BACKGROUND:

At our institution, the treatment of infants with neonatal abstinence syndrome (NAS) is guided by a function-based assessment called the Eat, Sleep, Console (ESC) approach. Infants room in with their parent(s) on the inpatient units, and most infants are treated exclusively with nonpharmacologic interventions. The experience of parents of infants with NAS treated with the ESC approach is unknown.

METHODS:

We chose a deductive, hypothesis-driven approach to perform a content analysis of transcripts from in-depth, semistructured interviews of parents of infants with NAS in our institution. Responses were audiotaped, transcribed, and reviewed by at least 3 members of the research team.

RESULTS:

We interviewed 18 parents of infants with NAS. Most participants were ≥30 years, were white, and had a high school or equivalent level of education. Four major themes emerged: (1) parents were supportive of fewer interventions and normalizing of newborn care in the ESC approach; (2) parents felt encouraged to lead their infant’s NAS care; (3) parents perceived gaps in communication about what to expect in the hospital immediately after delivery and during their infant’s hospital stay; and (4) parents experienced feelings of guilt, fear, and stress and expressed the need for increased support.

CONCLUSIONS:

Parents in our study had an overall positive experience with the ESC approach. This engagement probably contributes to the success of the ESC approach in our institution. Future opportunities include better preparation of expectant mothers and continued emotional support after delivery.

The opioid epidemic in the United States led to the rise in use and misuse of opioids among pregnant women.13  Infants exposed to opioids in utero may develop withdrawal signs after birth, referred to as neonatal abstinence syndrome (NAS) or neonatal opioid withdrawal syndrome. These signs and symptoms include jitteriness, loose stools, poor feeding, inconsolability, and hypertonia.3  Before 2008, in our institution, infants with NAS were routinely assessed with the Finnegan Neonatal Abstinence Syndrome Scoring System (FNASS).4  Scoring on the FNASS was used to guide treatment with opioid therapy in the NICU.4 

Between 2008 and 2016, the assessment of infants with NAS in our institution transitioned from a score-based to function-based approach.4  Specifically, the treatment of NAS was determined by the infant’s ability to eat, sleep, and be consoled.5  This method of assessment is known as the Eat, Sleep, Console (ESC) approach. The symptoms of withdrawal relevant to the ESC approach were poor feeding, problems sleeping, and difficulty consoling.5  A quality improvement bundle was implemented. This included the standardization of nonpharmacologic care of infants across units (NICU, well newborn, and inpatient pediatrics), implementation of routine rooming-in of mother and infant dyads, delivery of empowering messaging to parents, and decreased use of morphine.4  Since the implementation of the ESC approach and quality improvement bundle, the average length of stay decreased from 22.4 to 5.9 days, and the proportion of methadone-exposed infants treated with morphine decreased from 98% to 14%.5 

There is limited information about the experience of parents of infants with NAS in the general inpatient setting. In 1 qualitative study of parents whose infants were treated with pharmacotherapy and admitted to the NICU routinely, mothers reported feeling judged and misunderstood by the staff taking care of their infants, making it difficult to form trusting relationships.6  Mothers in this study struggled with their own understanding of addiction and felt that the staff caring for their infant needed education about addiction.6  Mothers in this study also reported that watching their infants experiencing withdrawal brought about feelings of guilt and shame.6  In another qualitative study of parents of infants with NAS, mothers roomed-in with their infants but may have been transferred between hospital units (mother-infant, NICU, and/or inpatient pediatrics), depending on the severity of symptoms.7  Infants in this study were assessed by using the FNASS and treated with pharmacotherapy.7  Investigators reported the following 5 domains of family experience: parents’ desire for education about the course and treatment of NAS; parents valuing their role in the care team; quality of interactions with staff (supportive versus judgmental) and communication regarding clinical course; transfers between units and inconsistencies among providers; and external factor, such as addiction recovery and economic limitations.7 

Elements of the ESC approach rely heavily on the parent to respond appropriately to the infant’s withdrawal symptoms, and, from our experience, we hypothesized that the ESC approach would be perceived favorably by parents. The experience of parents of infants with NAS in the general pediatric inpatient setting treated with the ESC approach is limited. Therefore, we chose a qualitative approach to better understand the parent’s perspective on the ESC approach to caring for their opioid-exposed infant during the birth hospital stay. We used established standards for the reporting of qualitative studies to describe our findings.8,9 

We chose a deductive, hypothesis-driven approach to perform a content analysis of transcripts from interviews of parents of infants with NAS in our institution. We used data from semistructured, in-depth interviews of English-speaking parents of infants who were treated for NAS on our general medical inpatient pediatric unit, either face-to-face during the infant’s hospital stay or via telephone after hospital discharge between September 2018 and April 2019. An infant with NAS was defined as any neonate with in utero opioid exposure during pregnancy who was admitted for management of opiate withdrawal as the primary reason for inpatient admission.

