Bringing Families Back to the Bedside

According to the CDC, about 6 newborns are diagnosed with NAS for every 1,000 newborn hospital stays in the U.S. — roughly one baby every 24 minutes, more than 59 a day. (2)

Opioid-related diagnoses at delivery increased 131% between 2010 and 2017, and NAS diagnoses among newborns rose 82% over that same period. (2)The trend has been climbing for two decades: from roughly 1.5 per 1,000 births in 20046 to a national range of 6 to 20 per 1,000 by 2010-2017, with some states like Vermont, reporting rates as high as 47.3 per 1,000 births. (7)

More recent Healthcare Cost and Utilization Project (HCUP) statistics show a national rate of approximately 5.7 NAS diagnoses per 1,000 newborn hospitalizations in 2023, but that number masks significant variation by state and region, ranging from under 2 to well over 25 per 1,000 births, depending on where the baby is born. (3) Pennsylvania’s most recent state surveillance data show NAS incidence varying by region from 5.7 to 17.3 per 1,000 live births, (4) and California’s own regional data range from roughly 5 to 9 per 1,000 live births, depending on the county. (5)

There is no single national NAS surveillance system; incidence is tracked primarily through state hospital discharge databases and public health dashboards, which themselves pose a standardization challenge this field continues to face.

Beyond incidence, NAS carries steep costs at every stage. A NICU stay for a newborn with NAS costs an average of $71,540 in hospital charges, nearly $56,000 more than a stay without NAS, with an average length of stay of 16 days, compared with 3 days for newborns without NAS. Across the U.S., NAS-related hospitalizations totaled an estimated $1.8 billion in a single year, the large majority of it billed to Medicaid, which covers 83% of NAS- related hospital stays. (8)

The costs continue after discharge: child welfare systems absorb an estimated $2.8 billion annually, tied to opioid misuse, with $1.6-1.9 billion of that in foster care placements alone. (9) Pennsylvania reported more than $500,000 in annual special education costs for this population. (10)These are not abstract statistics; they are families and systems absorbing the consequences of a fragmented approach to care.

For decades, the Finnegan Neonatal Abstinence Scoring System, developed in the 1970s, drove treatment decisions, often resulting in unnecessary pharmacologic treatment and prolonged hospital stays. The Eat, Sleep, Console (ESC) approach changed that conversation. Instead of scoring symptoms in isolation, ESC asks a simpler, more functional question: can this baby eat well, sleep for a stretch, and be consoled within about ten minutes? A 26-center NIH-funded cluster-randomized clinical trial, the strongest evidence yet for ESC, found it cut length of stay by 6.7 days and reduced pharmacologic treatment by more than 30% compared with usual care. (11)

What makes ESC powerful isn’t just the assessment tool; it’s the philosophy behind it. ESC treats the parent as the primary intervention: rooming-in, skin-to-skin contact, breastfeeding, low-stimulation environments, swaddling, and parental presence at the bedside all directly reduce the severity and duration of withdrawal. When families are supported rather than separated, babies need less medication and go home sooner.

Did you know that states are stepping in to help hospitals standardize family-centered care for NAS/NOWS?

State Perinatal Quality Collaboratives: Standardizing Care at Scale

State Perinatal Quality Collaboratives (SPQCs) are networks of public health officials, clinicians, stakeholders, and community members working together to standardize evidence-based practice across an entire state.

Three examples stand out:

• Colorado’s CHoSEN Collaborative (Colorado Hospitals Substance Exposed Newborn Quality Improvement Collaborative) brought together 19 birthing facilities and, within two years, reduced pharmacologic treatment by more than 30% and shortened average length of stay by nearly nine days. (12)
• Ohio’s Perinatal Quality Collaborative (OPQC) standardized treatment across 54 facilities statewide, reducing average treatment duration by 1.4 days and length of stay by 1.3 days. (13)
• Ohio’s collaborative didn’t stop at length-of-stay and treatment metrics. In a later “sustain” phase, OPQC also measured something harder to quantify: how providers felt about caring for mothers with opioid use disorder. The result was a measurable improvement in healthcare providers’ attitudes toward this population. (18)
• Massachusetts’s PNQIN Collaborative rolled out the ESC Care Tool across the state’s birthing hospitals — laying the groundwork for the 26-center NIH trial that later confirmed ESC’s results nationally. (19)

Single-Center Quality Initiatives: Where the Culture Change Starts

At the individual hospital level, Single-Center Quality Initiatives (SCQIs) using Plan-Do-Study-Act (PDSA) methodology have produced some of the field’s most striking results:

• Yale New Haven Children’s Hospital reduced the average length of stay from 22.4 days to 5.9 days. It cut per-patient costs from roughly $44,800 to $10,300 by transferring NAS care off the NICU, modifying assessment approaches, and prioritizing breastfeeding, low-stimulation environments, and parental engagement. (14)
• Boston Medical Center reduced pharmacologic treatment by 40% and shortened the length of stay by 8 days through a cuddler program, prenatal parent education, and ESC methodology. (15)

What ties every successful SCQI together is a genuinely interprofessional team of neonatology, nursing, neonatal therapists, case management, social work, lactation, child life, developmental specialists, and family advisors that meets on a consistent cadence, reviews data, and treats parental presence as clinical infrastructure rather than a nice-to-have.

Community Awareness: The Piece that is Still Missing

Standardizing hospital care solves only part of the problem. In my dissertation research, I mapped this out as a socio-ecological model: change has to happen at every level of society, community, hospital, and individual provider because each layer touches the same set of forces working against these families: healthcare provider stigma, social determinants of health, variation in care, and the availability of community resources. (16)

In practice, that means:

• Society and policy: reduced stigma around pregnant and parenting people with substance use disorder, since stigma itself is one of the most cited barriers to families staying at the bedside. (16)
• Community: families need to know before delivery that nonpharmacological approaches exist and that rooming-in is possible, and postpartum systems (home visitation, early intervention, mental health referral) need to be as coordinated as the hospital protocols that got a family to discharge in the first place. (17)
• Hospitals and individual providers: consistent, bias-aware care regardless of which physician, nurse, or unit a family happens to encounter.

Highlight: Vermont’s CHARM program (Children and Recovering Mothers) shows what that coordination can look like in practice: a multidisciplinary network of OB/GYN, pediatrics, SUD treatment, child welfare, peer support, and home visiting that meets monthly and stays involved until the child is 12–18 months old. Participating mothers started OUD treatment earlier in pregnancy, fewer of their infants needed medication for withdrawal, and families needed fewer emergency child-welfare interventions than non-CHARM peers. The model has since been adapted in Arizona, North Carolina, Kentucky, and New York. (20)

This is where public health policy, hospital quality initiatives, and everyday community awareness must meet. A family-centered discharge means nothing if the family cannot access the community resources waiting on the other side of it, and supporting the mother-infant dyad must be the throughline connecting every layer of that system. (16)

Where This Leaves US

I’ve spent over thirty years watching this field move from a treatment center behind a pediatric unit, to a decade of separation and rising NICU admissions, to today’s evidence-based return to rooming-in and nonpharmacological care. The research is unambiguous: when we support family-centered care instead of a medical model of care, babies need less medication, families heal faster, and health systems save real money. The work ahead is ensuring every birthing hospital, not just the flagship academic centers, has the toolkit, training, and community partnerships to make that the standard of care, not the exception.