ST. LOUIS _ The tiny babies typically arrive at Jill Bundschuh's foster home in Rock Hill, Mo., around her family's dinner time.
Social workers bring them on short notice, with maybe some formula and a few diapers. There are no extra onesies. No swaddling blankets. No car seats.
The paperwork is usually sparse beyond a name and maybe a few clues about the baby's first few days or weeks of life. Bundschuh knows from experience to quickly read the hospital notes before the caseworker leaves with the file.
Even when there is no medical history, this relatively new foster parent knows what to expect in the long night ahead.
The baby will constantly fidget. There can be sudden tremors in the arms and legs. The buttocks might bleed from open sores caused by runny diarrhea. The sucking reflex is off, so feeding can frustrate the baby.
Lullabies and cuddling rarely soothe the child who arches his or her back and cries in a high pitch. So Bundschuh will find a quiet spot away from the bedrooms where her husband and three boys are sleeping. She will rock the baby in her arms with his or her body vertical. Being cradled agitates the baby.
Mostly she will pace with the baby through the dark house _ because in her experience babies withdrawing from heroin or methadone or morphine or other opioids may be consoled by movement.
Bundschuh has cared for four babies in opioid withdrawal since she and her husband became licensed foster parents in Missouri two years ago. The most recent arrival came in late January _ a newborn preemie. The previous baby was agitated for six months, a fairly typical course for full withdrawal.
"There would be two to three hours every night where he just screamed; he was very hard to calm," she said.
Bundschuh made no special request to care for these cases when she signed on to be a foster parent.
Nonetheless, she has wound up on the front lines of Missouri's opioid epidemic, which is sending children at an alarming rate to a state foster care system that is straining to serve them.
It's not just newborns _ though the system is seeing far more of them. It's also older siblings who need care after Children's Division investigators find severe neglect in a household disrupted by opioid addiction and the often unsafe parental behaviors that go with it.
"We are in desperate need of more foster parents for the first time in a decade and a half," said Melanie Scheetz, executive director of the Foster and Adoptive Care Coalition of St. Louis. "We need them for both newborns and older children."
Scheetz said foster parents need to be trained about dealing with trauma in these children:
"We had a case where two kids were found in Fairground Park behind a bridge because their mother was turning tricks for drugs. It's just devastating for these families."
Bundschuh received no special training on how to care for babies in drug withdrawal after being exposed to opioids in the womb or given morphine in the hospital to taper the symptoms of their withdrawal. She's learned on her own.
Along with the risk of burnout and frustration with an inconsolable baby, there is constant worry. She knows, for example, that babies in withdrawal are at a higher risk for seizures or sudden infant death syndrome, or SIDS. If something happens, she could be legally liable.
"The first week is very exhausting because I'm constantly checking their breathing," she said. "I didn't go through that with my own. With my own kids, it's not so stressful."
THE NUMBERS CLIMB
Last year more than 650 people died from opioid overdoses in the St. Louis region, more than four times the number in 2007. Recently, the Post-Dispatch chronicled the toll those fatalities are taking on the region's families and communities.
But the epidemic is also measured in delivery rooms of Missouri hospitals, which have seen more than a fivefold increase in the number of infants born with symptoms of opioid withdrawal in the past 10 years, according to the Missouri Hospital Association. St. Louis stood out with one of the highest rates in the state, surpassed by just two counties in rural south-central Missouri.
The number of children going into foster care in Missouri began to climb in 2012, following years of a general decline. Last year 7,505 children entered foster care. That is a leap from 6,432 in 2013.
In the past five years, St. Louis County saw a 29 percent jump in the number of children entering foster care, peaking at 521 children last year. In St. Louis city, entries increased by more than a third. Jefferson County saw a 20 percent increase; St. Charles County, 14 percent.
The state lacks data to directly tie the spike in foster care to opioids.
But data from the St. Louis Family Court show the link.
Of the 46 children who have entered foster care in the city this year, 17 _ or 39 percent _ were due to drugs, either involving drug exposure to newborns or issues of abuse or neglect because of substance abuse by parents. One of the cases involved the fatal shooting death of a 6-year-old girl by a younger sibling while the mother and her boyfriend slept after smoking drugs, according to court records. The three living siblings, ages 3, 4 and 9, went into foster care.
Clinicians at Cardinal Glennon Children's Medical Center's Fostering Healthy Children medical clinic see nearly all the children who enter foster care in St. Louis and St. Louis County. About a third of some 900 children they've served since opening two years ago have been opioid addicted.
"I was totally unprepared," said Donna Erickson, medical coordinator. "I am friends with social workers in the NICU, and we've had one or two parents overdose in the bathroom while they are visiting. But I truly had no clue about its prevalence until I started working here."
Though foster care is intended to be a haven for a child, the transition into state custody, and the risk of multiple placements or re-entry into foster care when a parent fails to stop using drugs and neglects the child, are considered highly traumatic events.
An increasing body of research finds foster children struggle with lifelong health and behavioral issues because of the trauma of the initial abuse and neglect as well as the toxic stress from their years in foster care without adoption or reunification with family.