Our study setting was within a large tertiary academic medical center that includes a NICU, general pediatric inpatient units, and a delivery service of >4000 newborns yearly. The hospital serves a socioeconomically diverse urban and suburban community in Connecticut. Between 70 and 75 infants with NAS are treated in our hospital per year. For context, in the local county that we serve, ∼62% of the population is white, ∼12% is Black, and ∼18% is Hispanic.10  The majority of infants with NAS admitted to our hospital are of white race. In a study of 50 infants with NAS admitted to our hospital in 2014–2015, 45 (92%) were white, 3 (6%) were Black, and 1 (2%) was Hispanic.5 

All otherwise healthy infants with opioid exposure in utero are observed in the hospital for a minimum of 5 days, starting in the well newborn unit and, then, the inpatient pediatric unit, once the mother is discharged. Parents are encouraged to actively participate in their infant’s care and practice nonpharmacologic therapies, including breastfeeding, rooming-in, and swaddling.5,11  Treatment with pharmacotherapy is uncommon. The members of the research team at the time of the study were pediatric residents (K.M. and T.S.) and pediatric hospitalists (J.L. and M.G.). Pediatric residents and pediatric hospitalists on the wards may provide direct clinical care to infants with NAS. Interviews were conducted by 2 members of the research team (K.M. and J.L.) with experience in qualitative interviewing.

Purposeful sampling was used to recruit parents from the inpatient pediatric units, by members of the research team (K.M. and J.L.). Biological mothers of all infants admitted for management of NAS were referred to the study investigators by the pediatric housestaff and hospitalists on the unit during the study period. If present in the hospital at the time of recruitment, any parent self-identifying as the infant’s father was also invited to participate. Parents or guardians of infants placed in the care of the Connecticut State Department of Children and Families (DCF) were not included. Eligible participants were approached on the basis of the availability of the research team (K.M. or J.L.) to perform the interview and a convenient time for the participant. In cases in which no member of the research team was available to conduct the interview or a convenient time for an in-person interview during the hospital stay could not be found, participants were given the option for a phone interview. Up to 3 attempts were made to reach participants opting for a phone interview. Institutional review board approval included a waiver of written consent; therefore, verbal consent was obtained from each participant before the interview.

An initial interview guide was created on the basis of a review of the literature6,7  and expert opinion. The interview guide was revised as additional understandings emerged in the data. The interview guide was solidified after the first few interviews, and development of the coding framework was an ongoing process, which ended after interviews were completed. The final coding framework was applied to the initial interviews. See Table 1 for the interview guide. All interviews were audiotaped and transcribed verbatim by an independent transcription service (ASP.MD, Inc, Cambridge, MA). Members of the research team conducting interviews (K.M. and J.L.) took field notes during interviews. Interviews lasted from 15 to 30 minutes in a private hospital room or on the phone. Each participant was interviewed alone with their infant in a private hospital room, except in the 3 interviews in which both the mother and father requested to be interviewed together. Four interviews were conducted over the phone. Interviews were conducted by members of the research team only (K.M. and J.L.). To address potential conflicts of interest, only 2 members of the research team conducted interviews (J.L. and K.M.). If 1 member was providing direct clinical care to a potential participant, the other member of the research team conducted the interview. Demographic data (age, race and ethnicity, number of children, and parent’s years of education) were collected as part of the interview and collated in the transcripts. Enrollment continued until thematic saturation, when no new concepts emerged.

