’s fine. We would again encourage the participants,
if you’re running in to a situation that the juvenile court judges may have a different
view from the medical advice from the hospital, again, we’d encourage you to get in touch
with us and see if we might be able to be helpful with some technical assistance for
that. For the participants, you’ve seen the contact
information on the screen for quite some time. That’s an encouragement to please do be in
touch with us if there are questions that are specific that we didn’t get to in our
time today. We do have some of those that we will try
to respond to individually and those that we’ll refer on to Dr. Grossman for some of
the more clinical practice kind of issues. Again, we thank you so much for your participation
today. We are pleased with the response for the number
of registrants for this webinar. Know that this is a critical issue and appreciate
so much Dr. Grossman sharing his knowledge and the whole group he worked with to change
their practice. One final question that I have before we leave
came from one of the participants today and said, “Do you believe this approach is doable
across the country?” Dr. Grossman: Yeah, totally. It doesn’t take any resources. This takes far fewer resources than the traditional
approach. It’s just treating the babies like babies
and moms with the respect that they deserve as moms. There are some problems to deal with which
is mostly “How do you keep the mom and baby together in some areas?” but those are surmountable
problems. That’s the only thing. The rest of it is changing attitude and the
thought process about it. This is totally doable. There is no real other than figuring out the
problem on how you keep them together. There’s no need for any investment. It should be a major money saver. Dr. Young: Terrific. Thank you so much and thank you again to all
the participants. We look forward to hearing from you and appreciate
all the works that you’re doing on behalf of the nation’s children and their families. Thank you. Dr. Grossman: Thanks everybody.


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