Feeding Infants with Neonatal Abstinence Syndrome: Finding the Sweet Spot

METHODS

RESULTS

The following is a summary of the combined findings from the focus groups. The data yielded four overarching themes related to success with feeding infants with NAS (Table 1).

DISCUSSION

This study investigated strategies that nurses use to successfully feed infants with NAS in the NICU. Results showed that a baseline of appropriate pharmacologic management with opioid replacement therapy is very important, because it dampens the central nervous system irritability that disrupts feeding. Sucking behaviors were described as being disorganized and frantic before optimal medication management was achieved. Nurses did not expect to be successful in feeding infants with NAS whose signs were not well under control, and usually collaborated with the medical team to re-evaluate the plan of care. Many experts believe that the infant’s neurobehavioral organization plays an important role in successful feeding, ^17–19 which is reflected by findings describing factors that disrupt feeding in infants with NAS. ⁵

The informers readily shared their expertise about how to increase success in feeding infants with NAS. We asked them about their most challenging infant to feed so that they would begin thinking about their strategies for success. All participants discussed the importance of recognizing infant cues. Informants reported that the baby is often not ready to feed when he is picked up, so nursing assessment of feeding cues were important for success. There was respect for allowing the infant some control, and helping the infant to prepare for feeding. They recognized that each infant was an individual and that even well-established techniques do not work in everyone. A technique that works one day may not work the next day, so continued trial and error is needed. We expect that even after an infant’s signs of NAS are well controlled, the infant will continue to recover and may experience some blunting of responses if the opioid dose lags behind his recovery. Thus, the infant's cues can be confusing throughout the hospitalization. Unclear cues have been reported in the literature in this population, ²⁰ as well as decreased responsiveness of mothers to infant cues. ⁸

The third theme that emerged, and which participants spent the most time defining, was “Calm and comfortable.” This theme emerged from two subthemes: calm the caregiver and a calm and comfortable baby. The informants strongly believed that anxiety in a caregiver could be felt by the infant, who was likely to react negatively. They helped the mothers relax by helping them to find a comfortable position in which to feed the infant. They ask about their comfort, and for anything they can do before leaving them alone.

Keeping the infant calm was crucial to being successful, and they used many techniques to that end. Several strategies to calm the infant and keep him comfortable were mentioned, some of which are described in the literature, such as swaddling and decreasing environmental stimulation. ^21–23 Swaddling is one of the few nonpharmacologic interventions that has been reported to be effective in infants with NAS to reduce crying. ²⁴ van Sleuwen and colleagues ²⁴ also reported that swaddling decreased startles and sleep arousals, enabling infants to increase sleep time and continuity. Informants also talked about an intervention called the C position they adapted for feeding. They place the infant on his side lying on their leg and arms slightly flexed, keeping the head slightly elevated by crossing one leg over the other. Searches for “C position” in the scientific literature as well as the Internet only revealed information about breastfeeding positions. We found no references to feeding infants in the position they described, although we acknowledge that it might appear in a paper without that keyword.

Some informants reported that they start with techniques such as a warm bath to calm the infant, whereas others reported that they start by helping the infant to burp. Many different techniques were described, such as burping before the feeding, whispering a “shhhing” sound in baby’s ear, and using a pacifier to help the infant relax to release a burp. Most informants reported that they try all available nipples until they find the one that works the best, and most reported using chin and cheek support as needed. Informants described using their gloved finger to find the “sweet spot” on the palate that helped infants form a good suck. They emphasized the importance of vertical versus horizontal rocking to calm the infant. They teach mothers to hold the infant vertically on their chest to rock, rather than rocking the infant horizontally in their arms. The vertical rocking intervention is mentioned in the literature, ²² although to our knowledge it has not been tested.

Some informants reported that they often bottle feed with the infant facing away from them when the infant cannot tolerate eye-to-eye contact. This maneuver is meant to decrease stimulation associated with eye contact, and is often successful if the infant opens his eyes. However, since eye-to-eye contact is an important element of attachment, ²⁵ mothers may need to be reassured that their infant’s inability to tolerate eye-to-eye contact is a temporary effect of withdrawal. As the infant begins to recover from withdrawal, he will be able to tolerate more face-to-face moments, which must be encouraged. Weber ²⁶ contends that inadequate eye-to-eye contact between mothers and infants may “result in the loss of a vital emotional connection.”^{(p 205)}

The final theme that emerged was “Nurture the relationship.” These caregivers encouraged the mothers to be available for as many feedings as possible, and use that time to engage the mother in learning infant cues and how their infant responds to different interventions. Most had a strong message to avoid being judgmental toward the women, helping them as you would any other new mother. If a mother is made to feel uncomfortable in the NICU, she may not visit as often, creating missed opportunities to help the mother develop a healthy relationship with her baby, learn valuable parenting skills, build her confidence, and be encouraged to continue her own drug treatment. Caregivers explained that it was important to provide continuity of care so that they could develop a trusting relationship with the mother. Morris and colleagues ²⁷ found that as the quality of relationships between midwives and their drug-dependent pregnant clients improved, patient care outcomes improved.

An intervention not reported by our expert informants was a discussion of breastfeeding. It was mentioned by only one participant, and she remarked that mothers often pump while they are in the NICU, but it is difficult to sustain because the infants are hospitalized for so long. Breastfeeding is recommended in this population, however, as long as the mother is abstaining from alcohol, illicit drugs, and amphetamines; has a negative screening for human immunodeficiency virus (HIV); and has no other contraindications for breastfeeding. ²⁸ There is evidence that breastfeeding infants with NAS results in shorter treatment duration and less severe withdrawal signs, ²⁹ and conflicting evidence that it has no specific effect on NAS. ³⁰ Even if breastfeeding has little effect on NAS, it has many other beneficial effects for both mother and baby that should not be overlooked. ³¹

Additionally, rooming-in as an intervention has appeared in the literature as demonstrating improved infant outcomes, ³² but was not mentioned by any participant. Holmes and colleagues ³² implemented a multidisciplinary quality improvement project, and found that in comparison to baseline levels, infants with NAS who roomed-in with their mothers used less morphine and phenobarbital, had a shorter length of stay with decreased costs, and had no adverse events. Their interventions were parent- and infant-focused, in a calm, family-centered environment. For example, infants were not awoken for scheduled assessments, and many care activities were conducted with the infant skin-to-skin. Others have reported similar findings. ^{32 , 33}

This study provides the first insight into a characteristic skill set used by NICU caregivers to promote feeding success for infants with NAS. The first question, “Tell us about the most challenging infant with NAS that you have fed,” helped to establish the shared experience among the clinicians at three hospitals. These experts were faced with similar challenges across this population of infants. In general, about 80 percent of infants with NAS in this region are born to women in a methadone program. Drug addiction is treated as a chronic disease in Florida rather than a crime as in some communities. Although it is not uncommon to care for infants whose mothers are poly-substance abusers, there is not a big culture of methamphetamines or heroin that other communities are facing. Because of these regional characteristics, the tips from these experts may not be generalizable beyond this region, or to regions that do not share these unique characteristics.

More work needs to be done to learn how to best manage infants exposed to a wide range of street drugs, and we welcome opportunities to learn more about that from expert caregivers. Although using strategies that are individualized to each infant was a prevalent theme, many specific techniques matched to the NAS population were identified across every group. These techniques or considerations can be used to develop a training protocol to assist NICU staff in promoting the best feeding outcomes for these infants. Our goal is to develop a standardized intervention based on these findings and others in the literature that can be tested for efficacy in this population.