TABLE 1

Final Iteration of Interview Guide

General QuestionsProbing Questions
Tell me about your infant. Tell me what it was like when your infant was experiencing withdrawal. 
 What things did you do to take care of your infant during this time? 
 What was your greatest concern for your infant? 
Tell me about your relationship with the staff (physicians, nurses, etc) when your infant was in the hospital.  
Have you experienced being in the hospital with an infant with NAS in the past? What is your understanding about how we take care of infants with NAS at Yale? 
 (If yes, tell us about your experience and how it is different from your previous experience)  
 (If no, do you know someone who has been in the hospital with their infant for NAS and what did they tell you about their experience?)  
What were you expecting for your infant’s hospitalization in terms of treatment and how long your infant would be in the hospital? How did you prepare yourself for what to expect with your infant’s treatment after the delivery? 
Tell us about your experience in the hospital so far. What is your understanding about the important parts of your infant’s treatment of NAS at Yale? 
 How are the staff assessing your infant’s withdrawal symptoms? 
At Yale, our focus on treatment is making sure that the parent is with the infant, making sure that the infant can eat, sleep, and be consoled. We used to treat many infants with medication, but the focus now is on eating, sleeping, and being consoled. What do you think about this treatment approach?  
How involved do you feel in your infant’s care?  
Tell us about your feeding plan with your infant and why you chose this feeding plan.  
If you could offer any advice to the staff about caring for mothers and infants with substance addictions, what might you say to them? What advice might you offer to other mothers like yourself? 
Is there anything you would like to share with me that I have not already asked about? 
General QuestionsProbing Questions
Tell me about your infant. Tell me what it was like when your infant was experiencing withdrawal. 
 What things did you do to take care of your infant during this time? 
 What was your greatest concern for your infant? 
Tell me about your relationship with the staff (physicians, nurses, etc) when your infant was in the hospital.  
Have you experienced being in the hospital with an infant with NAS in the past? What is your understanding about how we take care of infants with NAS at Yale? 
 (If yes, tell us about your experience and how it is different from your previous experience)  
 (If no, do you know someone who has been in the hospital with their infant for NAS and what did they tell you about their experience?)  
What were you expecting for your infant’s hospitalization in terms of treatment and how long your infant would be in the hospital? How did you prepare yourself for what to expect with your infant’s treatment after the delivery? 
Tell us about your experience in the hospital so far. What is your understanding about the important parts of your infant’s treatment of NAS at Yale? 
 How are the staff assessing your infant’s withdrawal symptoms? 
At Yale, our focus on treatment is making sure that the parent is with the infant, making sure that the infant can eat, sleep, and be consoled. We used to treat many infants with medication, but the focus now is on eating, sleeping, and being consoled. What do you think about this treatment approach?  
How involved do you feel in your infant’s care?  
Tell us about your feeding plan with your infant and why you chose this feeding plan.  
If you could offer any advice to the staff about caring for mothers and infants with substance addictions, what might you say to them? What advice might you offer to other mothers like yourself? 
Is there anything you would like to share with me that I have not already asked about? 

Data from the transcripts were analyzed by using constant comparative methodology through an iterative process, with concurrent data collection and analysis until no new themes emerge (saturation).1214  In the first part of the analysis, an initial code list was created on the basis of participant data. Codes (words or phrases) served as labels for important concepts. Transcripts were coded independently by at least 2 reviewers familiar with qualitative techniques (J.L., K.M., T.S., and/or M.G.). The initial code list was iteratively revised by using the constant comparative method as new data were collected. In the second part of the analysis, codes were clustered by members of the research team to form cohesive categories and, then, reviewed for themes that expressed main ideas. In the third part of the analysis, data were reviewed for evidence of relationships among themes.

To establish trustworthiness of data, analysis included ongoing debriefing sessions with at least 2 researchers who reviewed emerging themes (K.M., J.L., T.S., and/or M.G.). Members of the research team conducting the interviews (K.M. and J.L.) performed member checking by discussing tentative themes and interpretations with a subset of research participants after conducting the initial analyses. An audit trail was maintained to document all decisions made throughout the study. We attempted to bracket researcher’s bias by writing memos throughout data collection and analysis as a means to examine and reflect on the researcher’s engagement with the data.15 

There were 42 infants with NAS admitted to the hospital during our study period. We did not collect specific information on parents who did not participate. Reasons for nonparticipation included an infant being in DCF care, members of the research team being unavailable to recruit or conduct the interview during the hospital stay, or an inability to connect with the parent by phone after discharge. The demographics of our participants are described in Table 2. We interviewed 18 participants, of whom 12 mothers were interviewed alone and 3 mothers were interviewed together with 3 fathers on request. All mothers were on medication-assisted treatment (MAT) with either methadone or buprenorphine. None of the infants were treated with pharmacotherapy. Most of the participants were at least 30 years old, were white, and had a high school or equivalent level of education. Participants recognized the components of the ESC approach. One participant shared that her understanding of the ESC approach was to “…keep your baby comfortable and hold them close because that’s really what they want…be held nice and close and swaddled. I always had him on my chest near my heart when he would start getting crazy and that would calm him down.”

