Dear neonatal colleagues,
I am thrilled to introduce this special Advances in Neonatal Care series, titled “Care of the Infant and Family Affected by Neonatal Abstinence Syndrome (NAS) Across Multiple Settings.” In this series, we showcase the innovative work occurring within the field of neonatal care to support families impacted by NAS and contribute to better health outcomes and quality of life. In the context of our current nationwide opioid crisis, opioid use in pregnancy has quadrupled in the United States.1 Accordingly, NAS rates have also increased by 5-fold, with 1 US2 infant now being born every 15 minutes experiencing the withdrawal symptoms of NAS that include gastrointestinal distress, tremors, and a high-pitched, inconsolable cry.3
While there is no universally agreed-upon standard of care for these infants and their families, their care has traditionally been provided in the high-acuity environment of a neonatal intensive care unit (NICU).4,5 Some experts are now beginning to question whether this environment is truly the most ideal for infants with NAS.6 The management of newborn withdrawal symptoms usually begins with common soothing techniques such as swaddling, rocking, skin-to-skin holding, and breastfeeding. However, because of the nature of most NICUs, infants are often separated from their mothers, which is a barrier to these recommended soothing techniques.7 Furthermore, if the hospital environment is such that the mother is unable to be present or feels uncomfortable visiting her infant, her ability to sooth and comfort her own infant may be jeopardized.8–10 This has not only led to some challenges for neonatal care providers but has also inspired the pioneering of novel approaches, such as those you will discover in this special series.
The second line of management for infants with NAS is pharmacologic intervention using some type of opioid whether naturally occurring such as morphine or synthetic such as methadone. While medications may be necessary to alleviate some NAS symptoms, their initiation has been linked to longer and more costly hospitalizations11 and a prolonged separation of infants from their primary caregivers.6 Furthermore, longitudinal research on the safety of these medications in young infants is lacking.6
For some neonatal care providers, care of the NAS-impacted family has resulted in challenges to include internal conflicts about the disease of addiction.12–15 According to the American Society of Addiction Medicine, “Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual's life experiences.”16 Yet, for many, substance use in pregnant and parenting women remains an emotionally charged issue that may be surrounded by stigma and personal bias. Neonatal care providers play a critical role in dismantling this health-related stigma that can interfere with quality, early maternal–infant interactions and attachment.
As neonatal care providers, we must all examine our own thoughts and beliefs about substance use in pregnant and parenting women. Not only must we not participate in stigmatizing behavior that can impact the families we serve but we must also act as change agents who address this stigma head-on when we witness it in the patient care setting. We should further strive to be powerful advocates for the families we serve both locally and nationally. First, we can ensure supportive policies and procedures in our units and hospitals. These policies should be designed to limit separation of infants from their mothers. Next, we can be champions for change at the state and national levels advocating for legislation that supports wholistic and affordable treatment and recovery support services for families impacted by substance use. Less punitive approaches that support the integrity of the family are critical and have the potential to impact future generations.17,18
Ten years ago, when I first began my journey of research and program development focused on families impacted my NAS, very little was known about these families or the multiple challenges they face on a day-to-day basis. Worse, no one was even asking the types of questions you will see presented in this special series. Some had reservations about my interest in this topic and wondered why I was pursing this line of research and program development. Today, I am truly encouraged by the progress of the science this special issue represents. However, there is always a need for continued research to improve outcomes for these families.
In conclusion, it is truly my pleasure to present to you this in-depth series on the care of families affected by NAS. Through these thoughtful articles, I believe you will come to better understand the important role we, as neonatal care providers, play in supporting and caring for families affected by NAS. Thank you so much for your interest in this topic and for your compassionate care of these families.
Lisa M. Cleveland, PhD, APRN, CPNP, IBCLC, FAAN
School of Nursing
The University of Texas Health Science Center at San Antonio
1. Haight SC, Ko JY, Tong VT, Bohm MK, Callaghan WM. Opioid use disorder documented at delivery hospitalization—United States, 1999-2014. MMWR Morb Mortal Wkly Rep. 2018;67:845–849. doi:10.15585/mmwr.mm6731a1external icon.
