Swaddled in a white blanket with blue and pink stripes, a tiny baby boy tried to steal a few moments of needed peace in the quiet, low-lit neonatal intensive care unit at Sarasota Memorial Hospital.
Six hours after his first breath, the infant told nurses something was wrong the only way he knew how — through incessant screeching cries and fidgeting feet.
He was hurting.
He was stressed.
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He was withdrawing.
His mother had been a user of multiple substances, but the only thing found in the infant’s system was methadone, a drug used to treat opioid addiction. A thin white tube kept him nourished as he couldn’t to eat on his own. His skin was pale and marbled across his underweight body. He struggled to get 18 hours of much-needed sleep.
The baby has been diagnosed with neonatal abstinence syndrome, or NAS, another symptom of the heroin epidemic that is scourging Florida, perhaps most profoundly in the Manatee-Sarasota area.
From 2014 to 2015, the number of babies born with NAS in Florida increased by 30 percent and broke the 2,000 mark, with 2,487 NAS babies born last year out of 218,176 total live births, or 1.14 percent, according to the Florida Agency for Healthcare Administration.
Out of 67 counties in Florida, Sarasota had the third-highest percentage of babies born with NAS, 3.19 percent. Manatee came in at No. 4, at 2.95 percent.
The baby struggling at Sarasota Memorial is one of thousands expected to be born with NAS this year in Florida.
When babies are exposed to drugs in the womb, it can take a few hours or days for withdrawal symptoms of NAS to show. The intensity of these symptoms can vary from baby to baby and isn’t limited to the type of drug or how much the baby was exposed to.
This infant’s caretaker, Sarasota Memorial NICU nurse Krista Caffrey, said that when babies are withdrawing, their unrelenting cry sounds like a cat; they have severe tremors and sometimes seize; their skin is susceptible to breaking down; and they have trouble eating, sleeping and excreting.
Caffrey has been an NICU nurse for nine months. As of late, half of the babies taken to the NICU at Sarasota Memorial show symptoms of NAS.
“This is all I know,” she said. “I walk into work and I expect at least one of my babies to have NAS.”
Neonatologist Dr. Tony Napolitano said the surge in NAS babies began around 2006. A task force at Sarasota Memorial was created in 2007 to address the rise in babies experiencing withdrawals.
At the time, Sarasota Memorial NICU medical director Heather Graber said cocaine and marijuana were the main culprits; then prescription pills abuse was more common in pregnant women.
Now, heroin has grabbed hold of its new victims.
Yet it’s not just methadone or illegal opioids that will lead a baby to go through a withdrawal after birth. Even a mother’s caffeine hankering, cigarette habit or painkiller dependance after a bad accident can cause a baby to painfully detox.
“Unfortunately, this is something that can’t go away tomorrow,” Napolitano said.
He hasn’t yet seen in new mothers the impact of fentanyl, the painkiller that is often used to cut heroin, but he said it doesn’t mean it’s not there.
For a soon-to-be mother who is addicted to opioids, seeking treatment is often a double-edged sword.
Methadone, the most common and legal treatment with opioid addiction, is itself an opioid.
But without treatment, a withdrawal causes the addict’s muscles to painfully contract, including the uterus; if a pregnant woman goes through a withdrawal, she will most likely miscarry.
With treatment, a pregnant woman’s baby will have NAS.
Napolitano said the best thing a mother can do is seek treatment and be honest with her health care provider about what she is using. He said doctors and nurses never judge what a family is going through.
“You have to have a compassion for that baby, and you have to have a compassion for that mother,” Graber said.
Fewer pills, more problems
In 2011, Gov. Rick Scott signed House Bill 7095, dubbed the “anti-pill mill bill.” In an effort to abolish businesses that irresponsibly gave out prescription drugs and hopefully eliminate prescription drug abuse in Florida, it led to the arrests of doctors and the shutting down of clinics.
One of the effects of the crackdown, according to data from the Florida Agency for Health Care Administration, was a slowing of the increases in the number of babies born with NAS.
The year before the bill was signed, Manatee saw a 155 percent jump in the number of NAS babies. After the bill passed, Manatee and Sarasota both saw decreases, 10 percent in Manatee and 32 percent in Sarasota.
But as the snake’s head was cut off, others grew in its place.
When it became harder for addicts to get oxycodone, heroin became the cheapest and easier-to-get opioid alternative.
After the sharp decreases, the number of NAS babies slowly crept upward over three years.
Sarasota County has seen higher rates compared with Manatee. From 2007 to 2015, the percentage of babies born with NAS babies increased tenfold, from 0.35 percent to 3.1 percent, or nine NAS babies in 2007 to 106 NAS babies in 2015.
