When Kiran Dwarakanath worked as a doctor in New York, hospitals had entire neonatology units devoted specifically to helping babies born addicted to drugs going through withdrawals.

Then he came to North Dakota. Bismarck has seen an uptick its number of babies born addicted, and the Bakken saw its own issues with babies going through withdrawals with the oil boom, according to a state senator. Across the state, there were 120 babies born in 2013 with the symptoms, the Department of Human Services reported.

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Grand Forks is no exception.

As a neonatologist at Altru, Dwarakanath sees a few cases a year in his department. While cases vary from year to year, most are related to prescription medications, specifically opioids, which can be highly addictive, he said.

"The medication that goes into the mother gets transferred to the baby, and the baby is also getting a dose of that medication," Dwarakanath said. "When they come out, they have withdrawal symptoms."

This is called neonatal abstinence syndrome, or NAS. The most common sign that a baby has NAS, Dwarakanath said, is that the baby is hyperirritable. The baby may also have a high-pitched, shrill-like cry, scratch itself, not sleep well, eat a bunch and like to be held a lot, he said.

"They're experiencing withdrawal like an adult, but they can't express it like we would if we were going through withdrawal," said Amy Zabinski, a nurse in Altru's neonatal intensive care unit.

NAS cases aren't just caused by mothers using street drugs, Zabinski said. It may be that a mother was prescribed medication for something like back pain and didn't fully understand the side effects that would affect her pregnancy, she said.

It's an issue the state legislature noticed. Sen. Nicole Poolman, R-Bismarck, heard from doctors, foster parents and others in Bismarck about their frustrations with how the state is addressing the issue.

Poolman helped create the North Dakota Task Force on Substance Exposed Newborns last year, and they released their final report last month, recommending that there needs to be more education, better communication between services and universal screening for NAS.

"We want to send the message to women out there that we don't want to punish you. We want to help you, and the help is available," Poolman said. "It's just that often times people don't realize that it's available."

Advocate for the baby

The easiest way for Altru doctors and nurses to know if a baby has NAS is to know the mother's history-what's she's prescribed or if she's using illegal drugs. They can find that out through medical records or a urine test.

They can also find out what a baby has been exposed to in the womb by testing its first stool sample, but they only test that if they suspect a baby has been exposed to substances, like if it shows signs of NAS, Dwarakanath said.

If the baby does test positive, the NICU helps the baby go through withdrawal.

"First, we try non-pharmacological methods," Dwarakanath said.

This means consoling and rocking the baby, keeping it in a dark, quiet room without a lot of sensory stimulants. However, if that fails, they have to take another route and start the baby on morphine to make the withdrawal more bearable.

"We give them enough so they calm down," Dwarakanath said. "It kind of takes the edge away. And then we slowly wean them off over the next few weeks."

Each case is different, but the withdrawal process can take weeks, meaning the babies are staying in the hospital longer than babies born without addictions.

The doctors and nurses are looking for the best way to help the baby, even beyond the hospital, recommending further treatment or help to make sure the baby recovers fully. Their primary goal, Dwarakanath said, is to be an advocate for the baby.

Mother and child

But there are two people at play in the situation-the baby and the mother. The number of women suspected of using drugs while pregnant, ranging from alcohol to meth, in Grand Forks County went from four in 2011 to 20 in 2015, the highest it's been in five years, according to the Department of Human Services.

"Really, advocating for the baby means advocating for the mom," said Lee Rerick, who was a social worker in Altru's NICU for 14 years.

Generally, every family staying in Altru's NICU longer than 48 hours works with a social worker, Rerick said, including those with babies with NAS.

"Our job, really, is to visit with the parents, provide them with support, acknowledge their baby was tested positive for a substance," Rerick said.

Even if a mother took a completely legal prescription that caused her baby to have NAS, she might feel some guilt, and a social worker helps her through that and look at how to move forward, Rerick said, including future treatment and services.

If a mother used an illegal drug, the social worker is legally obligated to report it to the county's human services department. The ideal situation is for a baby to go home with its family, but ultimately, it's up to the county to decide if that's the best situation for the baby. Employees like Dwarakanath, Zabinski and Rerick play an active role in helping the county in the decision by giving recommendations for future treatment and help for what they see as the best outcome.

How to improve

The state legislature's task force was able to come up with recommendations on how to alleviate the NAS situation. One recommendation stems from what made their work difficult: a uniform, central place in North Dakota that specifically collects NAS data.

"We don't even really understand the scope of the problem because we don't have anybody keeping track of it," Poolman said.

Since all hospitals don't test every baby for NAS, doctors have to rely on symptoms and medical history. Plus, symptoms might not show up for a handful of days after the mother and infant have been discharged from the hospital. At home, instead of recognizing it as NAS symptoms, the parents might think they just have an overly fussy baby.

Testing all pregnant mothers as early as possible would better help the babies and better help the mothers, Poolman said, but even if a doctor tests a mother and there are drugs in her system that could affect the baby, the doctor might not know how to help her, Poolman said.

"All the pediatricians and OBGYNs who came to me would say, 'Well, even if I have a mother who is on drugs, I don't have any place to put her. There's no treatment available,'" Poolman said. "What came out in the task force is that yes, actually, there is."

The state's Department of Human Services licenses more than 50 private addiction treatment programs in North Dakota, but people who seek treatment may face financial barriers or have to travel far from home for an opening, Poolman said. Plus, with the state's opioid epidemic, North Dakota has some work to do to improve treatment options and make them more convenient to people who need help, she said.

Moving forward

There needs to be better communication between all parties involved, ranging from doctors and nurses to human services to treatment facilities, Poolman said.

"The task force members believe the best way to address newborn withdrawal syndrome is to prevent it," the report states.

To do that, the state needs to provide targeted education and outreach to women before they even become pregnant, the task force found, not just to potential mothers, but also to their family members who can help reinforce this prevention. That's one of the main things Poolman said she is going to focus on going into the next legislative session, even when there will be little money to fund new programs. Existing departments can help produce and spread the education, she said.

But for it to be most effective, mothers must feel comfortable with coming forward. Some states have criminalized mothers who abused drugs while pregnant, but Poolman and the task force believe that does more harm than good.

"Once it's criminalized, they have a tendency just to hide, and we don't get to help them at all," Poolman said.

Instead, there needs to be more awareness so mothers do want to come forward and seek help, she said.

"In the long run, we certainly hope that we will be able to fund new programs that help new mothers stay clean," Poolman said.