They enter the world under difficult circumstances — often irritable, tense, and struggling with feeding, digestion, and sleep.

During pregnancy, these newborns were exposed to opioids, leading to withdrawal symptoms after birth, including heightened sensitivity and high-pitched crying. The first week can be especially challenging.

“These babies are going through so much, and it can be very difficult to witness,” says Liz Drake, a clinical nurse specialist in the neonatal intensive care unit (NICU) at Rady Children’s Hospital at Mission.

For decades, NICUs used the synthetic opioid methadone and, in a change made about a decade ago, morphine (a naturally occurring opioid) around the clock to provide some relief and comfort. Then they slowly weaned the newborns off the drugs.

Now, for the first time at Rady Children’s Health, NICU staff at Mission are reporting success with a drug-free, quality-improvement tool called Eat, Sleep and Console (ESC) to treat this patient population.

A change in thinking

Although ESC was first developed and introduced in 2014 by a team of researchers and clinicians at Yale New Haven Children’s Hospital, Boston Medical Center, and Dartmouth-Hitchcock Medical Center, it is new to Rady Children’s.

With four newborns treated with ESC over the last six months, the protocol is set to expand to Rady Children’s hospitals in Orange and San Diego, as well as NICUs at other pediatric hospitals in the region, says neonatologist Dr. David Kim, a leading champion of ESC who has been at Rady Children’s at Mission for a decade.

ESC was designed as a family-centered, function-based assessment for Neonatal Opioid Withdrawal Syndrome (formerly known as Neonatal Abstinence Syndrome), replacing more subjective historical scoring systems by focusing entirely on whether a newborn can eat, sleep, and be consoled.

“We have replaced morphine with snuggling, and we have seen better outcomes,” says Kate Gordon, a career NICU bedside nurse for 25 years — 20 of them at Rady Children’s at Mission. “The fact that we can cure addiction by holding these babies and loving on them instead of drugging them is so amazing to me.”

Dr. Kim says NICU doctors’ thinking on treating opioid-addicted newborns by giving them methadone and, later, morphine began to change following studies that began coming out about a decade ago that assessed the long-term neurological effects on newborns treated with opioids after birth.

“Ultimately, the goal of medicine is to do no harm, and we’re finding out that exposing these babies to more opioids isn’t the ideal thing,” Dr. Kim says.

The soothing touch

ESC significantly reduces the time opioid-addicted newborns have to stay in the NICU – from as few as three to four days instead of a few weeks.

The involvement of the mother in ESC helps because her presence, scent, and touch naturally ease withdrawal symptoms. However, because many of these newborns aren’t with their mothers – some are in treatment programs or, unfortunately, not involved in caring for them immediately after birth – it takes a large team to care for them using the ESC protocol.

The team includes nurses, volunteers, speech and occupational therapists, clinical associates, and physician practitioners of traditional Chinese medicine who make sure these babies’ environments are quiet and dark and as free of stress as possible.

Acupressure, for example, makes infants release endorphins and thus is a natural pain killer that requires less reliance on pharmaceuticals, notes Dr. Ruth McCarty, a practitioner of Chinese medicine who treats patients throughout Rady Children’s.

ESC treatment includes swaddling and gently rocking the newborns and providing them with high-calorie formula or donated breast milk.

Getting mom involved

Members of the NICU team at Mission do their best to involve mothers of opioid-addicted babies in their immediate care after birth – something that has required, at times, a change of mindset from judging these mothers to encouraging them, when possible, to be active in the care of their newborns.

Citing studies, as many as 60 percent of these mothers are victims of abuse who used opioids to self-medicate, says Eva Esmaeili, nurse manager of the NICU at Rady Children’s at Mission .

“I’ve never met a mom who doesn’t feel guilty about what their baby is going through,” Dr. Kim adds. “They’re not happy they’re addicted or being treated for addiction. We don’t want to put guilt upon moms – we want them to be involved.”

Kate, whose nursing background includes working in public health, notes that many of these babies are, at some point, reunited with their mothers.

