an infant’s hospital discharge. Most stakeholders we interviewed and several of the literature articles we reviewed recommended providing comprehensive, ongoing education to mothers on prenatal care and treatment for NAS and on the resources that are available after an infant’s discharge. (See text box below). The stakeholders and literature indicated that this education may (1) facilitate a non-combative relationship between the mother and health care providers; (2) help to reassure and support the mother, who may feel responsible for the infant’s suffering, in addition to facilitating treatment of NAS; and (3) help the mother understand her infant’s behavior and develop greater confidence in her parenting skills.48 For example, one article noted that an infant’s withdrawal behavior, such as fisting, back arching, and jaw clenching, may be misinterpreted by the mother as 46See Holmes et al., “Rooming-In to Treat Neonatal Abstinence Syndrome: Improved Family-Centered Care at Lower Cost,” and Mary Beth Sutter et al., “Neonatal Opioid Withdrawal Syndrome,” Obstetrics and Gynecology Clinics of North America, vol. 41, issue 2 (2014). 47For example, see Deborah W. Busch, “Clinical Management of the Breast-Feeding Mother-Infant Dyad in Recovery from Opioid Dependence,” Journal of Addictions Nursery, vol. 27, no. 2 (2016) and Cheryl Cirillo et al., “Does Breast Milk Affect Neonatal Abstinence Syndrome Severity, the Need for Pharmacologic Therapy, and Length of Stay for Infants of Mothers on Opioid Maintenance Therapy During Pregnancy?,” Advances in Neonatal Care, vol. 16, no.5 (2016). 48Tammy Casper and Megan Arbour, “Evidence-Based Nurse-Driven Interventions for the Care of Newborns with Neonatal Abstinence Syndrome,” Advances in Neonatal Care, vol. 14, no. 6 (2014). Volunteer programs to provide nonpharmacologic treatment for neonatal abstinence syndrome (NAS) Some stakeholders told us that some hospitals have established volunteer cuddler programs that train volunteers to help provide some of these non-pharmacologic treatments—-namely, swaddling, feeding, soothing, and coddling infants. However, health care providers at some facilities noted that volunteers are not necessarily available during late shifts. Source: GAO analysis of interviews with stakeholders. I GAO-18-32 Page 26 GAO-18-32 Newborn Health dislike of touch, and that educating mothers on these behaviors can help alleviate feelings of guilt.49 Source: GAO analysis of interviews with stakeholders and literature. | GAO-18-32 Educating health care providers on the stigma faced by women who use opioids during pregnancy, and how to screen for and treat NAS. Most stakeholders we interviewed and several of the literature articles we reviewed recommended educating health care providers, including providers who are not addiction specialists, on both the stigma faced by women who use opioids during pregnancy as well as on how to screen for and treat infants with NAS. The stakeholders and literature indicated that this education may: (1) improve care so that mothers with opioid use disorders feel more comfortable seeking and obtaining prenatal care, (2) help health care providers know how to recognize NAS symptoms to help ensure infants receive appropriate treatment, and (3) allow for more consistency among these providers in NAS screening and treatment. For example, 26 stakeholders told us that educating health care providers about stigma is important because provider attitudes affect how and if pregnant women obtain prenatal care and treatment for their opioid use disorders, which can affect the severity of NAS. Additionally, several articles we reviewed noted the importance of educating and training clinicians on how to administer the screening tools used to identify infants 49Grim et al., “Management of Neonatal Abstinence Syndrome from Opioids.” (2013). Education for mothers on prenatal care, treatment for neonatal abstinence syndrome (NAS), and resources for after an infant’s hospital discharge • Explaining to the mother during the prenatal period what she can expect when the infant is born to help ensure she understands the effects of and treatment for NAS; • Informing the mother about non-pharmacologic treatment techniques that can help reduce the severity of the infant’s NAS symptoms; • Modeling good parenting skills, such as demonstrating how to comfort an infant who may be crying inconsolably for hours because of withdrawal; and • Informing the mother about contraception for preventing future pregnancies. Page 27 GAO-18-32 Newborn Health with NAS, which helps ensure infants are identified and receive optimal care.50 Using a protocol for screening and treating infants with NAS. While there is no single national standard of care for screening and treating NAS, most stakeholders we interviewed and several of the literature articles we reviewed recommended that hospital and non-hospital settings use a protocol to screen for and treat infants with NAS.51 The stakeholders and literature indicated that having a protocol can help: (1) identify infants at risk for NAS, (2) ensure that care is provided consistently, and (3) reduce the length of stay for infants receiving pharmacologic treatment.52 For example, the stakeholders we interviewed explained