Nursing Care of Infants with Neonatal Abstinence Syndrome: A Systematic Review

Background to Neonatal Abstinence Syndrome

For many years, assessment was based on the Finnegan Neonatal Abstinence Scoring Tool, in which nurses scored many signs every few hours, with medication started when scores exceeded a threshold. The tool is detailed but time-consuming, involves disturbing the baby to check reflexes and has been criticised for subjectivity and for leading to high rates of medication. Babies with high scores were often transferred to the neonatal unit, away from their mothers.

The Eat, Sleep, Console approach was developed as an alternative. Rather than scoring many signs, nurses and parents ask whether the baby can eat adequately, sleep for at least an hour and be consoled within about ten minutes. If the baby is not managing these functions, the first response is to increase non-pharmacological care, such as more parental presence, skin-to-skin contact, swaddling, feeding on demand and a quiet environment. Medication is added only if these measures are not enough.

Non-pharmacological care is the foundation of all approaches. It includes rooming-in, where mother and baby stay together in the same room; breastfeeding, which is generally encouraged for mothers who are stable in treatment; skin-to-skin contact; holding and gentle rocking; swaddling; small, frequent feeds; and reducing light and noise. Volunteer cuddlers can help when parents cannot be present.

Caring for families affected by substance use requires sensitivity. Mothers may face stigma from staff, involvement of child protection services and their own recovery needs. Nurses who are supportive and non-judgemental can help mothers to stay with their babies and engage in care, while still recognising and acting on genuine safeguarding concerns.

Breastfeeding deserves particular mention. For mothers who are stable in treatment for opioid use disorder and not using other substances, breastfeeding is generally encouraged because small amounts of medicine in breast milk may ease withdrawal, and breastfeeding supports bonding. Nurses need clear local guidance on when breastfeeding is appropriate and how to support mothers who choose to breastfeed after opioid withdrawal is identified in their baby.

Search Strategy and Methods

Evidence for this example was identified through targeted searches of openly accessible bibliographic records, publisher websites and the reference lists of key reviews. Search terms combined keywords for the condition (“neonatal abstinence syndrome”, “neonatal opioid withdrawal syndrome”, “opioid exposure”) with terms for interventions and outcomes (“rooming-in”, “Eat, Sleep, Console”, “non-pharmacological”, “morphine”, “length of stay”, “pharmacological treatment”), joined with the Boolean operators AND and OR. A full systematic review for assessment would run the same strategy in CINAHL, PubMed/MEDLINE, the Cochrane Library and Embase and report the number of records screened in a PRISMA flow diagram.

Sources were eligible if they described the burden of neonatal abstinence syndrome or evaluated approaches to care, including assessment methods, rooming-in, non-pharmacological care and medication. Randomised trials and systematic reviews were prioritised, and a large cohort study and a detailed quality improvement study were included to show the scale of the problem and how change was implemented. Studies of maternal treatment only were excluded.

Five sources published between 2015 and 2023 were included: a national multicentre cohort study, a systematic review and meta-analysis, a quality improvement study, a Cochrane systematic review and a cluster randomised controlled trial (Table 1). The quality of each source was considered using the Critical Appraisal Skills Programme (CASP) checklists, drawing on the certainty ratings reported by the reviews, and findings were synthesised narratively.

Key Findings on Neonatal Abstinence Syndrome

Three themes were identified: the rising burden of neonatal abstinence syndrome, keeping mothers and babies together through rooming-in and non-pharmacological care, and function-based assessment and medication. Table 1 summarises the included sources, and Figure 1 shows how changes in care affected medication and length of stay.

Author, year	Design	Setting and sample	Key finding
Tolia et al. (2015)	Multicentre cohort study	674,845 admissions, 299 US NICUs, 2004–2013	Cases rose from 7 to 27 per 1,000 admissions; 87% treated with medication; median stay 19 days.
MacMillan et al. (2018)	Systematic review and meta-analysis	6 studies, 549 infants	Rooming-in: less medication (RR 0.37) and 10.4 days shorter stay.
Wachman et al. (2018)	Quality improvement study	240 opioid-exposed infants, one US academic hospital	Medication fell from 87.1% to 40.0%; stay from 17.4 to 11.3 days; parental presence increased.
Zankl et al. (2021)	Cochrane systematic review	16 trials, 1,110 infants	Opioids reduced treatment failure vs phenobarbital (RR 0.51); buprenorphine shorter stays than morphine.
Young et al. (2023)	Cluster randomised controlled trial	1,305 infants ≥36 weeks, 26 US hospitals	Eat, Sleep, Console: 8.2 vs 14.9 days to readiness for discharge; similar adverse outcomes.

Theme 1: The Rising Burden of Neonatal Abstinence Syndrome

A study of 299 neonatal intensive care units in the United States analysed 674,845 admissions between 2004 and 2013 (Tolia et al., 2015). Cases of neonatal abstinence syndrome rose from 7 to 27 per 1,000 admissions, and the share of neonatal unit days used by these babies rose from 0.6% to 4.0%, exceeding 20% in some units. The proportion of affected infants receiving medication rose from 74% to 87%, and median length of stay increased from 13 to 19 days.

