When Cailyn Morreale, a resident of Mars Hill, North Carolina, discovered she was pregnant with her second child, she was flooded with anxiety. While excited, she feared that her pregnancy would mean discontinuing buprenorphine, the medication that had been key to her recovery from opioid addiction. Morreale’s apprehension was exacerbated by the traditional medical treatment given to babies exposed to opioids in utero, which often involves separating them from their mothers, placing them in neonatal intensive care units (NICU), and prescribing medications to manage their withdrawal symptoms.
For decades, the standard approach to treating neonatal opioid withdrawal syndrome (NOWS) relied heavily on medical interventions. However, research now indicates that many babies can recover more effectively through non-medical interventions, keeping them close to their mothers. The evolving model, known as Eat, Sleep, Console (ESC), emphasizes family-centered care over medication-heavy protocols and is being increasingly adopted by healthcare providers.
Historically, babies born to mothers using opioids or opioid recovery medications like buprenorphine or methadone were immediately monitored for withdrawal symptoms. The primary tool used to assess these infants was the Finnegan Neonatal Abstinence Scoring System, which measures signs like excessive crying, sweating, and tremors. Babies showing significant withdrawal symptoms based on the Finnegan system were often given medications, usually morphine, which led to longer stays in the NICU and prolonged hospitalizations.
However, Dr. David Baltierra, a family physician and former director of West Virginia University’s Rural Family Medicine Residency Program, explains that this approach might not always be necessary. Baltierra points out that waking a baby to perform Finnegan scoring, even when the infant is sleeping soundly, doesn’t align with the logic that a baby resting well is not in immediate distress.
Instead, he and his colleagues have been promoting the Eat, Sleep, Console method, which involves assessing whether a baby is eating well, sleeping properly, and can be soothed when upset. If the baby meets these criteria, they may not require medications or NICU care. Baltierra believes this method is a return to what he calls “parenting,” and research backs its effectiveness.
A 2023 study found that babies treated using the ESC method were discharged nearly twice as fast as those receiving medication-based treatment and were significantly less likely to need pharmacological intervention. This research supports a growing body of evidence showing that non-medical interventions, such as keeping babies with their families, skin-to-skin contact, and breastfeeding, often result in better outcomes.
Dr. Matthew Grossman, an associate professor of pediatrics at the Yale School of Medicine, has been a leading advocate of the ESC model. Grossman’s research showed that babies who stayed with their mothers and were treated using non-pharmacological interventions fared better, and mothers, too, reported fewer feelings of shame and guilt, helping them bond more closely with their infants. Grossman explains that the original goal of the Finnegan system wasn’t to be rigid but that over time, the process became standardized and ingrained in medical practice, despite better alternatives emerging.
Interestingly, rural hospitals have been quicker to adopt the ESC model than larger urban institutions. According to Dr. Leila Elder, who researched neonatal withdrawal care at a rural hospital in West Virginia, babies were less likely to be sent to NICUs in bigger hospitals for treatment, which often led to them receiving medications. Instead, rural hospitals, with fewer resources but a more family-centered approach, saw the benefits of keeping babies close to their mothers.
Elder’s study revealed that from 2016 to 2020, the median stay for babies experiencing withdrawal dropped from 13 days to just three at her hospital. Fewer babies were prescribed medications, and those who were treated using the ESC method left the hospital sooner and with fewer complications.
Programs like Project CARA in Asheville, North Carolina, have been instrumental in changing the narrative around opioid-exposed newborns. Project CARA supports pregnant women with substance use disorders, assuring them that they do not need to discontinue their medications, such as buprenorphine, and that they can successfully breastfeed their infants. In fact, Morreale was told that the small amount of buprenorphine in her breast milk could help ease her son’s withdrawal symptoms.
Sarah Peiffer, a family health physician at Blue Ridge Health and a Project CARA practitioner, is a staunch advocate of the ESC approach. Peiffer recalls her distress during medical school when she first witnessed the Finnegan protocol being administered. She saw the emotional toll it took on both mother and child and felt that the method was punitive, making the mother feel guilty for her baby’s suffering. Now, Peiffer emphasizes a more supportive, family-centered approach, encouraging skin-to-skin contact, breastfeeding, and swaddling to calm newborns.
This approach, Peiffer notes, not only benefits the baby but also has a profound impact on the mother’s well-being. Skin-to-skin contact releases endorphins, which help reduce the risk of postpartum depression. Mothers, treated as the central figures in their babies’ recovery, feel empowered rather than ashamed.
The shift toward using ESC is part of a broader movement in healthcare that emphasizes judgment-free, compassionate, and family-centered care for individuals with addiction histories. Doctors like Grossman and Baltierra believe that treating mothers with the same respect as any other parent is crucial to this model’s success. By reducing the reliance on medication and hospital stays, this approach offers a more humane, effective way to care for opioid-exposed babies.
For Morreale, this meant that she could go home with her son after just five days. The ESC method allowed her to experience the joys of motherhood without the fear and guilt she had initially anticipated. Today, more mothers and healthcare providers are advocating for this approach, recognizing the profound benefits of keeping families together during one of the most vulnerable times in their lives.
Ultimately, the ESC method represents not only a shift in neonatal care but a cultural shift toward compassion and empowerment for mothers overcoming addiction.
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