by Allison Montag IBCLC and Anne Eglash MD, IBCLC, FABM
Does rooming-in with family reduce the use of medications, length of stay, and costs in the inpatient treatment of neonatal abstinence syndrome (NAS)?
Infants with neonatal abstinence syndrome (NAS) suffer from discontinuation of opiate exposure in-utero. Their symptoms include jitteriness, poor feeding, fussiness, sweating, diarrhea, vomiting, among others. In the last decade, the rate of NAS has risen by at least 400%. Traditionally, newborns with NAS have been treated in the neonatal intensive care unit (NICU) with opiates such as morphine, gradually reducing the dose over time.
A recent meta-analysis, published in JAMA Feb 2018, reviewed 6 studies that explored whether rooming-in with moms has an impact on the care of NAS for affected infants. They analyzed the effect of rooming-in on the treatment of NAS using medication, and whether rooming-in had an impact on duration of hospital stay, cost of hospitalization, harm from treatment, and re-admission rates. The studies included in the meta-analysis were from the USA, Canada and Europe.
What do you think are authors’ findings regarding the impact of rooming-in on NAS in affected infants?
- Rooming-in is associated with less medication treatment for NAS
- Rooming-in is associated with a 10-12 day shorter stay in the hospital for infants with NAS, as compared to NICU treatment
- Readmission rates were higher for infants with NAS who roomed-in with mom.
- Rooming-in is associated with lower cost of treatment for NAS
- Increased skin-to-skin time, improved soothing techniques, and more breastfeeding might contribute to the positive effect of rooming-in on NAS.
See the Answer
Correct Answers: All but C
Association of Rooming-in With Outcomes for Neonatal Abstinence Syndrome: A Systematic Review and Meta-analysis
Kathryn Dee L. MacMillan, MD; Cassandra P. Rendon, BA, BS; Kanak Verma, MPH; et al Natalie Riblet, MD, MPH, ; David B. Washer, MBA, MPH; Alison Volpe Holmes, MD, MPH
Importance
Rising incidence of neonatal abstinence syndrome (NAS) is straining perinatal care systems. Newborns with NAS traditionally receive care in neonatal intensive care units (NICUs), but rooming-in with mother and family has been proposed to reduce the use of pharmacotherapy, length of stay (LOS), and cost.
Objective
To systematically review and meta-analyze if rooming-in is associated with improved outcomes for newborns with NAS.
Data Sources
MEDLINE, CINAHL, The Cochrane Library, and clinicaltrials.gov were searched from inception through June 25, 2017.
Study Selection This investigation included randomized clinical trials, cohort studies, quasi-experimental studies, and before-and-after quality improvement investigations comparing rooming-in vs standard NICU care for newborns with NAS.
Data Extraction and Synthesis
Two independent investigators reviewed studies for inclusion. A random-effects model was used to pool dichotomous outcomes using risk ratio (RR) and 95% CI. The study evaluated continuous outcomes using weighted mean difference (WMD) and 95% CI.
Main Outcomes and Measures
The primary outcome was newborn treatment with pharmacotherapy. Secondary outcomes included LOS, inpatient cost, and harms from treatment, including in-hospital adverse events and readmission rates.
Results
Of 413 publications, 6 studies (n = 549 [number of patients]) met inclusion criteria. In meta-analysis of 6 studies, there was consistent evidence that rooming-in is preferable to NICU care for reducing both the use of pharmacotherapy (RR, 0.37; 95% CI, 0.19-0.71; I2 = 85%) and LOS (WMD, −10.41 days; 95% CI, −16.84 to −3.98 days; I2 = 91%). Sensitivity analysis resolved the heterogeneity for the use of pharmacotherapy, significantly favoring rooming-in (RR, 0.32; 95% CI, 0.18-0.57; I2 = 13%). Three studies reported that inpatient costs were lower with rooming-in; however, significant heterogeneity precluded quantitative analysis. Qualitative analysis favored rooming-in over NICU care for increasing breastfeeding rates and discharge home in familial custody, but few studies reported on these outcomes. Rooming-in was not associated with higher rates of readmission or in-hospital adverse events.
Conclusions and Relevance
Opioid-exposed newborns rooming-in with mother or other family members appear to be significantly less likely to be treated with pharmacotherapy and have substantial reductions in LOS compared with those cared for in NICUs. Rooming-in should be recommended as a preferred inpatient care model for NAS.
Milk Mob Comment by Allison Montag IBCLC and Anne Eglash MD, IBCLC, FABM
This meta-analysis was primarily based on 6 well-designed studies. The authors note that none of the studies reported on adverse events with rooming-in in the setting of NAS, such as readmission rates, suffocation or rates of insufficient weight gain. These potential hazards need to be evaluated to make sure that rooming-in is safe for infants with NAS.
According to the American Academy of Pediatrics, rooming-in is consistent with models of family-centered care, by improving patient satisfaction, reducing the risk of infant abandonment thru improved maternal-infant bonding, more opportunity to supervise maternal-newborn interactions and of course more frequent breastfeeding. Increased breastfeeding could decrease the infant’s need for opiate therapy, assuming that the mother is still taking opiates and that opiates are being transmitted through her breastmilk. In addition, rooming-in enables bedside educational opportunities to model care and soothing techniques, which will help the family develop the necessary skills to care for their infant, with the added bonus of reduced healthcare costs and medication use.