On learning last year she was pregnant with her second child, Cailyn Morreale was overcome with fear and trepidation.
“I was so scared,” said Morreale, a resident of the small western North Carolina town of Mars Hill. In that moment, her joy about being pregnant was eclipsed by fear she would have to stop taking buprenorphine, a drug used to treat opioid withdrawal that had helped counter her addiction.
Morreale’s fear was compounded by the rigidity of the most common approach to treating babies born after being exposed in the womb to opioids or some medications used to treat opioid addiction.
For decades throughout the opioid crisis, most doctors have relied on medication-heavy regimens to treat babies who are born experiencing neonatal opioid withdrawal syndrome. Those protocols often meant separating newborns from their mothers, placing them in neonatal intensive care units, and giving them medications to treat their withdrawal.
But research has since indicated that in many, if not most, cases, those extreme measures are unnecessary. A newer, simpler approach that prioritizes keeping babies with their families called Eat, Sleep, Console is being increasingly embraced.
In recent years, doctors and researchers have found that keeping babies with their mothers and ensuring they’re comfortable often works better and gets them out of the hospital faster.
Despite her worst fears, Morreale was never separated from her son. She was able to begin breastfeeding immediately. In fact, she was told, the trace of buprenorphine in her breast milk would help her son withdraw from it.
Her experience was different because she had found her way to Project CARA, an Asheville, North Carolina-based program, administered through the Mountain Area Health Education Center, that supports pregnant people and parents with substance use disorders. Morreale’s care team assured her she did not need to discontinue buprenorphine and that her baby would be assessed and monitored using the Eat, Sleep, Console approach. The protocol deems babies OK to be sent home so long as they’re eating, sleeping, and consolable when upset.
“By the grace of God, he was awesome,” Morreale said of her son.
David Baltierra, MD, former director of West Virginia University’s Rural Family Medicine Residency Program, chair of WVU’s Department of Family Medicine – Eastern Division, and a family physician, suggests this protocol could simply be called “parenting.”
The method is increasingly being used instead of the long-embraced approach to treating opioid-affected newborns called the Finnegan Neonatal Abstinence Scoring System. That tool includes a list of 21 questions (is the baby crying excessively, sweating, experiencing tremors, sneezing, etc.), the answers to which determine whether the newborn should get medication to counteract withdrawal symptoms, which would then require an extended stay in a neonatal ICU.
Baltierra, though, has issues with the Finnegan method. For example, it often results in a soundly sleeping baby being awakened to be scored. That didn’t make sense to Baltierra. If the baby is sleeping, she’s likely doing fine.
Instead, health professionals should look for the telltale signs of a baby experiencing opioid withdrawal syndrome, he said. “Their body is in tension, they have a high pitch, they don’t calm down.”
Baltierra and his colleagues have been training residents to use an Eat, Sleep, Console approach for a decade, progressively more so in the past six years. The results are persuading more health professionals to adopt the method.
A 2023 study found babies treated this way were discharged from the hospital in nearly half the time and less likely to receive medication than those receiving Finnegan-based care.
Matthew Grossman, MD, an associate professor of pediatrics at the Yale School of Medicine, refers to the introduction of the model of treatment he has helped pioneer as “the least innovative” undertaking imaginable.
Research shows that optimal care for pregnant women who’ve experienced opioid use disorder includes treatment with buprenorphine or methadone, which carries the risk their newborn will have withdrawal symptoms. Grossman and colleagues found a non-pharmacological-first approach works best.
He said the Finnegan tool is useful but often too rigid. Under its scoring, one sneeze too many could send a baby to the NICU for weeks.
Grossman said he observed that some babies receiving medications did well for a few days but began to decline when their mothers were sent home without them. Those observations made him ask, “Did the kid need more medicine, or more mom?”
Research by Leila Elder, MD, and Madison Humerick, MD, who each did their residency in WVU’s rural program, found that median stays for newborns in withdrawal dropped from 13 days in 2016 to three in 2020.
Elder said babies born at the 25-bed rural hospital where they performed deliveries received medications to treat their withdrawal symptoms only when unrelated issues sent them to other hospitals for NICU care.
The simpler treatment also means more babies born in rural communities can receive care closer to home and has reduced the likelihood a mother will be released before her baby is cleared to go home.
Grossman suggested that rural hospitals are better suited to employ the Eat, Sleep, Console approach than big-city institutions, given the latter’s generally easier access to a NICU and propensity to choose that option.
Sarah Peiffer, MD, recalls the first time, as a medical student, she witnessed a nurse administering the Finnegan protocol, discussing it in clinical terms at a new mother’s bedside.
“And I remember being kind of horrified,” she said. The process was clearly distressing to both mother and child. “I felt like there was almost a punitive feeling to it, like we were telling this mom, ‘Look what you did to your baby.’”
Peiffer is now a Project CARA practitioner and family health physician at Blue Ridge Health in western North Carolina and a vocal proponent of ESC and its approach to partnering with families. “You look at all the nonpharmacologic stuff you’re supposed to be doing — like keeping the lights low in the room, keeping the baby swaddled, doing as much skin-to-skin with mom as possible — and you really treat mom as medicine.”
Research suggests immediate postbirth skin‐to‐skin contact offers “vital advantages” to short‐ and long‐term health and bonding.
That contact, Elder said, “releases endorphins for mom,” which helps lower the risk of postpartum depression.
Grossman said developing the Eat, Sleep, Console protocol was simply a matter of pausing to reassess.
The original intent of the Finnegan tool wasn’t to render the process so rigid. But “everybody is excited to have a tool, and then this approach calcified around it,” he said.
Grossman said the objective of the simpler approach was to place the family at the core of care, and shorter hospital stays for babies was simply a fortuitous outcome. The shift in approach fits into a wider move toward judgment-free, family-centered care for those who’ve experienced addiction and for their children.
Now, he said, after five days, mothers often say “‘Can we go home? I think I got this,’” and they’re treated “with the same respect as any other mom.”
Peiffer said she has witnessed this mother-centric care counter “that sense of shame that people feel instead of families feeling empowered to care for their infant.” It represents “such a major shift in how we think about neonatal withdrawal both medically and culturally.”
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