There he was in my arms, a beautiful baby boy, just days old, in his blue and pink striped hat and swaddling blanket that were hard to keep on as he tightened his body, arms and legs flailing while he cried that high-pitched, nails-on-the-chalkboard cry. Bouncing, swaddling, holding him tight all helped, but didn’t completely calm him. His butt was red from many diarrhea stools, his cheeks chapped from the constant motion of his head, his mouth rooting and sucking without satisfaction.
“Meningitis?” you might ask. No, this baby was experiencing Neonatal Abstinence Syndrome (NAS). We had started medications for comfort yesterday and would need to increase them today.
What is NAS? It is the group of symptoms an infant displays as he withdraws from narcotic exposure, narcotics taken by pregnant moms — sometimes illegally, but often prescribed to treat pain. Narcotics, also called opioid pain relievers, are powerful pain-reducing medications that include prescription oxycodone, hydrocodone and morphine, as well as the illegal drug, heroin.
Down the hall from the nursery, his mom was crying. She would go home tomorrow, but knew her baby would need to stay in the hospital, likely for weeks, to wean off the meds started to keep him comfortable. Her tears weren’t just about sadness though. They were tears of frustration and regret. Why hadn’t someone told her? Three years ago she began taking oxycodone medication for back pain, after a bad accident left her with bulging discs and pain that kept her from doing normal activities. Someone should have told her that use of this medicine could lead to her baby undergoing withdrawal. She would have done whatever it took to decrease or stop her meds if only she had known.
Whether you have had chronic, debilitating pain for years or you have been a healthy, pain-free person your entire life, once you become pregnant, it is very likely you will have some degree of pain. Pain originating from the changes your body experiences during pregnancy is normal, whether it is headaches, back pain or abdominal pain. Some women with chronic pain syndromes will have less pain during pregnancy, some will experience an increase in pain. How you choose to treat pain during pregnancy has important and long-term consequences for your baby.
In the 1990s, studies began to show that physicians were under-treating pain. Initiatives and guidelines to help improve pain control were created. Newton said, for every action there is an equal and opposite reaction. This was definitely the case with pain management. Between 2000 and 2009, prescriptions for narcotic pain killers quadrupled in the US. Not surprisingly, the number of infants born with symptoms of withdrawal, NAS, tripled during that same period.
Inadequately managed, persistent pain during pregnancy has negative consequences for both the mother and her growing baby. Finding solutions to appropriately address pain during pregnancy is a challenging but important part of obstetric care. Women with persistent pain who may require high doses of narcotics during pregnancy should seek advice about optimizing their pain management before pregnancy. Sometimes alternative drugs, including tricyclic antidepressants, may help to control persistent pain and reduce narcotic exposure.
Another solution is to use nonpharmacological treatments for pain. Without question, taking a pill is much easier than learning a new skill such as exercise, mindful relaxation or yoga. However, If all doctors talk about are pills for pain management during pregnancy, we are having the wrong conversation with our patients. Exercise, relaxation training and yoga have been shown to both decrease pain and improve pregnancy outcomes. External pain stimulators, injections directly into joints, warm ultrasound and water therapy all have a place in managing pain without exposing the baby to negative impact of pain medications. For some women, these approaches allow discontinuation of narcotic medications. For others, they allow the amount taken to be greatly reduced.
Despite these modalities, some women will need to take narcotic pain medicines for pain during pregnancy. There are ways to minimize NAS in the infant while allowing mom to treat her pain. Recent studies show that decreasing or cessation of smoking and decreasing or eliminating antidepressants lessen the chance your baby will experience NAS. Tapering off of narcotic pain medications slowly by 2 weeks prior to delivery also greatly decreases the likelihood babies will experience NAS. These medications can be restarted after the baby is born as needed.
For women whose pain management requires narcotics, the care of the infant can be optimized to allow the infant to be comfortable and slowly weaned off of medications. It’s important moms are given all the information, though. Recent studies show that in addition to NAS, babies born to moms on narcotic pain medications for longer than a few weeks are more likely to be born prematurely and smaller in size. Both mild prematurity and small size are linked to long term and irreversible neurologic and health consequences for the baby.
Women make all kinds of choices with their bodies during pregnancy: water birth, delayed cord clamping, lots of family at the delivery, no family at the delivery. In regard to pain management, women are sometimes made to feel like they have done something wrong, or their bodies have failed them. Education empowers. Discuss with your OB how to manage your pain so your pregnancy can be a positive experience and your baby can be born healthy.
Six facts to take action
- Severe pain left untreated during pregnancy has negative effects on mom and baby.
- Completely eliminating pain during pregnancy should never be the goal.
- Non pharmacological management of pain whenever possible and appropriate is the safest approach for mom and her baby.
- Treatments such as good sleep hygiene, a nutritious diet, exercise, relaxation, meditation and stress reduction are all known to improve pain.
- The use of opioid/narcotic medications in combination with cigarette smoking and certain anti-depressant medications increases the likelihood babies will experience NAS/ withdrawal after birth.
- Early and ongoing conversations with your OB about your pain and ways to treat it are very important.