One of the more heartbreaking ripple effects of America’s opioid addiction epidemic is a massive increase in newborns experiencing drug withdrawal. Public health officials have tracked a 400 percent increase in such cases — known as neonatal abstinence syndrome — with one impacted baby born every 25 minutes as of 2012.
Finding the capacity to care for newborns with NAS is a growing challenge for health care providers, hospitals and neonatal intensive care units (NICUs). Newborns with NAS are more prone to breathing and feeding difficulties, are at higher risk of low birth weight and typically have to stay in the hospital much longer than newborns without NAS. The challenge has many hospitals looking for innovative ways to mitigate the symptoms of NAS beyond the use of pharmacologic interventions such as methadone, morphine or buprenorphine. One such promising intervention builds on a hospital practice that’s increasingly commonplace: keeping new mom and baby together in the same room throughout their hospital stays, a practice known as “rooming-in.”
At New Hampshire’s Dartmouth-Hitchcock Medical Center, providers instituted a rooming-in policy for babies with NAS in 2014. At the time, according to Kathryn Dee L. MacMillan, a pediatrician in Dartmouth-Hitchcock’s Leadership Preventive Medicine Residency, the number of babies born at the hospital with prenatal opioid exposure had gone up to about one in 10. Rooming-in seemed to be making a difference, leading to fewer pharmacologic interventions and shorter hospital stays.
Still, the literature base on NAS and rooming-in was limited — a gap that MacMillan and colleagues hope to help address with a study published this month in JAMA Pediatrics. Their big take-away: keeping babies with NAS close to their mothers, as opposed to automatically caring for them in a NICU, should be the preferred practice for babies suffering from opioid exposure.
“We’re still providing treatment as needed, but we like to think of the mothers themselves as the first line of treatment,” MacMillan told me.
The study, a systematic review and meta-analysis of relevant studies from the U.S., Canada and Europe, compared infants automatically admitted to the NICU versus infants who were only admitted to a NICU if it was determined they needed increased observation and pharmacologic intervention. Overall, researchers found that rooming-in was associated with a lower proportion of infants needing withdrawal medications. All six studies included in the meta-analysis found “significantly” shorter hospital stays for rooming-in babies compared to standard NICU care, with stays shortened by up to 12 days. A number of the studies reported less costs associated with rooming-in, and none of the studies reported adverse events related to keeping mom and baby together.
Study co-authors MacMillian, Cassandra Rendon, Kanak Verma, Natalie Riblet, David Washer and Alison Volpe Holmes write: “Our findings are relevant to current practice because implementing rooming-in for opioid-exposed newborns is straightforward and has clear benefits. It allows for greater parental involvement by increasing opportunities for families to provide nonpharmacologic treatment and permits more efficient use of institutional resources.”
MacMillan said she wasn’t surprised at the results. Intuitively, she said, it makes sense that the quieter, calmer environment in mom’s room — versus the busy, noisy and bright environment of a NICU — would benefit a baby struggling with opioid withdrawal. And while the study didn’t tease out the exact characteristics of rooming-in that made the difference, MacMillian suspects it’s due to the calmer environment, skin-on-skin contact between newborn and mother, increased bonding time, and more opportunity for breastfeeding.
She noted that newborns who do need medication to mitigate withdrawal symptoms still benefit from rooming-in and can be effectively monitored during that treatment outside a NICU. (She said that at Dartmouth-Hitchcock, babies with NAS who receive morphine aren’t automatically separated from their mothers and brought to the NICU — they’re monitored while rooming-in.) In fact, MacMillan said many babies with NAS and rooming with their mothers never get to the point of needing pharmacotherapy.
MacMillian said shortening a baby’s hospital stay is an especially important effect of rooming-in, as it’s often difficult for families to be at the hospital for long periods of time. At the same time, she said, it’s incredibly important for newborns to be with their families during their entire hospital stays. The situation can be particularly tricky for newborns with NAS, whose mothers are typically discharged before they are. To address the problem, Dartmouth-Hitchcock lets moms board at the hospital as guests to stay close to their babies. The medical center also runs a “cuddler” program with volunteers specifically trained to comfort babies with NAS as well as a Moms In Recovery program.
Of course, not every hospital has the resources to make such accommodations, MacMillan said, but with NAS on the rise, rooming-in is a promising intervention that many hospitals can and should consider.
“Our findings support this as a best practice for babies (with NAS) — it emphasizes that parents should think of themselves as an important part of their babies’ care and treatment,” she told me. “We’ve shown this is better for babies. And anecdotally, it’s better for families too.”
For a copy of the new rooming-in study, visit JAMA Pediatrics.