A staff member at Hushabye Nursery in Phoenix feeds one of the babies on Nov. 8, 2022. Infants brought to the nursery are withdrawing from drugs they were exposed to before birth – opioids, in particular. Across the country, cases of neonatal abstinence syndrome increased 82% from 2010 to 2017. That means that in the U.S., a baby is diagnosed with NAS every 19 minutes.
The 12-room nursery is surprisingly quiet. Rather than beeping monitors, there are whispered conversations. The hum of a bottle warmer.
A cry occasionally pierces this silence, and within moments a parent, nurse or volunteer cuddler is at the baby’s side. Do they need to be fed or changed? Rocked or held? Or, in this facility, given medication to ease their discomfort?
In central Phoenix, down the street from a tire shop and a florist, Hushabye Nursery is home to babies born withdrawing from addictive substances they were exposed to in the womb. They spend their first days of life in dimly lit rooms equipped with cribs, changing tables and adult-size beds so their parents, many of whom are still in recovery, can stay with them.
Framed prints on the walls read: Inhale. Exhale.
As their babies are treated, parents are connected with addiction treatment, child services and, if necessary, help obtaining essentials such as housing – ideally before their children are born.
The Hushabye model is built around trauma-informed care, and its goal is to end the cycles that lead to multigenerational patterns of addiction. It’s a departure from traditional thinking about how to treat infant withdrawal, clinically referred to as neonatal abstinence syndrome, or NAS.
Babies with NAS may suffer tremors, sleeping problems, irritability, fever, diarrhea, difficulty eating and seizures.
“Some people say moms are the best medicine,” said Tara Sundem, founder and executive director of Hushabye Nursery. “And so if we create an environment (where) the moms and dads feel welcome and not judged, meaning trauma-informed, they’re here and their babies do better.”
Across the country, cases of neonatal abstinence syndrome increased a startling 82% from 2010 to 2017, research shows. That means that in the U.S., a baby is diagnosed with NAS every 19 minutes.
In Arizona, these cases increased 41% from 2017 to 2021; Black and Indigenous children had the highest case rates in 2021, according to the state Department of Health Services.
This rise comes amid an opioid epidemic that hasn’t slowed down. From 2020 to 2021, Arizona reported nearly 4,000 opioid overdose deaths and about 7,500 nonfatal opioid overdoses. That doesn’t include hospitalizations and emergency department visits in which opioids were mentioned – those number in the tens of thousands.
Policymakers, health care workers and advocates are seeking more effective solutions for how to treat NAS and its root causes. Hushabye is, in many ways, the culmination of these efforts, and has received support from nonprofit organizations and state agencies alike.
“We know, obviously, that in order to survive and successfully thrive in this world, you have to address the baby’s needs within the entire unit, including those that are taking care of that baby,” said Dr. Sara Salek, chief medical officer for the Arizona Health Care Cost Containment System, the agency that administers Arizona’s Medicaid program.
“And so I think from our perspective, (Hushabye) is coming at it from a trauma-informed lens but also just a pro-social and biologically driven lens.”
Salek met Sundem years ago when Hushabye was just an idea and Sundem was exploring how to secure Medicaid funding. Today, Hushabye contracts with five of AHCCCS’s seven health plans, according to Salek.
“It takes persistence, as well as passion,” Salek said. “And really, Tara has both that persistence and passion to do the right thing for babies and their parents.”
Sundem worked for years as a neonatal nurse in the Phoenix area before starting Hushabye. She remembers seeing more and more babies coming into her unit with withdrawal symptoms and wondering what could be done to improve the ways providers respond to these babies and their families.
“We didn’t really grasp that opiate use disorder is not a moral failure, not a choice, but a chronic illness – a brain disease,” Sundem said. “That these families are just like you and I, and they don’t want to be unwell.”
As she was seeking solutions, Sundem also gained a deeper understanding of the root causes of addiction, leading her to learn about what the medical community has come to refer to as adverse childhood experiences, or ACEs.
The Centers for Disease Control and Prevention defines ACEs as “potential traumatic events” or environmental factors that occur before age 18 that correlate with poor mental and physical health later in adulthood. Seeing violence at home, having a parent who uses drugs or struggles with mental illness, and being placed in foster care all fall under this. The more of these events, the worse the outcomes.
“Once I found out about them, I was like: Oh my gosh, our babies are born with usually two or three adverse childhood experiences,” Sundem said.
“If we remove a baby and place them in foster care, we’ve set them up for chronic illness, which means we’re just going to continue with this generational trauma. So we need to meet these families prenatally to get them well.”
In 2015, Sundem visited Lily’s Place in West Virginia, which offers a dedicated facility for NAS newborns. Soon after, she began forming support groups for expectant families. She spread word of the effort through addiction and recovery centers, and gained a better sense of the larger system she was navigating.
