Neonatal Abstinence Syndrome: A (Toxicologist) Mother’s Perspective
A Birth Defects Insights Blog by Melissa J. Beck, PhD
On February 6, 2017, I first learned of the impending birth of my second daughter. That was the day that I also learned that she had already been exposed to a variety of drugs prenatally, and her birth mother had not had access to prenatal care for most of the pregnancy. Being a developmental toxicologist and motivated to become a second-time parent, I was not put off by this information. I was given some basic information about potential exposures but was warned that this may not be fully accurate.
Less than two months later, my daughter was born. On her first day of life, lab tests confirmed that her birthmother had continued to abuse several drugs throughout the remainder of her pregnancy, including heroin. Her birthmother volunteered that she had taken a final dose of heroin shortly before arriving at the hospital in an attempt to alleviate labor pains. This would have been my daughter’s last exposure to the opioid before birth.
The amazing team of healthcare professionals immediately began to monitor her for symptoms of withdrawal over the next few days. As this was all happening during the early explosion of the opioid epidemic, the healthcare team were well-versed in diagnostic protocols. Within 24 hours of birth, she began to develop classic symptoms of neonatal abstinence syndrome (NAS), including irritability, mild tremors and muscle rigidity, among other things. Over the next several hours, symptoms increased in number and severity until it was apparent that she would need pharmacological intervention.
At the time, there were no cross-hospital standardized treatment guidelines. Healthcare professionals within each hospital developed their own approaches, and they may have varied widely from hospital to hospital and state to state. We were at a large institution in California which used methadone titrated up to alleviate symptoms of withdrawal. Their approach also involved beginning weaning off the methadone as soon as possible, and once it was demonstrated that the child could successfully handle the tapering process, the child was allowed to be discharged under the care of a pediatrician affiliated with the hospital. Traveling back to our home state of Ohio became a bit of an issue for us, since Ohio did not allow infants on methadone to be cared for at home (a tale for another time).
When I was first informed about the true nature of my daughter’s exposures in the hospital, I turned to my colleagues for data. Having been a member of the Society for Birth Defects Research and Prevention (BDRP) for nearly 20 years at that time, I immediately started mining the literature. My first stop was the MotherToBaby website (being old school, I initially searched for the March of Dimes website and was appropriately directed to mothertobaby.org). The information I found there became a lifeline of hope and a trigger to dive deeper. While I had previously been aware of how gifted the members of our organization and the members of the Organization of Teratology Information Specialists, which provides the MotherToBaby service, I had never observed those giftings through the lens of a mother needing information.
After that initial review, I began performing my own literature searches, finding articles on diagnosis using Finnegan scoring (I may have begun stalking the scoring tool used by the nurses to log my daughter’s symptoms), anticipated symptoms and approaches to treatment. It was at that point that I realized how varied the potential treatment plans were. I was also struck by how much we didn’t (and still don’t) know. For example, the immediate effects of prenatal exposure to synthetic opioids were fairly well characterized. We could expect, and did, see tremors, muscle rigidity, excessive sneezing, excessive yawning, skin mottling and skin excoriation. We were fortunate, in that most of her symptoms were not severe and that she adapted quickly to treatment. However, what became abundantly clear was the paucity of data on long-term outcomes in children who fell under her situation.
In 2018, I was fortunate to be able to attend a platform symposium on the impact of opiates on pregnancy and child development at the BDRP Annual Meeting, which was co-sponsored by the Developmental Neurotoxicity Society (DNTS). Between that symposium and my own personal research over the next months to years, I noted that much of the clinical research into long-term effects of prenatal opiate exposure was focused heavily on children who remained with their birthmothers. This made perfect sense since many children remain with their birth families. Understanding the impact of that environment on growth and development of the child would help establish family-centered goals to improve the health of the entire family and prevent some of the negative long-term outcomes that were being identified. Some of these studies have identified cognitive delays, an increased incidence of attention-deficit hyperactivity disorder and other behavioral changes in children prenatally exposed to opiates. Further research indicated that when the family was offered support, some of these outcomes were less severe.
However, there have been fewer studies that have evaluated the long-term outcomes of prenatal opiate exposure in children who were removed from the birth family altogether. Were these children as likely to exhibit the same long-term effects as noted for children remaining with their birth families? More recent studies have tried to tease out potential differences by comparing children remaining with their birth families to those that were moved to foster families, although the data from these studies are difficult to interpret for one very important reason: confounders.
Over the past nearly 8 years, I have spent more and more time following the research, trying to anticipate what we may be looking at in terms of my daughter’s future healthcare needs. Yet, what has become increasingly evident is that most women who abuse drugs during pregnancy do not limit their intake to only one drug, either by choice or by expediency. Therefore, studies examining the impact of prenatal drug exposure, including those focusing on prenatal opiate exposure, are conducted in children exposed to multiple, sometimes unidentifiable, drugs. Thus, children are often grouped into those exposed to opiates with the caveat that other drugs may have been ingested during pregnancy. Alternatively, the exact exposures may be much less well-defined, such as “drug exposure,” or “multiple drug exposure,” or even “primarily opiates,” indicating that other drugs were clearly present at some point during pregnancy. Thus, the effects that have been identified may or may not be due to opiate exposure. Indeed, even our own experience bears this out, since my daughter’s laboratory results indicated more than one drug was present at birth. As a scientist, I understand this lack of clarity, but as a mother, it can be enough to keep you awake at night.
As I watch my daughter grow and mature, I am reminded of the fact that she has beaten so many odds. She has been fortunate to have avoided many of the more negative consequences of prenatal opioid exposure, although she does exhibit at least one of the apparent long-term outcomes associated with the drug. However, I am also keenly aware of how much we still don’t know about the extent of possible future outcomes she may face or those that are already present but as yet unidentified.
As I reflect on the fact that January is Birth Defects Awareness Month, I cannot begin to describe the pride I feel in the efforts of my colleagues across the globe who have striven to characterize, treat and prevent birth defects. I also cannot fully express my gratitude for your tireless efforts to provide hope and support for the families affected by these diseases through prevention, diagnosis, awareness of the potential outcomes and treatment. From one BDRP (family) member to another, thank you!
