Oklahoma Children's Hospital improves care for babies with neonatal abstinence syndrome

In years past, health care providers took a punitive stance toward women giving birth to babies exposed to substances like opioids in the womb. Today, backed by research showing better outcomes through an educational, compassionate approach, providers at Oklahoma Children's Hospital OU Health have created a process for surrounding mom and baby with the care they need in the hospital, at home and in their communities for the years to come.

The American Academy of Pediatrics granted funding to the University of Oklahoma for hospital providers to refine and improve the discharge process for mothers and babies with neonatal abstinence syndrome, also known as neonatal opioid withdrawal syndrome. The project, called the Perinatal Health and Substance Use Quality Improvement Virtual Learning Collaborative, is helping establish best practices for this transition. Oklahoma Children's Hospital is one of eight hospitals nationwide chosen for the program.

Babies born with neonatal abstinence syndrome may experience withdrawal from the drugs that crossed the placenta while in utero. Symptoms include jitteriness, trouble sleeping, diarrhea, vomiting, poor appetite and, in severe cases, seizures. If symptoms can be managed in the Mother-Baby Unit, the health care team focuses on soothing techniques, feeding and sleep support. If a higher level of care is required, including medications, the baby is transferred to the Neonatal Intensive Care Unit. Once discharge is possible, it is essential to have a well-structured plan to ensure caregivers receive adequate guidance and support.

We want to provide continuity of care for mom and baby. Care starts prenatally and goes through labor and delivery, and for this project, we are focusing on our discharge planning. This is work we are already doing, but participating in the collaborative will allow us to learn how to do it better."

Benazir Drabu, M.D., neonatal hospitalist, associate professor of pediatrics at the OU College of Medicine and team leader for the project

Mothers and babies affected by substance use usually stay in the hospital longer than the general population of birthing mothers. When discharge approaches, an interdisciplinary team of physicians, nurses, social services providers, physical therapists and occupational therapists shifts its focus to keeping the family well-supported at home.

Soothing strategies used in the hospital are reinforced, including providing the family with a "sleep sack" that swaddles the baby and teaching them how to console a fussy baby. Safe sleep at home is also emphasized. The team encourages caregivers to have a crib or "pack and play" instead of letting babies sleep with parents.

"In many cases, families don't have a separate place for the baby to sleep, so they put them in their own bed, which puts the baby at risk for an adverse event," said neonatologist Patricia Williams, M.D., associate professor of pediatrics at the OU College of Medicine and a co-leader of the project.

Mothers are screened for depression and coached on successful breastfeeding. The hospital team also aims to strengthen communication with primary care providers to ensure continuity of care. Social service providers connect the family to community organizations, such as Sooner Start and Oklahoma Family Network, that provide everything from diapers to respite care to support groups.

In addition, families are referred to the Little STAR clinic for an appointment 30 to 90 days after hospital discharge. Little STAR is a follow-up program to the Substance Use Treatment and Recovery (STAR) prenatal clinic at OU Health.

"Studies have shown that babies who have prenatal substance exposure can have poor developmental outcomes, both cognitively and behaviorally," said developmental and behavioral pediatrician Susan Redwine, M.D., an assistant professor of pediatrics in the OU College of Medicine and co-leader of the project. "We want to prepare caregivers for that but also give them hope because there are clinics and programs that can help. Early intervention is so important, as is being non-judgmental. Our goal is to provide as much support as possible."

When babies reach 1 year old, they qualify for services at OU's Child Study Center, which continues developmental and behavioral support up to age 7. "We want to be the bridge between the baby leaving the hospital and getting families into programs at the Child Study Center," Redwine said.

OU was previously part of a national effort to improve the care of babies exposed to substances in the womb with its participation in the "Eat, Sleep, Console" clinical trial funded by the National Institutes of Health. The trial evaluated the "ESC" approach to caring for babies with neonatal abstinence syndrome. ESC includes feeding babies every three hours around the clock to address the weight loss that often comes with substance exposure. ESC also prioritizes consoling and ensuring babies get adequate sleep. If a baby cannot be consoled within 10 minutes, medication may be considered. The trial had good outcomes, including a shorter hospital stay and decreasing the likelihood the baby would need medication. ESC has now become the standard of practice.

"It gives us a sense of fulfillment to help these babies and their caregivers and to keep them together as much as possible," Drabu said. "Sending them home happy and prepared is priceless."