Editor’s Note: This is the second piece in a two-part series. Please read the first piece here.
Dr. Alison Holmes, a pediatric hospitalist at Dartmouth-Hitchcock, did not expect to work in perinatal addiction. “I had no interest in addiction,” Dr. Holmes admits. Her pediatrics training equipped her with very little knowledge about addiction in general, not to mention its effects in neonates. Additionally, after completing a fellowship in Rochester, New York, one of the states least affected by the opioid crisis, perinatal addiction was not on her mind at all. So when she moved to Concord, New Hampshire, labeled by state representatives as the “home of an opioid crisis,” she was presented with new challenges and surprises.
New Hampshire is at the heart of the national opioid epidemic; it is the second highest state for overdoses and the highest for fentanyl-related deaths per capita. Just as on the national scale, New Hampshire has seen dramatic increases in neonatal abstinence syndrome (NAS), the collection of withdrawal symptoms that neonates present with at birth following prenatal exposure to narcotics. Over six percent of infants are exposed to illicit drugs in utero, and between the period of 2006-2009, there was a 600 percent increase in NAS diagnoses nationally. Dr. Holmes reports that after well newborn hospital discharges, NAS is the most common pediatric discharge diagnosis at Children’s Hospital at Dartmouth-Hitchcock. Untreated narcotic addiction in pregnancy is associated with an increased risk of fetal growth restriction, abruptio placentae, fetal death, preterm labor and intrauterine passage of meconium.
As such, perinatal addiction is an urgent public health crisis. And yet, Dr. Holmes says that “we [pediatricians] were left out of the books,” citing the fact that the leading scholarship within pediatrics has traditionally omitted the psychosocial aspects of addicted mothers and their affected children. Additionally, Dr. Holmes notes that many hospitals and health care systems have not been equipped to handle the volume of addicted mothers and their withdrawing infants. “We can’t put 10 percent of newborns [the current proportion at DHMC] in the hospital for four weeks — that’s not good for anybody,” she says.
At Dartmouth-Hitchcock, Dr. Holmes has collaborated with the Moms in Recovery Program to educate addicted mothers on NAS and how they can participate in the care of their child.
She has helped develop a “rooming in” model, where the mothers stay with their babies in the hospital while they receive NAS treatment. According to The New York Times, citing a Dartmouth study in Pediatrics, rooming in “reduced the length of stay for morphine-treated infants to 12 days from nearly 17, and the average hospital costs per infant to $9,000 from roughly $20,000.”
Within the hospital setting, however, Dr. Holmes describes a subtle tension between obstetrics and pediatrics. “They’re the mothers’ doctors, we’re the babies’ doctors … Pediatricians are very protective of children. That’s part of our professional role. We’re always thinking about what’s best for the baby — not always necessarily thinking about what’s best for the parent.” Goodman believes that the program does a good job of taking care of both the needs of the mother and the child: “We see the mother and baby as a dyad, not as two distinct or competing entities, and our goal is safety and health for both of them, hopefully together. ”
At the same time, Holmes has advocated for toxicology screening of all mothers in high prevalence regions like New Hampshire, so that no potential affected baby is missed; the obstetrics department believes that SBIRT screening is sufficient, consistent with national practice guidelines and research suggesting that drug testing prevents some women from accessing prenatal care.
Dr. Holmes also finds that some of her colleagues have a difficult time not passing judgment on these mothers, though notes that she has seen major improvements in this regard. “People who go into pediatric or neonatal fields — we’d throw ourselves under a bus for any kid … It’s a tough bridge to draw empathy between people who choose those professions and people who struggle with addiction.” Colleagues will sometimes ask “how could someone do that to their baby,” which she believes compromises care and the relationship between the mother and the care team. To combat this mindset, Dr. Holmes urges clinicians, especially those in pediatrics, to take a holistic view of a child born to a recovering mother, and be careful not to pass judgment on that mother. She encourages her colleagues to consider the factors that fed the mother’s addiction in the first place and to realize that expressing compassion to the mother fosters a relationship where the mother feels like a valued member of the care team of her child, and can aid her recovery process.
In her experience, Dr. Holmes has found that this approach works. She is optimistic that this system of support for the infants bolstered by an ethos of compassion for the mothers can help change the culture. Proud that Dartmouth-Hitchcock’s work has begun to garner national attention, she hopes that more hospitals — and not just university hospitals — will adopt this framework. In her words, “It’s only when we come together as a team that we can fight and win this battle.”