JAMA Forum: Neonatal Abstinence Syndrome: Déjà Vu All Over Again?

Joshua M. Sharfstein, MD

Joshua M. Sharfstein, MD

Three decades ago, sensational magazine stories fueled fear of an epidemic of “crack babies.” A July 1986 Newsweek article called newborns of addicted mothers “heirs of America’s deadly romance with cocaine,” and noted “doctors can only guess at the scope” of the problems the children would have. A September 1988 Time article, titled “Crack Comes to the Nursery,” reported:

Even one ‘‘hit’’ of crack can irreparably damage a fetus or breast-fed baby. At birth the babies display obvious signs of crack exposure—tremors, irritability and lethargy—that may belie the seriousness of the harm done. These symptoms may disappear in a week or more, but the underlying damage remains.

Central to the concept of babies harmed by crack exposure in utero was the profound distance between a mother and her child. The former was seen as the perpetrator; the latter as the victim. During the 1980s, many poor women were prosecuted for crack use during pregnancy.

Misguided Panic

In fact, both mom and baby were suffering together. Subsequent studies of prenatal cocaine exposure showed no major effect on long-term developmental outcome; the greater culprit in poor development and health was identified as poverty.  Misguided panic over such infants obscured the single most important intervention for the future of the baby—helping her mother succeed in life.

With the alarming rise in opioid addiction, the spotlight is again turning to the effect on babies. The media is reporting an increase in neonatal abstinence syndrome, which is caused by in utero exposure to opioids, characterized by a range of withdrawal symptoms, and treatable with behavioral and pharmacological interventions.

Unfortunately, there is little evidence of progress in understanding since the last time around.  Reporters are focusing on the “heartbreaking development” of an increase in the number of newborns affected by their mothers’ drug use; one article, titled “Drug Addicts at Birth,” led with a district attorney’s concern over the “innocent victims.” Only the rare journalist recognizes that, although newborns may display physiological symptoms of drug dependence, they are not addicted.  Few examine access to the evidence-based treatments and social support needed to help both mother and baby.

Obsession over neonatal abstinence syndrome is especially unfortunate for another reason: the pharmacological therapies that are the standard of care for opioid-addicted women during and after pregnancy—methadone and buprenorphine—are known causes of the withdrawal syndrome after delivery. Indeed, in a Tennessee study, nearly half of the cases of neonatal abstinence syndrome were associated with the mother’s treatment, not her addiction. Declaring war on this condition risks stigmatizing effective therapy, leaving mothers more vulnerable to relapse, overdose, and death. Incredibly, in 2011, the State of New Jersey alleged child abuse and sought to remove a newborn from his mother’s custody because the baby suffered from neonatal abstinence syndrome as a result of medically indicated maternal methadone treatment. The state’s claim of child abuse prevailed in court, before the decision was finally overturned by the New Jersey Supreme Court in 2014.

The Best Prescription

For several years, I worked nights at a hospital that cared for many babies suffering from neonatal abstinence syndrome.  My experience was that babies born to mothers receiving effective treatment with methadone or buprenorphine typically had a less-rocky clinical course; once controlled, their symptoms were generally stable during the period of weaning off of medication. But it wasn’t the infant’s symptomatology that allowed me to distinguish quickly between a baby exposed to methadone and one exposed to heroin.

All I had to do was peek at the bedside. If heroin had been involved, caseworkers from social services could be found on site trying to figure out the baby’s placement, the biological mother often was running in and out of the hospital, and it was not uncommon for drama of all types to erupt by the nurse’s station. By contrast, mothers in treatment with methadone quietly held their babies for hours on end. I vividly recall one mother telling me her child was a gift from God.

Making sure women and men of all ages receive medication-assisted therapy recommended by the National Institutes of Health, Centers for Disease Control and Prevention, World Health Organization, and other authorities—without stigma—is the best long-term prescription for their children, too.

Nearly a century ago, the Literary Digest published an article, “Born a Dope Fiend,” describing a baby born with symptoms of opioid withdrawal. “How the sins of the parents are visited upon the children … ,” it began. A lot has happened in the world of medicine since then. It’s time for our understanding and approach to drug-exposed children and their parents to reflect this progress.

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About the author: Joshua M. Sharfstein, MD, is Associate Dean for Public Health Practice and Training at the Johns Hopkins Bloomberg School of Public Health. He previously served as Secretary of the Maryland Department of Health and Mental Hygiene, as the Principal Deputy Commissioner of the US Food and Drug Administration, and as Commissioner of Health for Baltimore. He is a consultant for Audacious Inquiry, a company that has provided technology services and other support to Maryland’s Health Information Exchange. A pediatrician, he lives with his family in Baltimore.

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.



Categories: Health Policy, Neonatology and Infant Care, Substance Abuse/Alcoholism, The JAMA Forum

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