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RESEARCH ARTICLE
Parent Perspectives on the Eat, Sleep, Console
Approach for the Care of Opioid-Exposed Infants
Kamelia McRae, MD,aTheiju Sebastian, MD,bMatthew Grossman, MD,cJaspreet Loyal, MD, MSc
ABSTRACTBACKGROUND: 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.
a
Department of
Pediatrics, St.
Christopher’s Hospital for
Children, Philadelphia,
Pennsylvania;
b
Department of
Pediatrics, NewYork-
Presbyterian/Columbia
University Irving Medical
Center, New York, New
York; and
c
Department of
Pediatrics, Yale School of
Medicine, Yale University,
New Haven, Connecticut
www.hospitalpediatrics.org
DOI:https://doi.org/10.1542/hpeds.2020-002139
Copyright © 2021 by the American Academy of Pediatrics
Address correspondence to Jaspreet Loyal, MD, MS, Department of Pediatrics, Yale School of Medicine, Yale University, 333 Cedar St, New
Haven, CT 06445. E-mail: jaspreet.loyal@yale.edu
HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154-1663; Online, 2154-1671).
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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.
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The opioid epidemic in the United States led
to the rise in use and misuse of opioids
among pregnant women.1–3Infants 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.3Before 2008, in our institution,
infants with NAS were routinely assessed
with the Finnegan Neonatal Abstinence
Syndrome Scoring System (FNASS).4Scoring
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.4Specifically, the treatment
of NAS was determined by the infant’s ability
to eat, sleep, and be consoled.5This 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.5A 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.6Mothers in this
study also reported that watching their
infants experiencing withdrawal brought
about feelings of guilt and shame.6In
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.7Infants 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
METHODS
Qualitative Approach and Research
Paradigm
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.
Setting and Researcher Characteristics
Our study setting was within a large ter tiary
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.
Sampling Strategy
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
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parent self-identifying as the infant’sfather
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.
Data Collection
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.
Data Analysis
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).12–14 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
TABLE 1 Final Iteration of Interview Guide
General Questions Probing 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?
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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.
Techniques to Enhance
Trustworthiness and Credibility of
Data Analysis
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
RESULTS
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.”
Five main themes emerged from the data
collection. Themes, subthemes, and
exemplar quotes are shown in
Table 3.
Parents Were Supportive of Fewer
Interventions and the Normalizing of
Newborn Care in 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.
Parents Felt Encouraged to Lead Their
Infant’s NAS Care
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.
Parents Perceived Gaps in
Communication About What to
Expect in the Hospital Immediately
After Delivery and During Their
Infant’s Hospital Stay
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
TABLE 2 Participant Characteristics (N518)
Demographics n(%)
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)
Collegea4 (22)
Female infantsb8 (53)
GED, General Educational Development.
aAny college or diploma.
bN515 infants.
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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
TABLE 3 Parent Perspectives on the ESC Approach to the Management of Infants With NAS
Major Themes and Subthemes Quotes
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 cer tain 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)
aThis participant’s son was admitted during the previous NAS protocol and assessed with FNASS scoring. Her newborn daughter was treated with the ESC
approach.
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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.
Parents Experienced Feelings of Guilt,
Fear, and Stress and Expressed the
Need for Increased Support
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.
DISCUSSION
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.11,16–18 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.20–22 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.7In 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
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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.
CONCLUSIONS
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.
Acknowledgments
We thank the parents who par ticipated in
our study.
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