"Very often from the time the child leaves the NICU to the time we see them at the clinic, they may have already been moved a couple of times when they have withdrawal issues," said Maggie McVey-Vogt, a clinical nurse at the foster care medical clinic. "And the new foster parents have little or no knowledge about what they are looking at with these babies."
The Missouri Department of Social Services would not acknowledge or speculate if the increase in foster care placements is due to opioids, citing a lack of statistics. Nor would the department make a Children's Division official available for an interview about the increase.
Yet Gov. Eric Greitens campaigned heavily in rural areas on a platform that pledged to deal aggressively with the opioid crisis. His wife, Sheena, is a well-known advocate for foster parents. The couple chose to host foster parents at their first social event in the governor's mansion.
The governor has proposed in his preliminary state budget a $2.7 million increase in direct foster care funding to serve the increasing number of children in state custody and another $1.2 million increase for adoption resource centers. Those centers, including Foster and Adoptive Care Coalition in St. Louis, recruit foster parents and run programs to quickly find permanent relative placements for children recently entered in foster care.
Making decisions
The ultimate decision to separate a child from a parent and place him or her in foster care lies with the presiding family court judge in each of Missouri's circuit courts. In St. Louis, that's Robin Vannoy. Between foster care custody cases last week in her courtroom, she said reunification with the parent is almost always the goal with newborns and infants when a parent is facing a substance abuse issue.
That means children may stay in the foster care system longer and parental rights will not be terminated as quickly _ all with the understanding that addicts typically fail several times before they may be able to stop using drugs.
The National Institute on Drug Abuse estimates up to 60 percent of recovering drug addicts will relapse. With heroin, those rates are higher.
Many opioid addiction cases involving children never reach Vannoy's courtroom or the Children's Division because grandparents step in. When a child is unexpectedly born drug-addicted, a hospital typically calls the Children's Division. The baby can go into foster care after discharge with a judge's order.
But caseworkers can also opt to divert a custody hearing and keep the child with the mother through a system of "Team Decision Making" meetings. They identify family supports to ensure the child's safety as well as the mother's willingness to get treatment and parenting classes, therapy and other programs.
Mothers who seek prenatal treatment for addiction also tend not to lose children to foster care if they show progress in their recovery and a strong support network.
But some addicts burn through their safety nets. In those cases, Vannoy, on the recommendation of the Children's Division, often places the child in foster care. The ideal placement is with a relative.
In most cases that relative is a grandparent.
Sometimes those grandparents _ still joyful about the birth of a grandchild _ abruptly learn that their child is a drug addict.
'There was no time'
Donna Beckham Williams, 46, of Florissant, said a day after her grandchild Aaron's birth last year, she got a panicked call from her son begging her to take him because Aaron had tested positive for opioids and was being sent to foster care. Not long after, she was shocked to learn both her son and his girlfriend were using heroin. She waited an agonizing week to get foster care custody of her grandchild, who had been placed with a stranger in a foster home.
"I had to go right into mommy mode because there was no time," she said.
Beckham Williams has been caring for Aaron for 10 months. Additionally, she baby-sits her daughter's infant twins during the week and cares for her blind, elderly uncle. Her son and his girlfriend have made no effort to regain custody of their child and don't show up for required drug testing and other meetings set up by the Children's Division, she said.
"They're drug addicts," she said. "They stick together, and that's the hard part with getting them help."
Many newborns who enter foster care with opioid issues are reunited with parents within several months, Scheetz said.
Bundschuh, the foster parent, said all of the babies she's nursed through withdrawal went back to their mothers while still infants.
She remains in contact with two of the families and sees one of her former foster babies weekly. She knows, despite the bonds she made with those babies, they need permanent homes. But given the reach of heroin in families and the risk of relapse, she and others in the foster parent community worry some babies are being placed with relatives too quickly.
"The system is so big on trying to quickly move them to families that a lot of foster parents don't feel are safe or ideal," she said. "Sometimes, those babies end up back in foster care, causing them more disruptions."
Last Wednesday, though, those worries were not present in one case on Vannoy's foster care docket.
An 11-month-old babbled and bounced on her mother's maternal cousin's knee while clutching a burp cloth. The infant had been placed with the relative at 2 months after being placed in another foster home after birth. Court testimony said the newborn had tested positive for cocaine, heroin and fentanyl, a potent synthetic opioid that is often responsible for fatal overdoses.
Various court and caseworkers testified the young mother sitting in the courtroom had tested clean on all of her drug tests. She had taken required therapy and parenting classes, passed a psychological evaluation and obtained housing and employment. The baby had received therapy through day care and been through various developmental screenings.
Vannoy ruled the mother could have unsupervised overnight visits with her baby. If all goes well, mother and baby will spend three months together this summer on a trial basis.
"I have to say that it's unusual to get someone so young like you to cooperate and do everything you needed to do," Vannoy told the mother.
The mother beamed. After the hearing, the judge held the toddler in the folds of her black robe and spoke to her in a high, delighted voice.
"You made my day today."
