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Yale’s Dr. Grossman challenged dogma to change the outcome for infants.
Neonatal abstinence syndrome (NAS), also called neonatal opioid withdrawal syndrome (NOWS), is a condition seen in babies born to mothers taking opioid drugs such as heroin, morphine, hydrocodone, and methadone. In utero, these drugs transfer across the placenta, cross the blood-brain barrier, and accumulate in the brain of a developing fetus. At birth, infants with NAS suffer from a host of distressing symptoms because their bodies, grown accustomed to opioids while in the womb, are suddenly cut off from a steady supply of the drug.
As a result of the opioid epidemic over the past three decades, the number of newborns suffering from NAS in the United States has risen steadily. As many as 2% of babies born in the hospital go on to develop NAS, and a new case is diagnosed approximately every 15 minutes. An article published in the New England Journal of Medicine reported that from 2004 to 2013, “the total percentage of NICU days nationwide that were attributed to NAS increased from 0.6% to 4%.”
the standard of care across the country was to treat NAS with opioid medications — typically in the form of liquid morphine or methadone administered by mouth. The thought was that withdrawal symptoms could be reduced by replenishing the opiates babies were no longer receiving from their mothers.
Back to 2016: At the front of that packed conference hall stood Matthew Grossman, MD, a pediatric hospitalist who practices at Yale New Haven Children’s Hospital. He was accustomed to providing care for infants with NAS using methods similar to those I had been trained to use and similar to the way most of the country was treating NAS at the time. Grossman tells Elemental, “I used the traditional approach for three or four years before starting to make changes.”
Grossman and his colleagues at Yale formulated the simple premise that babies need to eat, sleep, and be consoled (ESC). That was it. It didn’t matter how much they sweated or sneezed; for the most part, they simply required those three essentials, which, as it turned out, were all easily quantifiable. Grossman’s medical team monitored the infants in their hospital with NAS and evaluated if they were able to take a one-ounce feed (or breastfeeding equivalent), sleep for an hour, or be consoled within 10 minutes. Pharmaceutical agents were administered only if these essential needs could not be met.
In addition to modifying the way infants with NAS were assessed, the ESC model changed how they were treated. Instead of placing babies on slow, scheduled opiate weans, single doses of morphine were given on an as-needed basis. As a result, requiring a dose of morphine no longer implied backtracking on a weaning protocol and another two to three days in the hospital.
Babies were no longer separated from their families. Instead of being treated in the NICU, they were kept on the mother-baby unit. Instead of starting with pharmaceuticals, the mother, or another caretaker, became the first line of treatment. Breastfeeding, skin-to-skin placement, swaddling, darkening the room, and limiting stimulation became the norm. Babies were fed ad lib rather than on a strict three-hour schedule. Grossman’s team brought back many of the naturally comforting things we tend to do for infants that weren’t available to babies with NAS in the NICU setting.