Matthew is a one-week-old term infant admitted to the NICU for neonatal abstinence syndrome (NAS). His mother used heroin for the first half of her pregnancy, but was then able to receive treatment in a methadone maintenance program. This morning, Matthew is screaming, mottled, sneezing, and his tiny jaw quivers. You try to console him while his nurse quickly prepares his bottle.
Just as he is beginning to respond to your efforts, his mother arrives. The nurse explains that Matthew has been very irritable today, and is ready to eat now. Mom scoops him up, brings him very close to her face, and sings loudly to him. She insists on putting him in the new onesie she brought for him before feeding. He continues to scream and is very tremulous.
You are always professional and do your best to remain truly nonjudgmental. You know there is no simple solution here.
And maybe what helps, like with all things we do in the NICU, is focusing on what’s best for the baby given his current circumstances. It’s the only starting point we have. The babies are the WHY of our work.
So what do we know about babies like Matthew? What do we know about the effect of his mother’s presence?
Opioid exposure in utero is increasing in the United States, thus an increase in babies who are treated for NAS. Mothers who have used illicit drugs, as well as mothers who have medical conditions that necessitate regular use of narcotic medications experience a wide range of medical, social, and psychological challenges. As neonatal therapists, we know that parental presence is important for the babies and families despite these challenges. Previous research has demonstrated that the model of allowing parents unlimited access to their babies, including overnight stay, results in decreased length of stay and decreased need for pharmacologic therapy. However, no study had examined the effects of the actual amount of time spent with the infant within this model.
Researchers at Boston Medical Center looked retrospectively at 86 infants who were treated for NAS on the pediatric unit using the rooming-in model of care. Parental presence was recorded every 4 hours in conjunction with nursing assessment. After controlling for multiple factors, including breastfeeding, the data showed that more parental time at the baby’s bedside was associated with a nine day shorter length of stay, eight fewer days of medication, and 1 point lower mean Finnegan score. Barriers to visiting identified through discussions with families included transportation, additional child care responsibilities, off-site methadone dosing, residential substance abuse program requirements, and stigma and guilt.
The American Academy of Pediatrics recommends nonpharmacologic care as first-line treatment for infants with NAS. This study demonstrates that basic interventions, such as facilitating parent presence, can have a significant impact on NAS severity. Neonatal therapists can encourage visitation and also enhance the quality of time parents spend by:
-Understanding that addiction is a disease often triggered by complex trauma, and that mothers of babies with NAS experience a range of emotions, as well as possible executive function deficits as a result of drug use – and tailoring our interventions accordingly.
-Teaching parents to read their baby’s cues and respond to their needs to enable them to function as the primary caregiver of their child.
-Instructing families on specific techniques for calming their babies.
-Promoting a culture that welcomes all families.
Howard, MB, Schiff, DM, Penwill, N, Si, W, Rai, A, Wolfgang, T, et al. (2017). Impact of parental presence at infants’ bedside on neonatal abstinence syndrome. Hospital Pediatrics, 7(2), 63-69.