In 2007, six out of 3,437 babies born in Manatee were treated for NAS. In 2015, that number jumped to 76 NAS babies out of 2,575 total live births, or 2.95 percent.
“We have more (NAS) babies than we had in the past,” said Katie Powers, a nurse at Manatee Memorial Hospital. “It just seems like it’s overwhelming because they’re here for such a long period of time.”
It takes a few days for the withdrawal to begin, Powers said. A typical stay for a baby born without any issues is two days. Manatee Memorial requires mothers and babies born with NAS to stay for five days, and Sarasota Memorial requires seven days.
But NAS babies can be in the NICU anywhere from 20 to 30 days. The extended stay can cost $30,000 to $60,000, compared with less than $15,000 for a regular delivery stay.
The statewide percentage of NAS babies had always been increasing, whether in monumental or incremental amounts, but stayed under 1 percent until 2015, when 2,487 babies were treated for NAS out of 218,176 live births in Florida, or 1.14 percent.
An eighth of those NAS babies were born in Hillsborough County alone.
Twenty-five of 67 counties that year had rates higher than the state average.
After the NICU
Babies are treated with morphine and phenobarbital until their withdrawal is extinguished, but the story isn’t over after a baby is discharged from the NICU.
Staying clean is a constant struggle for any addict. For a new mother, postpartum depression and the stress of a baby’s prolonged stay in the NICU are added obstacles.
As Heather Graber has seen at Sarasota Memorial, some of the mothers are in denial of their own addiction, or even what their baby is going through.
At Manatee Memorial, nurse Powers said addicted mothers go one of two ways when they see the pain their babies go through.
“Some mothers see this, and it changes their lives and they become more motivated” to come out of their addiction, she said. “Some mothers, it’s so painful (to see) that they become more immersed in drug use.”
Powers said addiction is like being at the beach — the sun heats the warm sand that’s sifting under your toes, the Gulf of Mexico invites you into its waters. For a moment, it’s perfect. Absolute bliss.
Then a rip tide of addiction drags you from shore.
NAS babies, said Powers, are born in that rip tide.
Understanding the causes of addiction is something Dr. Napolitano hopes will obliterate the riptide.
“Some of these women are dealing with domestic violence, a big history of mental illness and depression,” he said.
Napolitano added that there is no one type of person affected by addiction more than another.
“We’ve seen it in the rich just as equally as we’ve seen it in the poor,” he said.
As soon as a baby is born with NAS, a file opens with Child Protective Services. In severe cases, the Manatee County Sheriff’s Office child protective team will determine who the baby is discharged to.
It is unfortunate that we kind of, for lack of a better term, create this with them.
Ann Swanson, executive director of Operation PAR in Bradenton
The best thing for an addicted mother, said Graber, is to enter a treatment program.
At Operation PAR, a substance abuse clinic in Bradenton, there’s usually 25 to 30 pregnant women among the estimated 650 patients they serve, executive director Ann Swanson said.
They help addicts stay clean with drug screening and referrals for mental health counseling. But Swanson acknowledges that methadone treatment contributes to the NAS cases.
“It is unfortunate that we kind of, for lack of a better term, create this with them,” Swanson said. “However, methadone has been tested, approved. It’s considered to be the gold standard” for treating addiction.
Samantha Kolb, director of the addiction center at Centerstone Florida in Bradenton, said they also have seen a steady increase in pregnant and postpartum women seeking treatment in their residential program, which has correlated with the pill mill and heroin epidemic.
“We’re seeing a range of things, generally anxiety and depression,” Kolb said.
They work with the mothers so they are able to bond with their child every day, even if the child is still in the NICU. Mothers on methadone are allowed to breastfeed — Napolitano said only a small amount of methadone will be in the breastmilk and won’t harm the child — and parenting classes are offered to fortify that mother-child bond.
Not much is known about the long-term effects of NAS because it’s a relatively new issue. The recently opened Johns Hopkins All Children’s Hospital NAS outpatient clinic in Sarasota is keeping up with these children up to the age of 5.
“There’s a feeling that some of these babies ... may have problems later on,” he said.
Dr. Prahbu Parimi, director of Johns Hopkins All Children’s Maternal, Fetal and Neonatal Institute, said a recent study found that IQs and visual issues in NAS babies are the same as non-exposed babies at 55 months, but the study had only a small pool of patients.
Napolitano has seen about 50 to 60 percent of mothers participate in the study. The purpose is to get ahead and diagnose potential learning disabilities so NAS babies won’t fall behind in school. Attention deficit disorder is a possible effect researchers are expecting.
More participants and more time will paint a clearer picture of how NAS affects children later in life. For now, though, doctors, nurses and researchers are braced for the inundation of more NAS babies, like the little boy, trapped in the rip tide of addiction.