TABLE 2

Participant Characteristics (N = 18)

Demographicsn (%)
Parent  
 Mother 15 (83) 
 Father 3 (17) 
Parent’s age, y  
 <30 7 (39) 
 30–34 5 (28) 
 >35 6 (33) 
Total children  
 1 6 (33) 
 2 6 (33) 
 ≥3 6 (33) 
Race and/or ethnicity of parent  
 White 12 (67) 
 Hispanic 5 (28) 
 Black 1 (6) 
Highest education level  
 High school or GED equivalent 14 (78) 
 Collegea 4 (22) 
Female infantsb 8 (53) 
Demographicsn (%)
Parent  
 Mother 15 (83) 
 Father 3 (17) 
Parent’s age, y  
 <30 7 (39) 
 30–34 5 (28) 
 >35 6 (33) 
Total children  
 1 6 (33) 
 2 6 (33) 
 ≥3 6 (33) 
Race and/or ethnicity of parent  
 White 12 (67) 
 Hispanic 5 (28) 
 Black 1 (6) 
Highest education level  
 High school or GED equivalent 14 (78) 
 Collegea 4 (22) 
Female infantsb 8 (53) 

GED, General Educational Development.

a

Any college or diploma.

b

N = 15 infants.

Five main themes emerged from the data collection. Themes, subthemes, and exemplar quotes are shown in Table 3.

TABLE 3

Parent Perspectives on the ESC Approach to the Management of Infants With NAS

Major Themes and SubthemesQuotes
Parents were supportive of fewer interventions and normalizing of newborn care in the ESC approach.  
 Fewer interruptions “They didn’t really check her as much as my son. They came in a lot and did the assessment with him a lot more than they did with her. He didn’t like any of that; it was a lot of for him.” (parent 2)a 
 Normalizing newborn care “[The doctors wanted to focus on] his sleeping, his eating, like I said, pooping: if he was pooping and peeing normal. I guess they just wanted him to be doing stuff that normal babies were doing.” (parent 4) 
 Preference for no medications “I think it’s really good that you guys only detox him off the methadone...instead of doing the morphine and the medication.” (parent 9) 
 Shorter hospital stay “I was actually expecting to be here for a week and a half. But we actually weren’t there as long as I thought we were going to be.” (parent 2) 
Parents felt encouraged to lead their infant’s NAS care.  
 Keeping mother and infant together “I prepared myself mentally to not stay with him and they said, “No, you can stay with him” and I said, ‘great that was different.’” (parent 14) 
 Mother at front line of treatment “This is something that I really want people to understand; I was in there the entire time. I never left.” (parent 7) 
 Encouragement by staff to lead care “…the doctor’s message had been…always holding him and trying to comfort him and swaddling him…. He likes that. Just rocking him and singing to him. Stuff like that. Nursing him when he would nurse.” (parent 6) 
Parents felt inadequately prepared for what to expect in the hospital after delivery.  
 Lack of information about NAS from prenatal provider “I asked how long do you think the withdrawal is going to be? How long are we going to have to stay? She [obstetrician] couldn’t really tell me anything.” (parent 9) 
 Varied communication during inpatient stay “…they should have certain doctors really sit down and explain to you what are the tests they are doing…the level of detox that they are going through, really explain it just a little more.” (parent 14) 
 Unclear toxicology screening process “…all my urines were clean the entire time I was pregnant. I’ve been clean for six years and then the next day, they came in after I had him…you have benzos in your system, and I’m like no way.” (parent 9) 
Parents experienced feelings of guilt, fear, and stress and expressed the need for increased support.  
 Guilt and fear “Watching her suffer was the worst thing that I’ve ever seen in my life.” (parent 3) 
  “Just a lot of fears…I didn’t know if she would be really sick for a very long time.” (parent 12) 
 Stress from social work consult or DCF referral “They called DCF on me and everything and they made me feel like a bad parent when it wasn’t even like that.” (parent 4) 
 Resolve I am trying to be responsible for this kid, it’s a little baby…I don’t want to let her down.” (parent 13) 
 Breastfeeding “I was considering breastfeeding, but…I don’t want to give her more methadone.” (parent 11) 
 Empathy from staff “Try not to come off judgmental…leave your personal opinions and feelings outside because…a lot of people would be like ‘how could you have a baby in this situation?’” (parent 3) 
Major Themes and SubthemesQuotes
Parents were supportive of fewer interventions and normalizing of newborn care in the ESC approach.  
 Fewer interruptions “They didn’t really check her as much as my son. They came in a lot and did the assessment with him a lot more than they did with her. He didn’t like any of that; it was a lot of for him.” (parent 2)a 
 Normalizing newborn care “[The doctors wanted to focus on] his sleeping, his eating, like I said, pooping: if he was pooping and peeing normal. I guess they just wanted him to be doing stuff that normal babies were doing.” (parent 4) 
 Preference for no medications “I think it’s really good that you guys only detox him off the methadone...instead of doing the morphine and the medication.” (parent 9) 
 Shorter hospital stay “I was actually expecting to be here for a week and a half. But we actually weren’t there as long as I thought we were going to be.” (parent 2) 
Parents felt encouraged to lead their infant’s NAS care.  
 Keeping mother and infant together “I prepared myself mentally to not stay with him and they said, “No, you can stay with him” and I said, ‘great that was different.’” (parent 14) 
 Mother at front line of treatment “This is something that I really want people to understand; I was in there the entire time. I never left.” (parent 7) 
 Encouragement by staff to lead care “…the doctor’s message had been…always holding him and trying to comfort him and swaddling him…. He likes that. Just rocking him and singing to him. Stuff like that. Nursing him when he would nurse.” (parent 6) 
Parents felt inadequately prepared for what to expect in the hospital after delivery.  
 Lack of information about NAS from prenatal provider “I asked how long do you think the withdrawal is going to be? How long are we going to have to stay? She [obstetrician] couldn’t really tell me anything.” (parent 9) 
 Varied communication during inpatient stay “…they should have certain doctors really sit down and explain to you what are the tests they are doing…the level of detox that they are going through, really explain it just a little more.” (parent 14) 
 Unclear toxicology screening process “…all my urines were clean the entire time I was pregnant. I’ve been clean for six years and then the next day, they came in after I had him…you have benzos in your system, and I’m like no way.” (parent 9) 
Parents experienced feelings of guilt, fear, and stress and expressed the need for increased support.  
 Guilt and fear “Watching her suffer was the worst thing that I’ve ever seen in my life.” (parent 3) 
  “Just a lot of fears…I didn’t know if she would be really sick for a very long time.” (parent 12) 
 Stress from social work consult or DCF referral “They called DCF on me and everything and they made me feel like a bad parent when it wasn’t even like that.” (parent 4) 
 Resolve I am trying to be responsible for this kid, it’s a little baby…I don’t want to let her down.” (parent 13) 
 Breastfeeding “I was considering breastfeeding, but…I don’t want to give her more methadone.” (parent 11) 
 Empathy from staff “Try not to come off judgmental…leave your personal opinions and feelings outside because…a lot of people would be like ‘how could you have a baby in this situation?’” (parent 3) 
a

