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The title of this article captures very well the urgent need for a change in clinical practice regarding neonatal abstinence syndrome ( NAS ). The Canadian Paediatric Society’s Fetus and Newborn Committee’s ( CPS ) Clinical Practice Point addresses clinical concerns about the increase in NAS as a result of newborn infant drug withdrawal from maternal opioid use in Canada today. (1) The CPS suggestions are an important step forward in supporting a more holistic approach to the management of NAS by advocating a model of ‘rooming – in’ care for parents and families, advising less emphasis on pharmacotherapy, and highlighting the need for comprehensive discharge planning in this situation. The Practice Point does not elaborate on the requirements involved in implementing changes in perinatal care to make these suggestions a reality.
This rooming – in model of care for opioid using mothers and infants at risk of NAS was described in Canada in 2007 and 2010 by Dr. Ron Abrahams and colleagues. (2,3) This program has been running for over a decade in Vancouver and yet it’s principles and practice have not been adopted by the perinatal community across Canada. The implementation of this model of care as suggested by the recent CPS Practice Point requires a lengthy process of education and changing attitudes of health professionals towards these pregnant women and their families. The support of families in this situation requires a deep commitment by health care professionals ( HCPs ) to a non – judgmental broad based team approach to care during pregnancy, childbirth, and the post -partum period. This team approach should include HCPs supporting the above attitude to care comprising family practice, obstetrics, neonatalogy, pharmacies specializing in opioid prescribing, methadone clinics, and local social and economic support groups familiar with the pregnant women using opioids in the community.
Secondly the intra -partum and post – partum caregivers must be educated in a ‘ harm reduction approach ‘ to care for these pregnant women and their newborn infants. This harm reduction focus in education is traditionally absent from the standard medical and nursing educational programs. Harm reduction based care, relating to an understanding of previous life experiences involving neglect and abuse, is quite a foreign concept in tertiary care hospital settings where opioid exposed infants are likely to be born. This education requirement is in sharp contrast to the traditional perinatal and NICU approach of medically monitoring and treating babies with NAS only when they are in frank drug withdrawal. This approach removes the mother from the center of care thereby reinforcing many of these mothers’ previous negative experiences with institutions and persons in authority. (4)
A non – judgmental approach by care providers is essential to foster the basic trust necessary to support opioid using mothers during pregnancy , childbirth , and drug withdrawal in the newborn infant. Important aspects of this type of care may be easily overlooked in the traditional approach of treatment which separates mother and baby. For example the mother will require ongoing opioid medication after the infant’s birth. If this daily requirement is not met then her ability to care for her infant will be compromised. Understanding this aspect of care and acting on it is a ‘ leap of faith ‘ for many health professionals working in delivery rooms and perinatal wards in hospitals in Canada today. It contrasts sharply with the previous experience of mothers discharging themselves against medical advice in order to obtain their daily opioid requirement, resulting in almost certain legal apprehension of the infant.
While the CPS Practice Point indicated that careful discharge planning is ‘essential’ it did not highlight the importance of early frequent follow up of mother and infant together. This care must be undertaken by practitioners who are clinically experienced and trusted within the opioid using community. The ongoing care of both the mother and the infant in this situation requires considerable expertise, a trusting relationship , and HCP willingness to be flexible in their expectations of family dynamics, appointment scheduling, timetables etc.
Finally the success of the rooming – in model requires strong financial and infrastructure support in the birthing hospital to allow mothers, babies and other family members to remain central to care in hospital for 7-10 days. This duration of care is a considerable increase over the usual day or two post – partum stay currently available after birth. Strong leadership and institutional administrative support of the program is key to success in dealing with the myriad of obstacles that need to be overcome. As the rooming – in model is based on a dramatic change in focus, with the mother and family being primary care givers during the entire drug withdrawal phase, strong institutional support is key to success in implementation.
In 2014 we established a rooming – in program for mothers using methadone at the Grey Nuns Hospital in Edmonton. We received combined funding from the Government of Alberta and Covenant Health to support the program - Maternal Methadone use and Neonatal Abstinence Syndrome ( MMUNA ). The program involved identifying mothers using methadone in the community and arranging prenatal care, admission for delivery and post-natal care at our hospital. We also organized the renovation of two post-partum rooms to be available for the family members to stay in and provide 24 hour care within the program. The extensive staff education outlined above was a major undertaking as part of the program. To date our program has cared for 43 mothers and 46 infants. Almost all infants have remained in the care of family without pharmacotherapy or admission to neonatal ICU. Preliminary results have been presented locally and at a national bioethics conference. (5)
1. Management of Infants born to Mothers who have used Opioids during Pregnancy. Practice Point, Posted Jan 11, 2018, Canadian Pediatric Society, www.cps.ca
2. Rooming - in compared with standard care for newborns of mothers using methadone or heroin. Abrahams RR, Ann Kelly S, Payne S, et al. Can Fam Physician ; 2007, 10, 1722 – 1730 .
3. An evaluation of Rooming - in Among Substance - exposed Newborns in British Columbia. Abrahams RR, Mackay - Dunn MH, et al. JOGC 2010 ;32 (9) 866-871, 2010.
4. Canada FASD Research Network’s Action Team on Prevention from a Woman’s Health Determinants Perspective. www.canfasd.ca
5. Maternal Prenatal drug Use and Neonatal Abstinence Syndrome; A parable of vulnerability and intolerance( abstract ). Byrne P, Foss K, Clarke D, Cardinal K, Hare S. Presented at 28th Canadian Bioethics Society Conference, Montreal, Quebec, May 26, 2017 .www.cbs-scb.ca.
Paul Byrne
Paul J. Byrne MB,ChB,FRCPC,FAAP
Staff Neonatologist
Medical Director
Grey Nuns Hospital NICU,Covenant Health
Clinical Professor, Department of Paediatrics, FOMD
University of Alberta