2. Patrick SW, Schumacher RE, Benneyworth BD, Krans EE, McAllister JM, Davis MM. Neonatal abstinence syndrome and associated health care expenditures United States, 2000-2009. JAMA. 2012;307(18):1934–1940.
3. Leech AA, Cooper WO, McNeer E, Scott TA, Patrick SW. Neonatal abstinence syndrome in the United States, 2004-16. Health Aff. 2020;39(5):764–767. doi:10.1377/hlthaff.2019.00814.
4. Witt CE, Rudd KE, Bhatraju P, et al. Neonatal abstinence syndrome and early childhood morbidity and mortality in Washington State: a retrospective cohort study. J Perinatol. 2017;37(10):1124–1129. doi:10.1038/jp.2017.106.
5. Krans EE, Cochran G, Bogen DL. Caring for opioid dependent pregnant women: prenatal and postpartum care considerations. Clin Obstet Gynecol. 2015;58(2):370–379. doi:10.1097/GRF.0000000000000098.
6. Schiffa DM, Grossman MR. Beyond the Finnegan scoring system: novel assessment and diagnostic techniques for the opioid-exposed infant. Semin Fetal Neonatal Med. 2019;24:115–120. doi:10.1016/j.siny.2019.01.003.
7. Mangata AK, Schmölzer GM, Kraft WK. Pharmacological and non-pharmacological treatments for the neonatal abstinence syndrome. Acad Pediatr. 2017;17(4):374–380. doi:10.1016/j.acap.2016.10.003.
8. Cleveland LM, Gill SL. Try not to judge: mothers of substance exposed infants. MCN Am J Matern Child Nurs. 2013;38(4):200–205. doi:10.1097/NMC.0b013e31827816de.
9. Cleveland LM, Bonugli RJ, McGlothen KS. The mothering experiences of women with substance use disorders. Adv Nurs Sci. 2016;39(2):119–129. doi:10.1097/ANS.0000000000000118.
10. Cleveland LM, Bonugli RJ. Neonatal intensive care unit experiences of mothers of infants with neonatal abstinence syndrome. J Obstet Gynecol Neonatal Nurs. 2014;43:318–329. doi:10.1111/1552-6909.12306.
11. Winkelman TN, Villapiano N, Kozhimannil KB, Davis MM, Patrick SW. Incidence and costs of neonatal abstinence syndrome among infants with Medicaid: 2004-2014. Pediatrics. 2018;141(4):e20173520.
12. Maguire D, Webb M, Passmore D, Cline G. NICU nurses' lived experience caring for infants with neonatal abstinence syndrome. Adv Neonatal Care. 2012;12(5):281–285. doi:10.1097/ANC.0b013e3182677bc1.
13. Welborn A. Moral distress of nurses surrounding neonatal abstinence syndrome: application of a theoretical framework. Nurs Forum. 2019;54:499–504. doi:10.1111/nuf.12362.
14. Sweigart E. Compassion fatigue, burnout, and neonatal abstinence syndrome. Neonatal Netw. 2017;36(1):7–11. doi:10.1891/0730-08220.127.116.11.
15. Murphy-Oikonen J, Brownlee K, Montelpare W, Gerlach K. The experiences of NICU nurses in caring for infants with neonatal abstinence syndrome. Neonatal Netw. 2010;29(5):307–313. doi:10.1891/0730-0818.104.22.1687.
16. American Society of Addiction Medicine. Definition of addiction. https://www.asam.org/Quality-Science/definition-of-addiction
. Published 2019. Accessed June 22, 2020.
17. The American Nurses Association. Non-punitive treatment for pregnant and breast-feeding women with substance use disorders. Revised position statement. https://www.nursingworld.org/∼4af078/globalassets/docs/ana/ethics/nonpunitivetreatment-pregnantbreastfeedingwomen-sud.pdf
. Published 2017. Accessed June 22, 2020.
18. Jessup MA, Oerther SE, Gance-Cleveland B, et al. Pregnant and parenting women with a substance use disorder: actions and policy for enduring therapeutic practice. Nurs Outlook. 2019;67(2):199–204. doi:10.1016/j.outlook.2019.02.005.