This participant’s son was admitted during the previous NAS protocol and assessed with FNASS scoring. Her newborn daughter was treated with the ESC approach.

Participants liked the emphasis on responding to their infant’s withdrawal symptoms by picking them up, holding, and swaddling them, instead of immediately treating with pharmacotherapy. Participants appreciated aspects of their infant’s treatment being like otherwise normal newborn care, specifically the focus on feeding and adequate weight gain. Participants liked fewer interruptions by nursing staff to mother-infant bonding to assess for withdrawal symptoms and the overall shorter than expected hospital stay.

Participants universally shared that they felt like active participants in their infant’s care, in part because of being able to be in the same room as their infant. In our previous model, infants were routinely separated from their parents. Participants felt encouraged by members of the medical team including physicians and nursing staff to lead the treatment of their infant’s NAS, by maintaining a low-stimulation environment, and feed their infant, with support from experienced nurses and occupational therapists.

Some participants felt unprepared prenatally for how or where (NICU versus elsewhere) their infant would be treated and how long their infant would be in the hospital. Participants shared that any information about the ESC approach provided prenatally would have helped alleviate stress around the uncertainty of what would happen to their infant after delivery. Some participants shared that they were not prepared prenatally that breastfeeding would be encouraged, despite being on MAT. Participants also expressed concerns about a perceived unclear process for toxicology screening during pregnancy and lack of communication prenatally about positive toxicology screen results, which were later brought up during evaluations by the social work team postpartum. For example, 1 participant shared that she was compliant with urine toxicology screens during her pregnancy and was not told that her urine tested positive for marijuana until after she delivered (see quote in Table 3). This mother felt unprepared for the social work evaluation and referral to the state DCF.

During the hospital stay, some participants felt that communication about what to expect with their infant’s NAS was poor. Specifically, some participants perceived less medical intervention for their infant meant fewer interactions with physicians than they expected. Participants shared that they would see the physician teams on rounds in the morning and, often, not again till the next day. Some participants felt that they would have liked more face time with their child’s physician and more reassurance that the ESC treatment approach was working. Some parents were unsure of the severity of their infant’s withdrawal symptoms, and some were unsure of what the physicians were monitoring because infants were not being scored for their withdrawal.

