THE CASE FOR CUDDLING
A new approach is helping to keep opioid-dependent women with their newborns, for the benefit of both
As the time came near to have her baby, Rebecca Dowds was terrified the newborn would be snatched away by child welfare authorities.
Dowds was dependent on prescription opioids.
It was October 2015, but since 2013, she had been taking Percocet, a narcotic pain reliever containing a combination of oxycodone and acetaminophen, to treat spinal pain and sciatica. With the help of her obstetrician, she had weaned herself from six to three pills a day. “I got stuck at the threepill point,” she says.
Newborns born to mothers who are dependent on opioids may go through withdrawal almost as soon as they are born. While the mother is carrying the baby, opioids pass through the placenta from mother to baby, leaving the baby dependent. At birth, opioids are no longer passing from the mother to the child, and withdrawal symptoms appear as the drugs are clearing from the baby’s system. Babies born dependent may scream, tremble and convulse, or have less obvious symptoms, such as sneezing or yawning.
How to treat these babies — and their mothers — is of increasing concern. More than 1,800 newborns were born with “neonatal abstinence syndrome” in 2016-17, a 27 per cent increase compared to five years earlier, according to the Canadian Institute for Health Information. That’s about one in every 200 babies born in Canada.
Dowds, now 28, feared her own efforts to stop using opioids would be judged and found wanting.
Her doctor mentioned a program called rooming-in at the Kingston General Hospital, where she was a patient.
Here’s how it works: Dowds would be officially discharged as a patient soon after giving birth, but her baby would remain a patient. Dowds could remain 24 hours a day in a room with her newborn, giving the baby all the necessary non-medical care.
Even though she was fearful, Dowds called the Children’s Aid Society herself.
“I just wanted to make sure that it didn’t look like maybe I was hiding something. Although it was very scary,” she says. “I cried for days because I was so nervous. I knew I made the right choice, even though it was hard.”
That fear was well founded. Until recently, many hospitals have separated mothers who used opioids from their newborns at birth, placing the babies in the neonatal intensive care unit where they could received round-the-clock care.
But a growing pile of evidence suggests that keeping mothers and babies together is better for both. It reduces NICU admissions, shortens hospital stays and reduces the need to prescribe drugs for babies going through withdrawal. Rooming-in even reduces the involvement of child welfare authorities.
And it gives mothers an opportunity to change their lives.
“Moms and dads are receptive to conversations. It can be lifechanging. I have seen it. Now you are seeing a third party affected. It stimulates a lot of thought,” says Dr. Pradeep Merchant, site chief of neonatology at The Ottawa Hospital’s Civic Campus, where there are about 60 admissions of opioiddependent mothers every year.
Learning she was pregnant was life-changing to Dowds.
“There was no one I needed to be accountable for. So I probably wouldn’t have changed for awhile.”
The Canadian Paediatric Society has recognized the importance of allowing mother and baby to remain together. “Weeks of separation can be harmful to early bonding and attachment, and risks making a bad situation worse for both mothers and their babies,” says Dr. Thierry Lacaze, chair of the society’s fetus and newborn committee, which released new guidelines in January, including endorsing rooming-in.
“These babies are very challenging. They need a lot of attention. They need skin-to-skin care. You need leadership to create a multi-disciplinary program,” he says. “The effect of being cuddled on the skin is very impressive. We tend to believe that we have to give drugs or medical procedures. But just cuddling has a huge impact. The effect is remarkable.”
Pregnancy can be a significant motivator for mothers who use opioids, says Lacaze. “They express a feeling of guilt and responsibility. They are asking to minimize the risks for their babies. If they come on illicit drugs, they are asking for a substitution. Many on prescription drugs ask a lot of questions and they’re being compliant.”
“Separating the mom and the baby is a disaster. It just continues the guilt and stigmatization.”
Rooming-in felt like being at home with a very large family, says Dowds. Her daughter Sephira’s only withdrawal symptoms was sneezing, a common symptom of NAS. Most importantly, none of the staff made her feel like she was being judged, she says.
“Every move you make, you feel it. You feel smaller, less competent. Not feeling judged allows you to open up.”
Women who are pregnant are motivated to make positive changes and get healthy,” says Dr. Adam Newman, an attending physician at the Kingston General Hospital.
“If they don’t get proper treatment, they will keep on using drugs. When we routinely snatch babies away and put them in the NICU — even if we do it compassionately — we are physically separating them from their babies. They sense they are being judged. They feel amplified shame.”
Rooming-in allows bonding between mother and child, Newman says.
“It allows normal development. These mothers have real maternal feelings,” he says. “Women who do rooming-in get attention and positive feedback. They have the luxury of a safe and protected time together.”
Dowds had started using Percocet to treat back pain while she was working at a desk job for a landscaping company in Newmarket. She went to a pain specialist who slowly raised her dose of Percocet to six tablets a day. “I had a sit-down job at a desk and it was really hard to get through a day. At the time, it was a necessary evil. He just kept on prescribing the stuff.”
She moved to Kingston from Newmarket while she was pregnant because she has family nearby and was looking for more affordable housing and a fresh start. “I just wanted to start over. I just wanted better for her,” she says. “I wanted to make it as close to normal and perfect as could be.”
But Dowds had a hard time finding a pain specialist in Kingston. She contemplated tapering off the Percocet with a substitute such as methadone or Suboxone, but knew other people who had difficulties transitioning. She switched to Suboxone a few months after Sephira’s birth, and lowered the dose last summer.
Dr. Kimberly Dow, a neonatologist at Kingston General Hospital, says opioid-dependent mothers are a misunderstood group.
“There’s so many people that think that these mothers are addicts, they are taking illicit drugs, they shouldn’t even have their babies,” says Dow. “When, in actual fact, many, many of them are not addicts. They have never taken an illicit drug in their life. They have become physically dependent on drugs that have been prescribed for them, legitimately prescribed for them for pain.”
Many others who have had a substance abuse issue have struggled with it and are stable on maintenance programs, she says.
“They have turned their lives around. It’s very emotional to talk to them. It’s a very good feeling. They’re marginalized. They’re poor. They’re struggling socially and educationally. They don’t have a lot of the resources that other people have.”
A study by researchers at the Kingston General Hospital and Queen’s University has compared outcomes for infants with NAS before and after rooming-in was introduced. The results were significant — before rooming-in 20 out of the 24 babies needed pharmacologic treatment for NAS. After rooming in, it was only three out of 20 babies.
But the number of days spent in hospital was the most startling figure. Before rooming in, the median length of stay was 24 days. After rooming in it was only five days.
There are also economic benefits to the health-care system, Newman points out. “There are savings of hundreds of thousands of dollars at the Kingston General Hospital alone. Babies stay for a shorter period of time, and they stay in a less expensive place.”
Since birth, Dowds’ little girl, Sephira, has been with Better Beginnings, a program aimed at preventing children from lowincome, high-risk circumstances from having poor developmental outcomes. Sephira has surpassed most of the milestones for a child her age, says her mother.
“She has three-, four-word sentences. She has huge words for her age. Like upside-down, or dinosaur, dragon. She knows all of her colours and some shapes.”
Dowds’ back pain is a chronic condition and she would like to try physiotherapy, but can’t afford it. She recently took a job working the night shift at Tim Hortons.
“It’s not going to be quick. There’s nothing specific they can do to fix it,” she says.
Newman says opioids have been used by pregnant women for hundreds of years, and there is no evidence of birth defects or neurological defects, although there may be a genetic susceptibility to addiction.
“I follow a few women. Their children looked like well-developed little kids.”