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Neonatal Abstinence Syndrome and Frenectomy Recovery

Step foot into any major NICU, and you're likely to find babies being treated for Neonatal Abstinence Syndrome (NAS). Born to mothers with opioid use disorder, these babies go through heartbreaking withdrawal when their fetal substance exposure stops suddenly at birth. Traditionally, babies are given decreasing doses of morphine to help 'wean' them and their symptoms are regularly checked via the Finnegan Scoring system. The University of North Carolina Children's Hospital has abandoned the long-used practice of automatic morphine scheduling every 4 hours and has actually dropped the hospital length of stay from about 11 days to 5 days. The use of morphine fell from 93% of infants to just 12 % of infants with NAS!

What's the magic? The hospital switched to the eat/sleep/console (ESC) model which consists of keeping the infant with the mother, encouraging breastfeeding with supplementing feeds to help with weight gain if necessary, skin-to-skin contact and not waking them EVERY 4 HOURS for scoring and round-the-clock morphine dosing. Morphine was still used as needed but the constant Finnegan scoring was abandoned. As a former NICU PA, I can attest to the near number-neuroses: the "ins/outs", the count of apneas, bradycardias and desaturations, and the scoring of course. While these are important parameters to monitor, it is just as important to interact gently with these tiny patients and at times, stop messing with them! With the ESC strategy, nurses were asked to cue in to their charges and note if the babies were feeding adequately, sleeping at least an hour between feeds and being consoled when irritable. If so, they left the baby swaddled, comfortably soothed by ambient white noise of ocean waves and circled back to them later.

A baby experiencing pain or discomfort leaves parents panicking and medical providers prescribing. Mothers and fathers often turn to holistic social media groups for alternative remedies. Western medicine and pharmaceutical companies encourage the use of good old Tylenol and Motrin. There is no happy medium yet-- not enough studies conducted on naturopathic measures to make providers feel the comfort of suggesting something evidence-based. However, for those of us who straddle the fence; who are traditionally trained, yet practice more holistically, who are parents AND prescribers, it's exciting to know that philosophies are merging with ESC.

The management of babies who have had lip or tongue tie release can be very overwhelming for parents. The pain of the procedure is very brief but there is no denying that the 'aftercare' is uncomfortable for all involved (as a mom of a baby who had a frenectomy- it was undoubtedly harder for me than the baby). Parents may choose to use Tylenol or Arnica, a natural remedy, but shouldn't stop there. Using the Eat/Sleep/Console method is perfect for recovery and validates comfort measures lactation consultants have suggested all along. If baby will breastfeed, encourage it. If baby refuses the breast in the beginning, offer supplements via syringe or finger feeds. Sleep and console all at once by doing skin-to-skin on dad or mom's chest in between feeds. Watch for plenty of wet diapers but let that baby be! Don't forget the ocean waves on the smart phone--- or maybe try some Bob Dylan.

*Eat/Sleep/Console Approach, Pediatric News, Vol. 52, No. 10, October 2018

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