“These babies are at a high risk of disenfranchisement, so we need to draw these mothers in and educate them as much as possible,” she says. “We want our nurses to say, ‘Please mom come in — it’s so important for your baby.’”

An important building block

Iliana Medina Rodriguez, a clinical associate, says the ESC program has been very rewarding .

“As someone who wants to work with NICU babies when I become a nurse, it was such an amazing opportunity to learn alongside nurses but also getting to help the babies feel better,” Iliana says. “I think having someone in your corner giving you comfort when you are the most vulnerable is essential, especially with these tiny babies who can’t verbalize their needs the same way older kiddos can.

“I think the program is such an important building block for the babies, and we are super proud that we can be helpful.”

Sara Novak, aninpatient pediatric occupational therapist, explains that her goal is to support an infant’s overall regulation by meeting them exactly where they are developmentally and neurologically. Interventions are individualized and focused on supporting organization of the nervous system through sensory-based care.

“The aim is to help calm an overactive nervous system and gradually build tolerance to sensory input over time,” Sara says.

Occupational therapy interventions focus on matching the sensory needs of the infant at each stage of development. One key intervention is neonatal touch and massage, which has been shown to promote calming, reduce stress responses, improve sleep, and support physiologic regulation.

“It can also strengthen caregiver bonding by actively involving caregivers in their baby’s care and helping them learn to read and respond to infant cues,” Sara says.

Environmental modification is another important component of occupational therapy intervention, she adds. Care often begins with a low-stimulation environment tailored to the infant’s tolerance level, including dim lighting, reduced noise, clustered care, and minimizing unnecessary handling.

As the infant demonstrates improved regulation and tolerance, sensory input can be gradually layered in to support development without overwhelming the nervous system.

Additional non-pharmacological tools commonly used in occupational therapy include therapeutic handling and positioning, swaddling, non-nutritive sucking, vestibular and proprioceptive input, and caregiver education.

“Ultimately, we strive to maximize non-pharmacological interventions whenever possible to reduce stress, support neurodevelopment, and decrease the need for pharmacological management,” Sara says.

Rewarding volunteer work

Christina Culp is a volunteer in the NICU at Mission.

“Being a volunteer in the NICU is the most rewarding volunteer work I’ve participated in,” she says. “It’s a privilege to support the babies, families and NICU staff.”

Christina says when there’s a baby who needs comfort, her priority is to snuggle, giving the nurse an opportunity to attend to the baby’s health needs.

“When I’m able to comfort a newborn – helping them to relax and sleep — I know I’m providing support they need in that moment,” Christina says. “Many babies are there to grow, and all of them are experiencing the world for the first time. I think we all do our best to give them comfort while they are getting better so they can go home.”

When a newborn is accepted into the ESC program, volunteers receive an additional request outside of their regular scheduled times to come to the NICU to provide comfort for these babies with higher needs.

“I have had that privilege and feel thankful that it is one way we, as volunteers, can support the baby and the family,” Christina says.

A buy-in from leadership

Eva says ESC, a quality improvement initiative, isn’t easy to justify financially for NICUs.

“The acuity isn’t high, but the workload is high,” she explains.

But Rady Children’s leaders quickly realized the value of ESC, Eva adds.

“We gained the support of nursing leadership early on in the process,” she says. “Now that we’ve seen it in action, we’re elated. “And we think it actually might be using community resources more wisely because the stays in the NICU are shorter.” 

Adds Kate: “The leadership and entire staff at Rady Children’s at Mission are really supportive of the program and supportive of the moms.”

Before coming to Rady Children’s Health, Dr. Kim had some experience treating newborns undergoing opiate withdrawal.

“The thinking was we didn’t want to treat these babies with synthetic or naturally occurring opioids for a long period of time because we didn’t know the longtime effects on their brains,” he says.

Because methadone is longer acting, the switch to morphine was made.

“Now, with ESC, we’re sticking to the three things we really want a baby to do to get a handle on their withdrawal systems,” he says. “These newborns are going through something from no fault of their own and seeing how effective this new protocol has been very gratifying.”