Participants shared their feelings of guilt from feeling responsible for their infant having NAS and fear of the severity of withdrawal in the infant. Participants shared feelings of anxiety and stress from social work evaluations and referrals to the state DCF. Some participants channeled their negative emotions into a resolve to rigorously embrace all aspects of the ESC approach to help their infant to get through the withdrawal.

Despite feeling more involved in the care of their infant with NAS, for some mothers, there was a perception of variable breastfeeding support and lack of information about the safety of opioid exposure from breast milk. For some participants choosing to breastfeed, feeding their infant with moderate withdrawal symptoms was difficult and added to their feelings of anxiety and guilt. Participants felt that they could have benefited from more immediate support after delivery from nursing and lactation consultants, in the form of multiple more prolonged sessions. Some participants shared that having early access to breast pumps while inpatient would have been helpful. When asked to share advice for hospital staff about their experiences, participants emphasized needing continued empathy, respect, and nonjudgmental communication from the medical team.

We found that parents of infants with NAS treated with the ESC approach valued the more holistic approach to their infant’s management. This is, in part, because of an emphasis on responding to withdrawal symptoms by holding and consoling their infant, resulting in less initiation of pharmacotherapy, reinforcing normal aspects of newborn care, such as feeding and weight gain, and a shorter hospital length of stay. We, also, found that the ESC approach, coupled with rooming-in, allowed parents to feel like they were integral in their infant’s care. The biggest differences between parent perspectives on the ESC approach compared with those on the score-based Finnegan approach was the perception of fewer interruptions to parents bonding with their newborn for scoring and less immediate initiation of pharmacologic treatment on the basis of reaching a specific score threshold. This finding is limited by the small number of participants with infants treated with both approaches at different times in our institution. We found that feelings of guilt, fear, and stress were not completely mitigated by the shift to the ESC method and may be inherent to the situation of having a hospitalized infant in conjunction with an opioid use disorder. Although parents did feel mostly supported, some did point out specific opportunities in which there could be improvement in setting expectations, communication, and transparency, both during the pregnancy and in the immediate postnatal period.

Our findings that parents perceive the ESC approach favorably has implications for the continued success of the treatment approach in our institution. In other qualitative studies in which infants roomed-in with their parents and the withdrawal assessment was score-based, investigators reported that parents felt valued in their role in the care team. It may be that rooming-in and parental presence plays a major role in parents feeling more at the front lines of their infant’s care.11,1618  To our knowledge, ours is the first study of parent perspectives of NAS management with a function-based scoring tool while rooming-in. It may be that rooming-in combined with a treatment approach that encourages parents to respond to their infant’s symptoms further augments the parent’s role in their infant’s management. The willingness of parents to take on this role while recovering from the infant’s delivery and working through their own opioid dependence is important for members of the clinical team to recognize and support.

Some of our study findings are similar to results reported in previous qualitative studies of mothers of infants with NAS, specifically around parent’s feelings of guilt, feeling judged, and stress.6,7  Despite our main study findings that parents whose infants were treated with the ESC approach valued their role in leading their infant’s care, parents in our study, also, reported not always feeling supported by some staff members, which is similar to reports in other studies.6,19  Opioid use disorder is a complex disease, and, despite shifts in the role of the mother from being mostly excluded in the care of her infant with NAS to becoming a central and necessary member of the care team, there are opportunities to improve how mothers with opioid dependence are treated, specifically around respect and support of emotional needs after delivery. Education of staff and clinicians about opioid use disorders and associated complexities should occur with the onboarding of new staff, residents, and faculty and periodically, as part of routine continuing education and resident didactics. Educators should consider partnering with families to bring the voice of the patient to educational activities. There is also a growing body of literature on emotional intelligence (EI), defined broadly as a set of abilities that enable a person to understand and evaluate their own and others’ emotions and integrate these to guide thinking and action. This is a dynamic area, with some studies revealing that training can improve EI in health care professionals and, potentially, positively affect the delivery of patient care.2022  Training nurses and clinicians to use EI while caring for newborns with NAS and their families may be an area of future study.

