Rooming-In the Mother/Infant Dyad in Cases of NAS, Decreasing Length of Stay, and Pharmacologic Treatment

Caring for newborn infants with Neonatal Abstinence Syndrome (NAS), is very challenging for the clinician and the parents. Neonatal Abstinence Syndrome is defined as signs and symptoms of withdrawal that infants develop after in-utero exposure to opioids. Newborns typically start showing signs of withdrawal two to five days after birth, and those infants whose symptoms are severe enough to require pharmacologic intervention are typically treated with replacement opioids such as methadone or morphine, and then weaned off over days to weeks. Once diagnosed with NAS, most infants are taken from mom’s room and placed in the Neonatal Intensive Care Unit (NICU) where they may stay for an average of three weeks, separated from their mothers and cared for by a nurse who has two to three other infants in her assignment. The nurses and parents get very frustrated, knowing that the NAS infants are not getting the calm, quiet, individual care they require. Recent evidence and clinician experience have shown that NAS infants are often receiving more opioid exposure in the weaning process than would be necessary if the mother could be caring for the infant around the clock. In cases of NAS, it is in the best interest of the baby and mom to be in a quiet environment where mom can be available to hold and soothe her infant.

Rooming-in mom and baby offers the appropriate environment to maximize non-pharmacologic therapy for the NAS baby, such as holding, rocking, low singing, and reading to baby. In the rooming-in model, baby stays with mom on the mother/baby unit in the immediate post-partum period. The mother/baby nurses monitor baby for NAS signs and symptoms and baby receives treatment as necessary. When the mom is discharged from the hospital, the infant, if needing further hospitalization, is transferred to the pediatrics unit, to a private room where mom can stay 24/7 with her baby. The nurses can educate and support mom about NAS and treatment and interventions she can do for her baby. Mom gains confidence as she is able to comfort and soothe her baby and sees that baby has less need for pharmacologic treatment. Mom is also able to learn parenting techniques as she cares directly for her baby. Mom is able to learn about resources available to her and baby for after discharge.

Rooming-in optimizes the opportunity to breastfeed. Breastfeeding is better for NAS babies not only for the nutritional benefits, but also for the bonding and calming it offers mom and baby. Breastfeeding can also help the infant with the gastrointestinal difficulties that come with NAS. Oftentimes, when baby is in NICU, it is difficult for mom to visit and be available for baby to breastfeed. Mom often feels a great deal of guilt and anxiety. These feelings lead to difficulty establishing a good milk supply. Breastfeeding also benefits mom as she recovers in the postpartum period, and rooming-in optimizes these benefits for both mom and baby.

Evidence has shown that rooming-in can decrease length of stay and the need for or duration of pharmacologic intervention. Rooming-in can also increase mothers’ confidence and satisfaction in caring for her baby with NAS. It must be considered that caring for the mother/infant dyad affected with NAS brings many feelings. Clinicians are dealing with opioid-addicted mothers and mothers in treatment for addiction. There is a vast array of scenarios involved when considering each mother/infant dyad. It is impossible for anyone caring for a baby that is withdrawing from any drug exposure not to feel strong emotions toward the mother. Because of their unique situation, some of the mothers will not be candidates to room-in with their babies. Some of our NAS babies will go into foster care because the mother can’t take care of the baby. It will be very important to include training for the staff on substance abuse and caring for the mothers well. Having a better understanding of what the mothers are going through will help the nurse gain mom’s trust and will increase the efficacy of rooming-in care. We must be sure that we are considering the rights and values of all our mothers. Staff must assist mom to do what is in the best interest of the mom and baby.

Changing to a rooming-in model includes a change in culture, to include the mother/baby and pediatric units. Training is required for all nurses that care for NAS mother/infant dyads regarding scoring and non-pharmacologic interventions. All stakeholders will need to be involved in the change, to include neonatologists, pediatricians, nurses, child life specialists, case workers and discharge coordinators. Evidence from institutions that have already changed to this model show significant decreases in length of stay and need for or duration of pharmacologic therapy. A review of the evidence shown to all stakeholders can help to solidify buy-in and recruit stakeholders to the process change team.

As evidence becomes available and data is gathered from mothers, babies, families, and clinicians, we see that we can improve outcomes for NAS infants and families by changing to a rooming-in model. This change is not easy as it involves multiple units and stakeholders. As the literature clearly shows, significantly improved outcomes for infants, families, staff and organizations are clearly worth the investment of time and resources.