In collaboration with community partners and funders, and with consultation from the Arizona Substance Abuse Task Force, Sundem joined with another neonatal nurse and opened a permanent location for Hushabye in November 2020.
Since then, Hushabye has cared for more than 400 infants.
“What we found is that environment makes a difference,” Sundem said.
The facility operates 24/7, with the capacity to bring babies from the hospital within 24 hours of birth. The average stay at Hushabye is seven days, compared with more than three weeks at a hospital in the neonatal intensive care unit, or NICU.
This is mostly due to a cornerstone of Hushabye’s treatment plan: a model called Eat, Sleep, Console, first brought to Arizona by Lisa Grisham, a neonatal nurse practitioner and director of the Family Centered NAS Care Program at Banner University Medical Center in Tucson.
“We’re really trying to change the care to involve the families in part of the treatment to maximize nonpharmacologic care,” said Grisham, who learned from the model’s creator, Dr. Matthew Grossman of Yale University.
Eat, Sleep, Console focuses less on medical intervention for the infant – with morphine, methadone, buprenorphine and other medications – and more on human touch and family. Mom and baby are kept together in close proximity in quiet spaces to allow more time for feedings and increased cuddling.
The National Institute for Children’s Health Quality notes the model is promising: “Along with proven health benefits of skin-to-skin contact, moms and other caregivers can provide support … that their baby can’t get anywhere else. They can give their baby their undivided attention – holding the baby when cranky or upset … and providing feedings as often as the baby is hungry.”
A 2019 study found that NICUs using Eat, Sleep, Console saw a nearly 80% reduction in morphine use for these babies, cut hospital stays in half, and reduced costs 48% on average.
“It’s a whole culture change. It’s a paradigm shift,” Grisham said.
In addition to requiring fewer medical interventions for their babies, 77% of mothers who work with Hushabye before giving birth maintain custody of their infants, the nursery reports.
A major component of Hushabye is having staff and peer support specialists advise families on how to navigate child services.
“It can be scary. Let me tell you that,” said Joey Fant, a peer support specialist at Hushabye. “For parents that don’t know what’s going to happen … it’s kind of like an unknown factor.”
Before working at Hushabye, Fant went through the program in 2019 with his newborn son, Jude. Fant met Sundem at a methadone clinic, soon after he found out he and his girlfriend were expecting. He had struggled with addiction for 10 years at that point and was determined to finally get sober.
“It was a lot, internally, to compartmentalize everything and try to put the pieces together of the future,” he said.
Sundem helped Fant understand what to expect. She taught him what NAS was and how to advocate once Jude was born. Fant was especially grateful for Sundem’s guidance in working with the Arizona Department of Child Safety. Now he does the same for other Hushabye families.
“Had I not had that, it probably would have had a lot more of a toll on me,” Fant said.
All cases of NAS are required to involve the child safety department as part of mandated reporting laws. Sundem encourages parents to initiate contact themselves, before they’re reported by a provider or someone else. That helps build trust.
“As long as we’re all working together to make sure the baby’s safe, it should be a cooperative approach,” she said.
Katherine Guffey, a child welfare consultant for the department, agreed that trust is essential.
“It makes a huge difference, because one of the things that we look at in assessment is that parent’s readiness for change,” Guffey said.
Guffey stressed that the goal of the Department of Child Safety is not to separate families. Caseworkers also aim to connect parents to services and are seeking federal funding for preventative programming that could help reduce such cases.
“You can recover from your addiction. You can,” Guffey said. “And DCS wants your children to stay in your care.”
Experts and advocates agree that stigma is the biggest barrier to achieving that. They note that mothers will sometimes avoid seeking help early in their pregnancies, or avoid seeking help at all, because they fear being judged, whether by a NICU nurse or a DCS caseworker.
“Families are ashamed. They’re embarrassed. They’re hopeless,” Sundem said. “And when they ask for help they’re at the lowest of the low. And to not be treated well when they ask for help, if that’s an eye roll or if that’s just a rude comment – different body language? They’re not going to get help.”
Work is underway to educate health care providers and caseworkers about how to better approach parents of babies with NAS. The Department of Child Safety has taken steps to help caseworkers better check biases when meeting with families.
“Behaving in a way that communicates empathy is something that can be taught to people,” Guffey said.
And as NAS cases continue to rise, providers, caseworkers and parents agree that spreading word about programs like Hushabye could lead to better outcomes for babies and families alike.
“I want all of these parents that come in here to have the same chance to succeed – to take their child home and raise their child, just like I did,” said Fant, the peer support specialist. “That is my goal at the end of the day.”
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