Dr. Kimberly Spence ’94 treats the youngest victims of the nation’s opioid crisis.T
heir tiny hands spasm at the slightest noise. Their skin is soft and wrinkled. The babies Dr. Kimberly Spence ’94 treats look like typical newborns. But these infants at Cardinal Glennon Children’s Medical Center in St. Louis, where Spence is an attending neonatologist, are different.
They are the littlest victims of the biggest drug crisis in American history.
Born to mothers addicted to opioids, including heroin or prescription opiates, Spence’s patients are dependent on the drugs at birth and suffer through withdrawal, a condition known as neonatal abstinence syndrome.
Their numbers are growing. But it’s not just in St. Louis. It’s in small towns in America’s heartland, in New England’s suburbs, in big cities up and down the East and West coasts.
The opioid problem is nationwide, and newborns are paying the price.
The numbers of babies born with NAS in the U.S. tripled between 1999 and 2013, according to the Centers for Disease Control and Prevention. Infants with NAS now make up 20 percent of the population in neonatal intensive care units. Nationally, NAS affects six of every 1,000 newborns; in West Virginia, as many as 33 of every 1,000 are born drug dependent.
Every 25 minutes, a baby suffering from opioid withdrawal is born.
“It’s an epidemic,” Spence says.
STANDARD OF CARE
Both a medical doctor and an associate professor of pediatrics at Saint Louis University School of Medicine, Spence became interested in NAS out of pure necessity.
After earning a medical degree at the University of Missouri in 1998, Spence, who studied chemistry at Conn, completed a pediatric residency at St. Louis Children’s Hospital and a three-year fellowship in neonatology through Washington University School of Medicine. She loved working with babies, and she thrived in the fast-paced intensive care unit treating sick and premature infants. When she started as a full-time neonatologist in 2004, only a fraction of her patients were babies with NAS. But over the next 15 years, the number of cases shot up 200 percent.
So Spence, a self-described “organizer of chaos,” started looking into treatment options and ways to optimize health outcomes for infants and their mothers. Now, she’s part of an effort to create a new national standard of care.
It usually begins with a consult. Spence sits down with the mother-to-be and explains exactly what it’s going to be like for her baby.
Babies born with NAS can experience a host of symptoms, including diarrhea, poor weight gain, difficulty feeding, irritability, increased wakefulness, high-pitched crying and increased muscle tone or stiffness. In some cases, the newborns also experience seizures.
It’s never an easy conversation.
“Every single time, the mother is crying. She’s upset, she’s embarrassed and she feels terrible,” Spence says.
Many of the mothers Spence sees have already taken the first step to getting clean. They are no longer on street drugs, but withdrawal can be dangerous for both the mother and her fetus, and the risk of relapse is great. So the women enroll in maintenance programs and are treated with controlled doses of a synthetic opioid, like methadone or buprenorphine. Usually administered in a clinic, these drugs suppress symptoms of withdrawal, prevent fetal distress and allow for healthier pregnancies.
But they are still narcotics, and they do not prevent NAS.
Until recently, the standard treatment for all infants with NAS was to wean them with small doses of morphine. Now, experts like Spence recommend nonpharmacological treatments, like swaddling, rocking and skin-to-skin contact, as the first line of care for all but the most serious cases. “Rooming in”—keeping the infant in the room with the mother—is encouraged over treatment in the neonatal intensive care unit.
“These babies do well in a low-stimulation environment,” Spence says.
“We realized pretty quickly that it was not a good idea to put them in a nursery setting, with bright lights, lots of noise and activity, and minimal opportunities for skin-to-skin contact.”
There are other important benefits to rooming in: family bonding and breastfeeding.
Breast milk can significantly reduce the need for pharmacological intervention in babies with NAS and shorten the average hospital stay, according to a 2013 study published in Acta Paediatrica. Not all mothers are good candidates for breastfeeding, Spence says, but those participating in a drug rehab program, including those on methadone, can be very successful.
Even in situations where breastfeeding isn’t possible, skin-to-skin and family bonding can be crucial for the short-term health outcomes of both the mother and the infant, as well as the long-term success of the family as a unit.
That’s why, in that first meeting, Spence encourages each mother to see herself as an important partner in her baby’s care.
“They want to be successful,” Spence says. “Every situation is different, but many of these moms just want to take their babies home and get better. And that’s what we want—moms do better with their babies, and babies do better with their moms.”
After an infant is born, Spence evaluates the severity of NAS by scoring the infant on a series of tests and observations. These scores are calculated at regular intervals to assess the levels of withdrawal, monitor the progression of symptoms and decide on the course of treatment.
In the best-case scenario, Spence recommends rooming in and nonpharmacological treatments as a first step. But in the more serious cases, when an infant’s scores rise, the baby is transferred to the NICU and treated with morphine.
“Morphine is used to treat babies who are failing to thrive, miserable or more likely both,” says Spence.
Caring for infants with NAS has a huge price tag, no matter how they are treated. The average hospitalization costs upward of $53,400, and Medicaid is the primary payer, covering approximately 78 percent of the cost of care. The new approach to care can shorten average hospital stays from six weeks to as little as two weeks. However, some infants with severe cases stay for months.
Even in the mildest cases, where no pharmacological treatment is needed, infants must be monitored for up to seven days. And rooming in means the mother must stay, too.
“The average new mom stays in the hospital for two to three days; these moms are here for a week,” says Spence. “It’s a big expense and it can lead to a bed crunch.”
Still, rooming in allows doctors to treat not just the infant, but mother as well. That’s important, says Spence.
“You can’t treat mother and infant in a vacuum. You have to treat them together—the whole family.”