In Washington, hospitals automatically report newborns affected by their mother’s use of drugs or alcohol during pregnancy to Child Protective Services. State guidelines then call for testing those infants every few hours using a complex scoring system to determine whether they need morphine or other medications to treat withdrawal. They’ll also often be sent to a neonatal intensive care unit and separated from their parents.
But in an effort to destigmatize parents with addiction, the state is pushing hospitals to soon offer another track.
Hospitals will no longer be required to report families to Child Protective Services if there are no safety concerns for the infants, the state announced last week. Instead, they’ll be offered “voluntary wrap-around services.” And by Jan. 1, 2025, hospitals will be required to shift to a new, increasingly widespread model of care called ‘Eat, Sleep, and Console,’ which prioritizes parental involvement and care that does not involve medication.
The change in state policy reflects research that shows emotional and physical parental involvement in a baby’s first few months is crucial to an infant’s development.
But the updated guidelines for reporting families to Child Protective Services still have some medical experts and advocates raising concerns. They point to the harsh realities for families in these situations, which can include difficulties like homelessness or parents who continue to use drugs.
“It is a wonderful idea,” said Dr. Julie Bledsoe, a professor of pediatrics at the University of Washington who studies fetal alcohol syndrome. “The devil, in a way, is in the details in terms of making sure we have enough people to help provide wraparound services.”
The rate of babies born in Washington who were affected by drug exposure before birth has increased sharply over the past 20 years. This condition, formally known as neonatal abstinence syndrome, occurred in less than two of every 1,000 births in the year 2000, according to state Department of Health data. In each year between 2013 and 2020, that figure was between eight and 11 babies per 1,000 births.
“The majority of our babies have between three to five drugs in their system,” said Barbara Drennen, founder and executive director of Pediatric Interim Care Center in Kent, the only transitional care facility for substance-exposed infants in the state.
“We need to look at the safety of the babies,” Drennen added. “Know that even if you discharge them to the mothers, quite often they’re not being taken care of. Where are the babies going to go?”
‘Eat, Sleep, and Console’
The state’s shift to the new model comes amid growing skepticism about the old standard assessment tool for these babies, known as the Finnegan Neonatal Abstinence Scoring System. The Finnegan model is “complicated, cumbersome and some people felt like it was very subjective,” said Dr. Sheela Sathyanarayana, medical director of the University of Washington Medical Center’s newborn nursery.
With the Finnegan model, providers look at a long list of symptoms every few hours to determine whether a baby will receive morphine or other drugs to treat withdrawal. In contrast, the Eat, Sleep and Console model assesses function, rather than medical symptoms, to determine what kind of treatment a newborn needs, and prioritizes care like swaddling, cuddling and a dark, quiet environment for the baby.
“Babies, instead of this really complex Finnegan scoring system, they get scored on ‘Are they able to eat? Are they able to sleep? Are they able to be consoled?’” said Sathyanarayana.
If the newborn needs more care in the Eat, Sleep, and Console model, instead of automatically turning to medication, there will be a “team huddle” involving medical staff and the baby’s mother or caregivers to discuss interventions that don’t involve medications or moving the baby to intensive care, said Ekaterina Burduli, a professor of nursing at Washington State University.
Burduli said the Finnegan model often overestimated the need for medication. The neonatal intensive care unit can be a stressful environment for infants, causing them to show heightened symptoms assessed in the Finnegan model regardless of their exposure to drugs. Experts also said keeping the mother or caregiver with the baby and involving them in the baby’s care — as in the Eat, Sleep, and Console model — often results in better outcomes.
“There’s a saying,” Burduli said. “The mother is the medicine.”
While Eat, Sleep, and Console has been around for a while, the new state standards come after the largest study on it to date was released in April 2023 by the National Institutes of Health. The study found that babies treated with the new model were medically ready for discharge almost a week earlier and less likely to receive medication compared to newborns cared for with the Finnegan model.
Sathyanarayana’s hospital, UW Medical Center – Montlake, is one of a handful of hospitals in the state that hasn’t already implemented Eat, Sleep, and Console. She said it’s not because the hospital doesn’t want to — it’s because of how difficult it is for hospitals to do when a caregiver isn’t present.
Babies calm much quicker with their biological parent consoling them, and when using the Eat, Sleep, and Console model, a baby going through withdrawal with an absent parent requires constant care, which can put a drain on hospital resources and staff, said Sathyanarayana.
“That’s been one of the barriers,” Sathyanarayana said, “but personally, I’m very happy that the state put out those guidelines and requirements, because it will move all the hospitals who haven’t been able to do this to a model that is much better for the mom, baby [and] dad.”
Sathyanarayana said the state’s offer of reimbursement through Apple Health (Medicaid) for ESC care will help hospitals like hers implement the new model.
Figuring out the details
Pediatric Interim Care Center has used a version of Eat, Sleep, Console for years, said Drennen, the center’s executive director. What concerns her about the new state standards is what happens after the baby has left the hospital.
Drennen, whose center works with Child Protective Services to provide a space for the babies to go when the agency is investigating families, said it should be up to CPS, not the hospitals, to determine where the baby goes next.
“Does the mother have a home to take the babies to? You never know,” Drennen said. “And wraparound services? Quite often the mothers don’t want it because they’re still using.”
Chelsea Loomis, a charge nurse at Pediatric Interim Care Center, said she’s concerned about what caregivers are expected to do while they wait for the wrap-around services.
“It’s not immediate. If it is, it might be temporary housing while they’re trying to get you into something more permanent,” Loomis said. “Even transportation takes time. There’s paperwork that has to go in.” Help parents can access right away can sometimes be limited to a gas card or a hotel room, Loomis added.
“It’s just like, we’ve kind of got a little bandaid on it, and here’s your baby,” Loomis said. “That’s not setting them up for success.”
But Burduli said the new standards are meant to encourage women to seek the wrap-around services, as Child Protective Services involvement can often invoke fear and prevent mothers from seeking resources they need. Research shows CPS involvement can also be damaging, particularly to families of color.
“Automatically reporting to CPS doesn’t do much to actually help the family,” Burduli said.
While the Department of Children, Youth and Families offers sample questions for hospitals to determine if there is a “safety concern” for a baby that would prompt reporting to state child welfare authorities, Bledsoe said there’s “certainly some subjectivity that goes into that” and it’s “always a challenge in pediatrics to figure out what that means.”
Bledsoe said she’d look for whether the babies’ basic needs are being met. The biggest thing Sathyanarayana said she looks at is whether the caregiver is both mentally and physically present and able to take care of the baby.
Sathyarayana also said it’s important to remember that not every mother with addiction is in the same situation.
“Most people think of people who may be using illicit drugs. But there are many, many people who are high-functioning who are addicted to opiates. They have professional jobs, they come in with chronic pain, they are on those opiates throughout their pregnancy — otherwise, they would be in too much pain,” Sathyanarayana said. “Similarly, there’s many, many people who are in methadone programs. They know they have an addiction, they’re working on it, they’ve been consistently in a program that has been helping them.”
Burduli said she doesn’t expect the new system to be perfect, but hopes that as wrap-around services become more ingrained into the health care system, access to them will come faster for families. Keeping families together while they receive the support they need should be the priority, she said.
“We all need access to services much faster,” Burduli said. “That doesn’t, in my mind, take away from the damage that can be done when you refer families to CPS for no good reason.”
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