Infant Feeding-related Hospital Policies and Practices for Neonatal Abstinence Syndrome, United States, 2020

Background: Opioid use disorder in pregnancy has been linked to preterm birth, low birthweight, feeding problems, and drug withdrawal in exposed newborns. Prenatal exposure to opioids and other drugs might lead to a constellation of withdrawal symptoms in newborns known as Neonatal Abstinence Syndrome (NAS). As use of opioids increased, the incidence of US infants born with NAS also increased from 1.5 (1999) to 7.3 (2017) per 1,000 births. Hospitals are faced with providing care for newborns who might be experiencing substance withdrawal. Historically, care has been provided in a neonatal intensive care unit with focus placed on pharmacologic therapies. Non-pharmacologic therapies, such as breastfeeding, skin-to-skin care, and rooming-in, are increasingly being recognized as important as they reduce severity of withdrawal signs, lengths of stay, medication usage, and hospital costs. Feeding-related hospital policies and practices for infants with NAS in the US were examined.

Methods: Hospitals providing routine maternity care in the US and Territories were administered the Maternity Practices in Infant Nutrition and Care (mPINC) survey in 2020 (n=2103, response rate: 74%). An online questionnaire was completed by the person(s) most knowledgeable about hospital policies and practices. A descriptive analysis of written hospital policies related to the management of newborns with NAS (“NAS-specific policy”) as well as feeding-related practices for newborns diagnosed with NAS (“NAS-specific practice”) was conducted.

Results: A majority of hospitals were non-profit (73.4%) and teaching (74.3%). Most (94.9%) had NAS-specific written policies, which included: use of a standardized tool to evaluate NAS symptoms (95.6%), pharmacologic treatment of NAS (73.2%), and promotion of non-pharmacological therapies including skin-to-skin/Kangaroo Care (86.2%), rooming-in (79.3%), and breastfeeding (77.7%). Among the hospitals (93.5%) indicating they had cared for newborns with NAS, the proportion of hospitals where a majority (≥50%) of newborns with NAS experienced non-pharmacologic therapies included: 82.8% (skin-to-skin/Kangaroo Care), 75.3% (rooming-in), and 56.2% (breastfed or provided expressed human milk). Twenty-five percent of hospitals, which cared for infants with NAS, reported a majority of newborns with NAS were cared for in the neonatal intensive care unit.

Conclusion: Evidence-based hospital policies and practices for infant feeding, such as skin-to-skin care and rooming-in, are optimal for most newborns but might be particularly important for those experiencing withdrawal. A majority of mPINC survey participants had written policies regarding the care of newborns with NAS, which included policy elements related to non-pharmacological therapies, and were providing non-pharmacologic therapies for these newborns. Hospitals might consider reviewing their NAS-specific policies and practices to ensure they are providing optimal care for all eligible newborns experiencing substance withdrawal and their mothers.