Pardon my profanity, but what the fuck is wrong with people?
That was my thought when I read a paper published yesterday in JAMA Pediatrics. The paper is Association of Rooming-in With Outcomes for Neonatal Abstinence Syndrome; A Systematic Review and Meta-analysis by MacMillan et al.
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]It sounds like a particularly ghastly joke, but sadly it isn’t.[/pullquote]
In this systematic review and meta-analysis of 6 studies comprising 549 patients, rooming-in was associated with a reduction in the need for pharmacologic treatment and a shorter hospital stay when rooming-in was compared with standard neonatal intensive care unit admission for neonatal abstinence syndrome.
Wait, what? We can save money on the care of drug addicted newborns by forcing their mothers — mothers who may lose custody — to room in with them and take care of them? Do the authors of the paper, and the people who reviewed and published it have any idea just how screwed up that is?
Consider the problem:
Neonatal abstinence syndrome (NAS) is a collection of signs and symptoms of newborn opioid withdrawal after intrauterine exposure. Other descriptions of the syndrome include neonatal opioid withdrawal syndrome and neonatal withdrawal syndrome. Neonatal abstinence syndrome manifests 24 to 96 hours after delivery with increased muscle tone, tremors, sweating, vomiting, diarrhea, and other symptoms. Between 1999 and 2013, the incidence of NAS in the United States increased from 1.5 to 6.0 cases per 1000 births,3 with a mean cost in 2012 of $93 400 per newborn stay.
So let me see if I get this straight: Opioid addicted newborns cost a lot of money because they need specialized care for their suffering: increased muscle tone, tremors, sweating, vomiting and diarrhea. The incidence of newborn abstinence syndrome is rising because the incidence of maternal opioid addiction is rising.
There are lots of ways we could address this issue. We could provide greater oversight of the pharmaceutical industry to prevent opioid addiction; we could provide better care for those addicted to opioids; we could provide specialized treatment programs for pregnant opioid addicts. Those measures would work by decreasing the number of infants forced to endure opioid withdrawal after birth. Apparently that’s too hard. The “solution” the researchers offer is to force opioid addicted the mothers — the same people who made their children deathly ill because they couldn’t pry themselves from the grip of addiction — to provide the highly specialized care their babies need despite the fact that they themselves are still recovering from childbirth.
It sounds like an particularly ghastly joke, but it isn’t.
Opioid-exposed newborns are typically cared for in neonatal intensive care units (NICUs), and standardized scoring systems, such as the modified Finnegan system, are used to quantify NAS symptoms and to adjust medications used in treatment. Paradoxically, studies have found that opioid-exposed newborns in NICUs experience more severe withdrawal, longer length of stay (LOS), and increased pharmacotherapy compared with newborns who room in. In rooming-in care, infant and mother remain together 24 hours a day unless separation is indicated for medical reasons or safety concerns. More maternal time at the infant bedside improves NAS outcomes but is harder to accomplish in a typical NICU. Neonatal intensive care units may be poor settings for newborns with NAS because of increased sensitivity to high clinical activity levels…
The excessive sensory stimuli present in a busy NICU is especially jarring for newborns withdrawing from opioids? You don’t say! We could provide one-on-one care is a quieter setting off the main NICU but that would be even more expensive.
Hey, I know how we could provide one-on-one care in a quieter setting and save money, too. Just let their addicted mothers take care of them in the privacy of their own rooms while they are recovering the the exhaustion and agony of childbirth!
While rooming-in may be effective for NAS, potential risks include unintentional suffocation, falling from an adult bed, or undertreated NAS after hospital discharge.
No fooling!
What did the authors find in their literature review?
This systematic review and meta-analysis demonstrates that rooming-in is associated with decreased need for pharmacologic treatment of NAS and shorter LOS. The results of several included studies suggest that rooming-in is associated with reduced hospital costs, but the significant heterogeneity across studies precluded quantitative analysis. Because of variable reporting, we were unable to draw formal conclusions about the role of rooming-in on other secondary outcomes of interest. The findings of 2 studies suggested that breastfeeding increases with rooming-in. There was no evidence that rooming-in for NAS was associated with a significant increase in hospital readmission. Reporting of adverse events was insufficient to draw any conclusions about an association between rooming-in and these outcomes.
In other words, the studies showed a decreased use of pharmacologic treatement that the authors interpreted to mean a decreased need for treatment and a shorter length of stay. The authors couldn’t tell if any money was saved and the study was too small to draw conclusions about adverse events.
It seems never to have occurred to the authors that the Dickensian premise of the study — that opioid addicted mothers should be employed for free to care for their suffering opioid addicted newborns so we can save money on skilled caregivers — is absolutely grotesque.
What was the impact on the mothers themselves? Surely you jest. It never occurred to anyone to check because no one cares.
Whatever happened to basic human compassion? It’s apparently less important than the drive to save money.
