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Withdrawing the Disparity: Equitable and Effective Care for Narcotic-Exposed Newborns

Friday, October 19, 2012
Room R06-R09 (Morial Convention Center)
Salem Magarian, M.D.1, Christine Terry, RN, PDLN2, Christina O'Halloran, LCSW2 and Susan True3, (1)Pediatric Clinic, Dominican Hospital, Santa Cruz, CA, (2)Pediatrics, Dominican Hospital, Santa Cruz, CA, (3)First Five Santa Cruz County

Purpose      Develop an integrated community hospital based program for infants exposed in-utero to narcotics and methadone that would improve their neurodevelopmental and social/emotional outcomes and potential to stay successfully with their birth mothers

Methods      Prior to this program mothers using narcotics during their pregancies were usually not detected until their delivery, if at all.  There was a substantial increase in adverse perinatal outcome, prolonged newborn hospital stay, later ER and in-patient care, foster placement, and adverse neurodevelopmental outcome.

       A professional group consisting of a hospital based pediatrician, NICU / ER nurse, MCH social worker, and public health nurse  devised an integrated program to create a community based system of care from the prenatal to the pediatric period for these mothers and infants.  

        All mothers using narcotics in pregnancy were offered rehabilitation services and methadone treatment.  Care was centered on one obstetrical group.  Mothers met the MCH social worker prior to delivery and were seen by Child Protective Services within 2 days following the infant's birth.  All infants were cared for in the NICU and received standardized neonatal abstinence/withdrawal scoring every 2 hours and started on morphine (0.2 mg) at a specifc threshold with a clinical pathway for rapid dosage adjustment.  All babies were seen daily by occupational therapy for help with feeding and state regulation.  Infants were discharged as soon as they were feeding well, gaining weight, not exibiting signs of withdrawal, with no change in medication dose for 48 hours.

     Infants were seen the day after discharge in the hospital based Pediatric Clinic and continued on the same dose of medication.   All infants were seen weekly in the pediatric clinic by the pediatrician with support from social work, OT, and case management.  Medication was gradually weaned by protocol from 4-8 weeks of age.  Mothers received drug treatment, social support, and life coaching.  Infants were given standard developmental assessments at 9, 18,and 24 months.

     During past 7 years, 150 infant/mother couples received care with this integrated program.

Results    Average NICU stay reduced from 14 to 9 days (35% decrease)

              ER and rehospitalization related to drug exposure were essentially eliminated

              Majority of infants remained with biologic mothers

              Significantly fewer foster placements

              Majority of infants normal on developmental screening and receiving no special intervention services at age 3 years.

              New pregnant narcotic using mothers in the community ask to be in this progrom.

Conclusion          A community hospital based program with community partnerships using standardized medication protocols, non-judgmental care, and maternal social and drug rehabilitation support can significantly decrease the lifelong disparities of neurodevelopmental and social emotional outcome between narcotic exposed infants and infants without this prenatal social/pharmacologic risk factor while lowering overall costs.