Amanda Ashley's baby daughter trembled uncontrollably. Her scream rang through the intensive care unit — high-pitched and shrill. She was so agitated no amount of rocking or cuddling could soothe her.
"I was taking prenatal vitamins and shooting dope," she said. "I wanted to stop, but I had no control psychologically and physically on how to do it."
Hospitals throughout the state are dealing with a sharp increase in the number of babies born exposed to drugs as the opioid epidemic grows and ensnares the youngest victims while they're still in the womb. These newborns suffer tremors, have trouble feeding and are not easily comforted — all signs of drug withdrawal.
The number of babies born in Maryland with opiates, alcohol, narcotics or other drugs in their systems has increased 56.6 percent in the last nine years to 1,419 cases in 2015, the latest numbers available.
While some have been exposed to marijuana and cocaine, an overwhelming number are born to mothers who have used prescription painkillers or heroin, the primary cause of deadly overdoses in Maryland and around the country. Some of these babies also have methadone or buprenorphine in their bodies because the mothers are using those drugs to kick their addiction to opioids.
The babies are weaned off the drugs in hospital neonatal intensive care units, but doctors say it is too early to determine the long-term health consequences. The new wave of addicted babies is reminiscent of the crack babies of the 1990s. Studies have shown that those children didn't grow up with the major health problems many doctors had predicted.
Hospitals are responding with new standards of care such as "cuddle" programs to help soothe drug-exposed babies. They are working with doctors to help identify pregnant mothers who are drug users, but also know they miss some who don't see a doctor until they arrive to the hospital to deliver.
The Maryland Patient Safety Care Center is working with 30 birthing centers around the state to come up with standardized care for babies suffering from what is known as neonatal abstinence syndrome, a range of symptoms common in babies exposed to opioids, alcohol, narcotics or other drugs while in the womb.
"This is not a syndrome that we used to see a lot of, so we are learning quickly," said Dr. Jim Rost, a newborn intensive care specialist and co-chair of the patient safety care center committee looking at the issue.
The group hopes to speed up the recovery time for these babies, who are now in the hospital an average of 26 days in Maryland. It also wants to reduce the frequency at which these babies are readmitted to the hospital. Another goal is to reach expectant mothers as early as possible.
"People don't show up with a sign on their head saying 'opioid user,'" said Rost, who works at Adventist HealthCare Shady Grove Medical Center in Rockville. "It is about screening the mother appropriately so we can help them and we can help their babies sooner."
When babies suspected or known to be exposed to opioids are born, they are screened and given a score based on the degree of their symptoms. This score determines how they are treated.
"Every baby is a little bit different," said Dr. Marie Kanagie-McAleese, director of the pediatric hospitalist program at the University of Maryland Upper Chesapeake Medical Center. "It really depends on the type of medication mom is taking, how frequently and whether she is taking many drugs simultaneously."
These calming techniques aren't always enough for babies with higher exposure to opioids. About 60 percent to 80 percent of infants with neonatal abstinence syndrome need drug treatment to help with withdrawal, according to a December article about the syndrome in the New England Journal of Medicine.
Most of these babies are given morphine or methadone, mostly to help relieve seizures, weight loss and other symptoms as they detox. But these drugs can lead to other health issues. For instance, use of morphine can lead to respiratory problems and a longer hospital stay for the baby.
The University of Maryland Medical Center is studying whether the use of cuddlers can decrease the amount of morphine and other drugs these babies need to recover and decrease the length of their hospital stay.
"A nurse can't always do this because they have to take care of other babies," said Dr. Dina El-Metwally, medical director of the Baltimore hospital's Drs. Rouben and Violet Jiji Neonatal Intensive Care Unit.
"There are usually residual symptoms that can last over the first year — stiff muscles, feeding difficulties, trouble sleeping," said Lauren Jansson, the center's pediatric director. "All of these symptoms can be managed at home, but it can be difficult without support.
Doctors said more studies are needed on the best way to treat babies. For instance, the way medical staff "score" a baby's symptoms is subjective. There are also questions whether there are other drugs that could be used to treat these babies. And the long-term effects of being exposed to opioids in utero are not known.
Ashley's baby was in the hospital for five weeks as the drugs in her system slowly dissipated.
Ashley said her addiction stemmed from a car accident at age 18 when she hit a tree. She was prescribed the opioid percocet and became hooked over the next two years. In search of a more intense high, she turned to heroin at age 20.
She hit her lowest point four months into her pregnancy. Her boyfriend had left her and she was working as an escort to feed a $200-a-day heroin habit. Deep down she feared what she was doing to her unborn child.
"I was scared she was going to come out with a lot of birth defects," said Ashley, who is now 28.
Feeling down and out, she tried treatment one more time — if not for herself, for her unborn daughter. Treatment specialists prescribed buprenorphine, a maintenance drug that reduces withdrawal symptoms and is used to help wean users off more addictive opioids and help them get sober.
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Ashley knew the buprenorphine would get in her baby's system but thought it was better than heroin.
Ashley said her daughter is now six months old and healthy.
"She is perfect," Ashley said. "I could not ask for a better child. She is extremely well-tempered. She is very loving, very sweet and always happy."
She wishes there were more treatment options so other mothers don't end up in the same predicament. But Ashley said her daughter has given her reason to stay sober.
"I couldn't imagine ever going back to that life," she said.