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Commentary on: MacMillan, KDL. et al. Association of rooming-in with outcomes for neonatal abstinence syndrome: a systematic review with meta-analysis. JAMA Pediatr. 2018; 172; 345-351.
Implications for practice and research
Evidence suggests that rooming-in is associated with a decreased need for pharmacological treatment and length of stay for infants with neonatal abstinence syndrome (NAS).
When safe and feasible, infants with NAS should room-in with their mothers.
Rigorous research is required on rooming-in to determine the effective components and short-term and long-term NAS outcomes, including risks.
The prevalence of neonatal abstinence syndrome (NAS) has increased globally, placing a significant strain on healthcare resources. Newborns with NAS typically receive care in the neonatal intensive care unit (NICU). Recent studies have identified that NAS treatment in the NICU may be associated with longer length of stay, more severe withdrawal and lower rates of breast feeding compared with rooming-in care where mothers and infants remain together. However, concerns exist regarding potential risks of rooming-in. The systematic review and meta-analysis by MacMillan and colleagues was conducted to evaluate the benefits and harms of rooming-in compared with standard care in the NICU for the treatment of NAS.1
The researchers used the Preferred Reporting Items for Systematic Review and Meta-Analysis2 guidelines for reporting of methods and findings. Three databases were searched up to 2016/2017 to identify studies for inclusion. Rooming-in was defined as infant and mother remaining together for 24 hours per day throughout the postpartum hospital stay unless separation was indicated for medical needs other than symptoms of NAS. The quality of studies was assessed using ROBINS-I risk of bias tool for non-randomised interventions.3 For evaluation of dichotomous outcomes, risk ratios and 95% CI were calculated and weighted mean differences and 95% CI calculated for continuous outcomes. Meta-analysis of all included studies was conducted on the outcomes of pharmacological treatment and length of stay. Due to the heterogeneity across studies, a sensitivity analysis was also conducted eliminating three studies. A qualitative analysis was performed for secondary outcomes.
The results of the meta-analysis, which included six studies and 549 infants, found that rooming-in was associated with a reduction in the need for pharmacological treatment of 0.37 (0.19 to 0.71) and a shorter length of stay −10.4 (−16.84 to −3.98) compared with traditional NICU treatment. The findings remained consistent when the sensitivity analysis was performed to reduce heterogeneity. Three studies reported that inpatient costs were lower with rooming-in. Similarly, higher rates of breast feeding and discharge home with parents were found in favour of rooming-in. Among the few studies evaluating risks, no adverse events were associated with rooming-in.
This is the first meta-analysis to examine the association between rooming-in and NAS outcomes. The findings suggest that rooming-in was associated with a decreased need for pharmacological treatment and length of stay. Additionally, there were trends in favour of rooming-in on secondary outcomes such as rates of breast feeding, discharge home with parents and decreased costs. The authors recommend that rooming-in should be a preferred non-pharmacological intervention for infants at-risk or experiencing NAS. This is consistent with another recent review recommending that when safe and feasible, infants with NAS should room-in with their parents.4
While this review strengthens the evidence in support for rooming-in, more evidence is required regarding the intervention of ‘rooming-in’. None of the included studies attempted to describe the effective component(s) of rooming-in nor provided descriptive data on rooming-in. Rooming-in may have included environmental changes (eg, decreased noise, stimulation), enhanced presence by mothers and/or family, skin-to-skin contact, breast feeding, variations in care delivery models and training of nurses. Thus, the effective mechanism(s) of rooming-in on NAS outcomes remain unknown.4. Future research should endeavour to provide detailed description of rooming-in so that the efficacy of components of rooming-in can be evaluated. Specific information regarding rooming-in (eligibility, intervention components) would also assist hospitals that may want to implement rooming-in and/or researchers to replicate a study.
The studies in the systematic review were primarily retrospective, before and after study designs. While the quality assessment appraisal identified they were at low risk of bias for non-experimental designs, there were some limitations including potential for selection and confounding bias, and small sample sizes. As such, there is a need for sufficiently powered randomised controlled trials and/or prospective studies to evaluate the effect of rooming-in on both short-term and long-term NAS outcomes, which includes risks. Detailed economic evaluations are also required.
Competing interests None declared.
Patient consent Not required.
Provenance and peer review Commissioned; internally peer reviewed.
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