Working to battle opiates' toll on next generation

Long-term effects of neonatal abstinence syndrome may show up at school, study finds

Nurses, therapists and specialists debrief before meeting with patients at the Neonatal Abstinence Development Follow-Up Clinic at All Children's Ouptatient Center in Sarasota. [Herald-Tribune staff photo / Dan Wagner]  

Nurses, therapists and specialists debrief before meeting with patients at the Neonatal Abstinence Development Follow-Up Clinic at All Children's Ouptatient Center in Sarasota. [Herald-Tribune staff photo / Dan Wagner]  

SARASOTA — In the first month of the new year, nine babies born in January already had been treated for neonatal abstinence syndrome at Sarasota Memorial Hospital. Eight newborns had been treated for NAS at Manatee Memorial Hospital, where administrators called it "a good month."

Babies diagnosed with NAS are born addicted to drugs because of exposure in the womb. The condition is most often caused by exposure to opioids, including heroin and prescription painkillers. NAS leads to painful withdrawal symptoms during a baby's first few weeks of life.

"While the baby is inside the mother, if she's been taking methadone or street drugs, the baby is used to that ongoing exposure so their body is accustomed to that," explained neonatologist Dr. Tony Napolitano, medical director of the SMH neonatal intensive care unit and chair of the Department of Pediatric Medicine at Johns Hopkins All Children's Hospital. "At the time of birth, the baby is no longer exposed so the body starts reacting and what you're basically seeing is a drug withdrawal."

NAS has seen a spike in recent years because of the ongoing opioid epidemic.

In Florida, the rate of newborns diagnosed with NAS in 2013 jumped to 6.3 for every 1,000 births, up from 0.4 in the year 2000, according to the Centers for Disease Control.

Sarasota County had the third highest percentage of babies born with NAS in the state in 2015, according to the Florida Agency for Healthcare Administration. Manatee County was fourth. A total of 106 newborns were diagnosed with NAS in Sarasota in 2015, compared with 53 in 2012.

Babies born with the condition stand out for their inconsolable crying. They are likely to have fast-paced breathing and elevated heart rates as well as fever. They struggle to suckle, which leads to feeding and digestive problems. The symptoms progressively get worse, says Napolitano, and can last for around 20 days.

The long-term effects of NAS, however, can be even more problematic.

A desire to understand the implications of NAS throughout childhood led to a $70,000 grant from the Johns Hopkins All Children's Hospital Guild to fund an NAS clinic in Sarasota. The Neonatal Abstinence Syndrome Development Follow-Up Clinic will track babies born with NAS at SMH until they reach the age of 5.

Extended problems

A study published last month in the journal Pediatrics found that a diagnosis of NAS at birth could signal poor and deteriorating performance when children enter school.

The longitudinal study followed more than 2,200 children in Australia. By third grade, the children who were born with NAS already were falling behind their peers academically. By seventh grade, their performance had deteriorated even further.

Children born with NAS also are more likely to experience behavioral problems and attention deficit hyperactivity disorder, according to some preliminary research. 

"This finding is of great concern because school failure increases the risk of myriad poor adult outcomes, including depression in women, criminal activity, and drug use," the study reads. "We showed that children with NAS performed more poorly in all five test domains, including reading or literacy skills, one of the most important predictors of school success."

One in six U.S. children who are not reading proficiently in third grade do not graduate from high school on time, according to the Campaign for Grade-Level Reading.

Follow-up clinic

Since it opened in 2013, the NAS clinic has seen 269 children.

Doctors, nurses and specialists — including physical, speech and behavioral therapists — at the NAS clinic screen kids for developmental delays and behavioral issues. They also collect data that will help inform the research on NAS.

"What we're looking for is watching to make sure they're progressing normally," said Napolitano, who is also the lead neonatologist at the clinic. "If we see they're falling behind, we try to work with them early so that as they're getting ready for school hopefully they can adjust better."

The study published in Pediatrics concluded that educating parents and families could decrease the risks. Early intervention is key, according to the researchers.

"It goes back to that age-old question: nature versus nurture," said Jane Shannon, nurse practitioner at the NAS follow-up clinic. "Babies' brains are very malleable, and if we can get to them early we can hopefully change the outcomes."

Jane Shannon is a nurse practitioner at the NAS follow-up clinic in Sarasota. [Herald-Tribune staff photo / Dan Wagner]   

Jane Shannon is a nurse practitioner at the NAS follow-up clinic in Sarasota. [Herald-Tribune staff photo / Dan Wagner] 
 

Clinic managers hope to secure more funding in order to continue to follow the children past 5 years of age and into their school years.

"A child's success in life depends on how well they do in school," Dr. Napolitano said. "To make them into functioning adults it's important that they can adjust to school, so our concern is that we need to continue to watch these children because they might have some problems as they start to go through the education system."

Caring, not judging

Part of the challenge in treating babies born with NAS is that sometimes mothers are not forthcoming about their drug use, Napolitano said. It's critical for doctors to be aware because babies who are discharged from the hospital before NAS symptoms begin to surface are likely to end up in the emergency room.

"We don't walk in their shoes so we make no judgments," Napolitano said. "We're here to help take care of the baby and help the mother be a good mother."

The clinic's approach is to encourage families to keep coming back and help connect parents and caregivers with resources and social services. A representative of the Healthy Start Coalition, a nonprofit for infants and pregnant mothers, is part of the clinic staff.

Because the clinic doubles as a research study, it will be important to have families return for their appointments, Shannon said.

For a baby's first appointment, families receive a care package filled with baby supplies and books. Funding also allows for gas cards to help pay for transportation.

Last year, medical staff from Tennessee came down to observe the clinic and replicate it back home, where they are struggling with similar increases in NAS numbers.

"It's a significant problem and all states across the country are having serious issues with it," Shannon said.

Findings in the Journal of the American Medical Association revealed that from 2000 to 2009, hospital charges for NAS were estimated to have increased from $190 million to $720 million.

"This is something that the United States will have to grapple with big time," Shannon said.