Washington has introduced a new policy that changes hospital reporting requirements for infants affected at birth by substance use, a step the state hopes will help combat stigma against parents with addiction.
The state has long instructed birthing hospitals to report all babies with prenatal exposure to any substances to Child Protective Services, but now newborns will be able to receive wraparound social and community services without a report, as long as there are no safety concerns, several state agencies said this week.
The plan for ongoing support is part of an increasingly popular model of care in the U.S. to assess neonatal withdrawal called "Eat, Sleep, Console," said Tiffani Buck, a nurse practitioner with the state Department of Health. The change reflects the state's efforts to address the growing opioid epidemic in the region, which has also in the last 20 years seen a fairly steady rise in hospitalization rates of infants with neonatal abstinence syndrome, or when babies experience withdrawals after being exposed to certain drugs in the womb.
The newer assessment model builds on recent opioid treatment research and shifts away from older tools, which many medical experts worry are too subjective and overestimate the need for medication. The results often exacerbate infants' withdrawal symptoms, alienate parents and disrupt families, Buck said.
Now, the shift formally states "medications and NICU admissions should no longer be the first line of treatment for infants exhibiting withdrawal symptoms," according to the state Department of Children, Youth and Families; the state Department of Health; the Health Care Authority; and the Washington State Hospital Association.
While the policy change takes effect immediately, hospitals will have until January 2025 to update their own guidelines and train staffers. About 44 of the state's 52 birthing hospitals have already implemented the Eat, Sleep, Console method.
"Not all families that have a child with prenatal substance exposure require child welfare intervention," Ross Hunter, state secretary of the Department of Child, Youth and Families, said in a statement this week. "We still want to connect these families with community-based services and resources that will support the family's needs, reduce risks, and increase protective factors."
If a medical team does have significant safety concerns or feels a child is at "imminent risk of serious harm" due to substance use, hospitals are still instructed to issue a report to the state, said DCYF spokesperson Nancy Gutierrez.
The main factor in determining a plan of care, however, is the safety of the newborn, not the substance itself, Gutierrez added.
Infants in Washington have been hospitalized at increasingly high rates with neonatal abstinence syndrome since 2000, when fewer than two hospitalizations per 1,000 births was common, according to state Department of Health data from 2020. Rates dropped significantly in 2018, but had climbed back up to about nine hospitalizations per 1,000 births by 2020. More recent data is not yet available.
The state's change also comes in response to the federal government's 2016 update to the Child Abuse Prevention and Treatment Act, which included a requirement that hospitals send a report to Child Protective Services for infants affected by all substance use, rather than just use of illegal substances.
In the U.S., clinicians have historically used a method called the Finnegan Neonatal Abstinence Scoring Tool, which was developed in the 1970s, to assess certain withdrawal symptoms in infants, Buck said. The scoring system looks for signs of withdrawal in more than 20 areas, including crying, sleeping, tremors, sneezing and poor feeding.
According to the Finnegan tool, if a baby showed certain symptoms, they were often rushed to the neonatal intensive care unit, a space filled with providers, bright lights and loud noises that could increase stress, she said.
"Parents are sometimes included in the care there, and sometimes they're not," said Buck, who leads a work group that addresses the impact substance use has on pregnancy, parents, children and families. "It depends on the facility."
In addition, some of the Finnegan symptoms listed can be normal behavior and don't always reflect serious signs of withdrawal, Buck said.
"It's normal for infants to cry," she said. "I think it's common for [symptoms] to be exacerbated with withdrawal, but they're not indicative of withdrawal."
In recent years, medical researchers and maternal health experts have questioned the reliability of the Finnegan tool — and in May, the National Institutes of Health reported one of its clinical trials had found the Eat, Sleep, Console model was more effective than the traditional scoring system in assessing and managing opioid-exposed newborns.
According to the study, babies cared for through the Eat, Sleep, Console model were ready to be discharged almost a week earlier than those cared for through the Finnegan system, and were less likely to receive medication as part of their treatment. Instead of an extensive scoring system, the newer program focuses on just three signs.
"What do we really need babies to be able to do? We need babies to be able to eat, we need babies to be able to sleep and we need babies to be consolable," Buck said. "Let's look at those three things, instead of subjective symptoms, to assess how the baby's doing and whether or not interventions are needed for withdrawal."
The Eat, Sleep, Console program, developed by Yale University researchers about eight years ago, encourages parental involvement in care and assessment, Buck said. The model also urges hospitals to keep infants in dark, quiet rooms with their parents; to teach skin-to-skin bottle feeding and lactation; and to support swaddling, among other treatments.
It also includes access to substance use disorder resources, early intervention referral for newborns, infant supplies, housing resources, developmental screening, home visiting and Apple Health, according to DCYF.
While the National Institutes of Health report notes that the Eat, Sleep, Console model has "not been rigorously tested in a large population" and "has raised some concerns about potentially underrating infants or discharging them prematurely," the model has been accepted as best practice by many national pediatric and maternal health leaders, now officially including those in Washington.
A report to DCYF is still possible if there are significant safety concerns or if the infant has a positive toxicology for an illegal or nonprescribed substance, according to the agency's plan of care.
To Buck, the shift in treatment is evidence of a push to reduce stigma and bias against those who use substances.
"This is a big shift in recognizing the value and worth that all people have," she said, "and that using substances and having a substance use disorder is a medical condition and not a moral failure."