A major theme in a previously published qualitative study was mothers’ perceptions around communication about the infant’s clinical course and inconsistences between providers within and across units.7  In our study, parents reported consistent messaging from hospital staff in both the well newborn unit and inpatient pediatric units regarding rooming-in, expected length of stay, and management of NAS by using the ESC approach. This may be because the hospital policy and education of staff and clinicians around care of the opioid-exposed infant is the same across all hospital units. However, in our study, parents reported inconsistences in communication and lack of clarity on their infant’s expected clinical course by providers before delivery. This highlights an opportunity for collaboration with local perinatal providers, including obstetricians and gynecologists, those in family medicine, midwives, substance abuse clinicians, pediatricians, and neonatologists, to help better prepare expectant mothers on MAT for what to expect after delivery. A way to bridge this gap is by providing educational materials in the form of handouts or giving presentations to these groups about the ESC approach, the evidence around breastfeeding in opioid-exposed newborns, aspects of the newborn hospital stay, and posthospital coordination of care and support. Given the stress and anxiety that these mothers are feeling, any additional reassurance that their prenatal provider with whom they have developed a trusting relationship over months may be able to give them can only help to alleviate the uncertainty of what may happen to their infant in the hospital.

Our study is limited by sample size and to the population in the local community. We attempted to interview until no new themes appeared, but it is possible that we have missed themes. The interview guide was not piloted before use in the study. All participants approached agreed to be interviewed; however, we were unable to interview some participants because of members of the research team being unavailable to conduct interviews. Of note, the majority of parents interviewed had infants actively being managed under the ESC approach at the time of interview, which lends the study to both participation and favorability bias. In 1 interview, a member of the research team conducting the interview had participated in a direct clinical of the infant, while covering the wards for 1 shift. For eligible participants who agreed to phone interviews, we did not connect with those who did not answer their phone after 3 attempts. In the 3 interviews in which mother and father were interviewed together, we may have missed perspectives that a parent may not have wanted to share in front of the other parent.

Our sample is a homogenous group of mostly white high school graduates. However, this fits with the local epidemiology of opioid-exposed newborns in our community, as previously described.10  The reported epidemiology of mothers with substance dependence is mostly white, so the racial composition of our participants is similar to what has been reported in other studies. For example, in a study of >19 million women with antepartum drug dependence in the United States, white female patients and those from low-income families constituted a higher proportion of the female pregnant inpatients with comorbid antepartum drug dependence.23  We did not collect information on how many infants were not in the custody of their parent and the infant’s race and ethnicity, creating the potential for selection bias. One of the exclusion criteria in our study were infants placed in DCF custody, and we recognize that there may be a racially associated bias that may have led to the exclusion of Black participants in the study. We acknowledge that our findings may not be transferable to parents of other racial and ethnic backgrounds and parents who speak languages other than English. With regards to transferability, our study is also limited by our setting in a large, tertiary care children’s hospital. Our interviews were relatively short, and, therefore, we may have missed some additional perspectives.

Parents in our study had an overall positive experience with the ESC approach. We believe that this engagement has been key to the success of the ESC approach in our institution. By hearing directly from parents whose infants with NAS were treated with the ESC approach, we found that the approach was well received by parents, and this has implications for uptake in other institutions looking to adopt evidence-based patient-centered practices. Next steps include increased education of perinatal providers about the ESC treatment approach to better prepare expectant families on what to anticipate during their hospital stay, barring any medical or psychosocial complications. Additional steps include more consistent messaging around breastfeeding guidance and support, and continuing medical education of nursing staff and clinicians about the emotional toll of opioid dependence. Additional research is needed to study the safety, clinical, and long-term impact of the ESC approach.

We thank the parents who participated in our study.

Drs McRae, Loyal, and Grossman conceptualized and designed the study and initial data collection instruments and critically reviewed the manuscript; Drs McRae, Sebastian, and Loyal coordinated data collection and conducted the initial analyses; and all authors approved the final manuscript as submitted.

FUNDING: No external funding.

