Dr. Adrienne Foran:

I thank Deputy Catherine Byrne for bringing up this important issue. I am a consultant neonatologist in the Rotunda Hospital and in the Children's University Hospital, Temple Street. I am also a member of the national clinical advisory group for neonatology. Recently, I was appointed as clinical director of Temple Street hospital.

The Rotunda and Coombe hospitals are in a unique position. They tend to have the largest volume of these patients. The document before the committee goes through the matter in more detail but in the interests of time, I will try to summarise it.

Neonatal abstinence tends to pertain to those babies who are withdrawing from mothers who are substance abusers, generally of opiates, including heroin and methadone, as well as other hypnotics. What we have seen in the past five or ten years is that the majority of these mothers are polydrug users. One of the greatest challenges in delivering a maternity service arises where the mother is on a benzodiazepine, for example, Valium or sleeping tablets. She may not always declare it. The half-life of these drugs is far longer than for others, so the baby may not actually withdraw for two to three weeks and by then the baby is home. The way we manage that and how we identify it are major challenges.

There is a policy in the UK and in some centres in the United States to encourage these mothers to abstain during pregnancy. We have found, through research between the Coombe and the Rotunda undertaken by our chief pharmacist, Brian Cleary, that this is probably not a good model. What tends to happen is that if we ask the mother to abstain she actually disengages from the services, does not attend her antenatal clinic and gets into far more trouble during the pregnancy. A good deal of research suggests that keeping these women on a methadone programme is actually safer for mother and baby.

Approximately 100 per year come to our services in the Rotunda. I have given the committee our clinical specialist midwife report. Some 68 of these delivered in 2014. Up to 10% of our deliveries, approximately 1,000 babies per year of the 9,000 delivered in the Rotunda, are admitted to the neonatal unit. Of the 68 deliveries, 33 were admitted for a variety of reasons, not always for neonatal abstinence syndrome. It may have been because they were born more premature or because they had problems with blood sugar. Approximately one third, that is, ten or 11 of that figure - sometimes it could be 15 or 20 - would have had full-blown neonatal abstinence syndrome.

One difficulty is that it is not necessarily the dose of the drug or the number of drugs the mother is on. Some babies have a genetic predisposition to withdraw more acutely while others withdraw more chronically. There are major social issues dealing with these mothers. They often come from troubled backgrounds. They do not have very good parental models. They may have had other children who are already in care. There are complex social issues. Having a drug liaison midwife has made a major difference. I apologise for the typographical error in the document provided in that the word "lesion" should be "liaison".

The infrastructure to which Dr. Coulter-Smith and Dr. Sheehan referred is a problem for us. Ideally, once these babies are identified under the scoring system as requiring more intensive management, they should be nursed in a dark quiet room with dimmed light and swaddling.

That is not possible in the Rotunda Hospital in 2015 because we do not have the space. Ideally it should be done in a transitional care unit so that the mum can stay with the baby which stops the social problems escalating. If we take the babies away from the mums, they are in a busy, high-dependency unit with 20 other babies. Our nurses are a bit nervous about nursing them in a side room because of the implications for staff safety as well as baby safety. The infrastructure is not there to provide the model of care properly and, therefore, our length of stays are far too long. The committee will see that the average length of stay for these babies is between 11 and 54 days. Although the numbers are small, they block our beds from a practical point of view. Furthermore, we are not giving the babies the service they deserve because they are not being managed as appropriately as they should be.

The elephant in the room is the very controversial issue of foetal alcohol syndrome. We probably have a lot more problems with this syndrome than is openly acknowledged in this country. We have proposed a project to the Health Research Board, HRB, which would study this anonymously, as was done 15 or 20 years ago for HIV. Babies would not be identified and we want to look at the their first poo at delivery and check the alcohol levels. That would give us some data because we do not have data on the number of babies exposed to alcohol during pregnancy. This is an issue that I and Dr. Miletin from the Coombe hospital have spoken about previously. We might see one or two babies a year who clearly have full-blown foetal alcohol syndrome but the mother would be an identified alcoholic. There are probably many more babies affected and those effects are probably a lot more subtle. They may not present with problems until they are two or three or at school-going age when we see learning difficulties. Unless we know how widespread the problem is, we will not know how to deal with it.

Despite all of the infrastructure and staffing problems to which I have referred, one can see from the report by our drug liaison midwife, Justin Gleeson, that the number of admissions is going down and that how we manage those babies and the number of babies who get to go home with mum, albeit with a grandmother or other support provider in place, has improved dramatically since he was appointed in 2008. We have a dedicated team in place. Patients see the same midwifery specialist antenatally, during labour and afterwards. He is the key link for us with social services, with the obstetrics team headed by Maeve Eogan, one of my obstetric consultant colleagues, and with a really good pharmacy support service. We do it well but it could be done a lot better.