Neonatal abstinence syndrome – a better way

The excellent practice point published in the June 2018 issue of Paediatrics & Child Health strongly advocates that rooming in with mother should become the normative way to manage infants at risk of neonatal abstinence syndrome. This stands in sharp contrast to the ‘usual’ pattern of practice where infants exhibiting signs of neonatal abstinence syndrome (NAS) are transferred to an neonatal intensive care unit (NICU) or ‘observational nursery’, as occurs in approximately 90% of Canadian hospitals as revealed by a national survey of practice published in 2017 (1). In Vancouver, we have been employing a ‘rooming in’ model of care at BC Women’s Hospital since 2001, when we dedicated an entire postpartum ward for the care of mothers and infants with opiate exposure at risk of NAS. NICU or intermediate nursery admission only happens if there are medical problems requiring other interventions such as respiratory support, NG feeding or IV antibiotics. We have demonstrated convincingly that this model significantly reduces the proportion of infants needing treatment with morphine, reduces the number of days they need treatment AND significantly increases the odds of breastfeeding and discharge in the custody of their mother (2,3). Our rooming in model of care has never employed the Finnegan numerical scoring system in the original or modified form, as we were very concerned that it would lead to over treatment. We opted instead for a variation of the ‘Eat/Sleep/Console’ model of observation espoused by Grossman et al. in their recently published article (4), which convincingly shows that use of the Finnegan scoring system leads to over treatment.

The ideal model of care for infants with neonatal abstinence syndrome is still evolving, but on balance of best evidence we should 1) bypass NICU and have the baby ‘room in’ with mother as the default strategy and 2) avoid the use of the Finnegan scoring system. Based on our 17 year experience with approximately 1,500 infants here in Vancouver, everyone will be happier!