1
Ko
JY
,
Patrick
SW
,
Tong
VT
,
Patel
R
,
Lind
JN
,
Barfield
WD
.
Incidence of neonatal abstinence syndrome - 28 states, 1999-2013
.
MMWR Morb Mortal Wkly Rep
.
2016
;
65
(
31
):
799
802
2
Patrick
SW
,
Davis
MM
,
Lehman
CU
,
Cooper
WO
.
Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012
.
J Perinatol
.
2015
;
35
(
8
):
667
3
Kocherlakota
P
.
Neonatal abstinence syndrome
.
Pediatrics
.
2014
;
134
(
2
).
4
Grossman
MR
,
Berkwitt
AK
,
Osborn
RR
, et al
.
An initiative to improve the quality of care of infants with neonatal abstinence syndrome
.
Pediatrics
.
2017
;
139
(
6
):
e20163360
5
Grossman
MR
,
Lipshaw
MJ
,
Osborn
RR
,
Berkwitt
AK
.
A novel approach to assessing infants with neonatal abstinence syndrome
.
Hosp Pediatr
.
2018
;
8
(
1
):
1
6
6
Cleveland
LM
,
Bonugli
R
.
Experiences of mothers of infants with neonatal abstinence syndrome in the neonatal intensive care unit
.
J Obstet Gynecol Neonatal Nurs
.
2014
;
43
(
3
):
318
329
7
Atwood
EC
,
Sollender
G
,
Hsu
E
, et al
.
A qualitative study of family experience with hospitalization for neonatal abstinence syndrome
.
Hosp Pediatr
.
2016
;
6
(
10
):
626
632
8
O’Brien
BC
,
Harris
IB
,
Beckman
TJ
,
Reed
DA
,
Cook
DA
.
Standards for reporting qualitative research: a synthesis of recommendations
.
Acad Med
.
2014
;
89
(
9
):
1245
1251
9
Tong
A
,
Sainsbury
P
,
Craig
J
.
Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups
.
Int J Qual Health Care
.
2007
;
19
(
6
):
349
357
10
US Census Bureau. Quick facts: New Haven County, Connecticut
.
Available at: https://www.census.gov/quickfacts/newhavencountyconnecticut. Accessed September 27, 2020
11
MacMillan
KDL
,
Rendon
CP
,
Verma
K
,
Riblet
N
,
Washer
DB
,
Volpe Holmes
A
.
Association of rooming-in with outcomes for neonatal abstinence syndrome: a systematic review and meta-analysis
.
JAMA Pediatr
.
2018
;
172
(
4
):
345
351
12
Charmaz
K
.
Constructing Grounded Theory: A Practical Guide Through Qualitative Analysis
.
Thousand Oaks, CA
:
Sage Publications Ltd
;
2006
13
Glaser
BG
,
Strauss
AL
.
The Discovery of Grounded Theory: Strategies for Qualitative Research
.
New Brunswick, NJ
:
Aldine Transaction
;
2008
14
Corbin
J
,
Strauss
A
.
Basics of Qualitative Research
.
Thousand Oaks, CA
:
Sage Publications
;
1998
15
Tufford
L
,
Newman
P
.
Bracketing in qualitative research
.
Qual Soc Work
.
2010
;
11
(
1
):
80
96
16
Holmes
AV
,
Atwood
EC
,
Whalen
B
, et al
.
Rooming-in to treat neonatal abstinence syndrome: improved family-centered care at lower cost
.
Pediatrics
.
2016
;
137
(
6
):
e20152929
17
Wachman
EM
,
Grossman
M
,
Schiff
DM
, et al
.
Quality improvement initiative to improve inpatient outcomes for neonatal abstinence syndrome
.
J Perinatol
.
2018
;
38
(
8
):
1114
1122
18
Howard
MB
,
Schiff
DM
,
Penwill
N
, et al
.
Impact of parental presence at infants’ bedside on neonatal abstinence syndrome
.
Hosp Pediatr
.
2017
;
7
(
2
):
63
69
19
Loyal
J
,
Nguyen
VN
,
Picagli
D
, et al
.
Postpartum nurses’ experience caring for infants with neonatal abstinence syndrome
.
Hosp Pediatr
.
2019
;
9
(
8
):
601
607
20
Giménez-Espert
MDC
,
Prado-Gascó
VJ
.
The role of empathy and emotional intelligence in nurses’ communication attitudes using regression models and fuzzy-set qualitative comparative analysis models
.
J Clin Nurs
.
2018
;
27
(
13–14
):
2661
2672
21
Bulmer Smith
K
,
Profetto-McGrath
J
,
Cummings
GG
.
Emotional intelligence and nursing: an integrative literature review
.
Int J Nurs Stud
.
2009
;
46
(
12
):
1624
1636
22
Stratton
TD
,
Elam
CL
,
Murphy-Spencer
AE
,
Quinlivan
SL
.
Emotional intelligence and clinical skills: preliminary results from a comprehensive clinical performance examination
.
Acad Med
.
2005
;
80
(
suppl 10
):
S34
S37
23
Ahmad
N
,
Robert
CA
,
Jampa
A
,
Ashraf
S
,
Patel
RS
.
Antepartum drug dependence and pregnancy- or birth-related complications: a cross-sectional study of 19 million inpatients
.
Cureus
.
2019
;
11
(
11
):
e6117

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.