These findings show how the condition had come to consume a growing share of neonatal intensive care resources, and how the dominant model of care relied on admission to the neonatal unit and medication. They also suggested that many babies were separated from their mothers for long periods, even though most were born at or near term and were otherwise well. This prompted a search for approaches that could keep families together.

The rising numbers also reflected wider social changes, including increased prescribing of opioids and growth in opioid use disorder among women of childbearing age. Neonatal abstinence syndrome is therefore not only a clinical problem but a public health one, requiring coordinated antenatal, postnatal and community services that support mothers through pregnancy and beyond.

Theme 2: Rooming-In and Non-Pharmacological Care

A systematic review and meta-analysis of six studies with 549 infants compared rooming-in with care in the neonatal unit (MacMillan et al., 2018). Rooming-in was associated with a lower need for medication (risk ratio 0.37) and a shorter length of stay, by an average of 10.4 days. The authors recommended rooming-in as the preferred model of inpatient care where safe and feasible, although the studies were observational and heterogeneous, and publication bias was possible.

A quality improvement study at a large urban academic hospital introduced a non-pharmacological care bundle, including parental presence, skin-to-skin contact, holding, breastfeeding and a low-stimulation environment, followed by staff education, a switch from morphine to methadone and replacement of Finnegan scoring with Eat, Sleep, Console assessment (Wachman et al., 2018). Medication use fell from 87.1% to 40.0%, mean length of stay from 17.4 to 11.3 days, and mean hospital charges by more than $11,000 per infant.

Parental presence at the bedside rose from 55.6% to 75.8% during the programme, and no adverse events were reported. Because several changes were introduced together in a single centre, it was not possible to identify which component was most effective. Nevertheless, the study shows how nurses, physicians and families can work together to transform care, and highlights parental presence as both a goal and a mechanism of improvement.

Theme 3: Function-Based Assessment and Medication

A cluster randomised trial in 26 US hospitals tested the Eat, Sleep, Console approach against usual care with Finnegan scoring for 1,305 infants born at 36 weeks or later with neonatal opioid withdrawal (Young et al., 2023). Among infants who met the trial definition of readiness for discharge, the time from birth to being medically ready was 8.2 days with Eat, Sleep, Console and 14.9 days with usual care, a reduction of 6.7 days. Adverse outcomes in the first three months were similar between groups.

A Cochrane review of 16 trials with 1,110 infants examined opioid treatment for withdrawal (Zankl et al., 2021). Opioids reduced treatment failure compared with phenobarbital (risk ratio 0.51) and diazepam, and buprenorphine was associated with shorter treatment and hospital stays than morphine. In one small trial, adding morphine to supportive care lengthened hospital stays by 15 days, but this evidence was of very low certainty. There was insufficient evidence on non-pharmacological care alone compared with care plus medication.

Together, these findings suggest that medication remains appropriate for some babies, but that many can be managed with non-pharmacological care when mothers and babies are kept together and assessment focuses on function. When medication is needed, the choice of drug and the duration of treatment matter, and nurses’ observations of eating, sleeping and consolability can guide decisions.

The trial also has implications for workload. Function-based assessment may take less time than detailed scoring, but it requires nurses to spend time with families, to support feeding and to coach parents in comforting their baby. In units where nurses care for many babies, volunteers and extended family members can provide additional support, and clear communication between shifts helps to maintain consistent care.

Discussion

This review found that neonatal abstinence syndrome placed growing demands on neonatal units, and that approaches keeping mothers and babies together, prioritising non-pharmacological care and using function-based assessment reduce medication use and length of stay without evidence of harm. The large randomised trial of Eat, Sleep, Console provides the strongest evidence and confirms findings from earlier observational and improvement studies.

The shift in care has important implications for nursing. Instead of scoring signs every few hours, nurses work alongside parents to observe the baby’s eating, sleeping and consolability, and to increase comfort measures when needed. This requires nurses to see parents as the most important part of the treatment and to create an environment where they can stay. Postnatal wards, rather than neonatal units, may become the main setting for care.

Stigma remains a significant barrier in neonatal abstinence syndrome care. Mothers who use opioids may feel judged by staff and may be reluctant to stay or to breastfeed. Training in trauma-informed, non-judgemental care can help nurses to build trust, while clear guidance on safeguarding ensures that genuine risks are addressed. Supporting mothers in their recovery benefits both mother and baby.

Practical challenges in caring for neonatal abstinence syndrome include staffing, space and the needs of mothers with complex social circumstances. Rooming-in requires private rooms or appropriate space on postnatal wards, and mothers may need support with their own health, accommodation and transport. Volunteer cuddler programmes and extended family involvement can help when mothers cannot be present.

This review has limitations. The rooming-in meta-analysis and the quality improvement study were observational, the cohort data are from the United States only, and the Cochrane review found little evidence on non-pharmacological care alone. This review relied on openly accessible, English-language sources and did not involve independent double screening. Future research should examine long-term developmental and family outcomes after different approaches to care.

Long-term follow-up is another gap. Children exposed to opioids before birth may face developmental, behavioural and social challenges, influenced by their home environment as well as by exposure. Connecting families with community health visitors, early intervention services and addiction support after discharge may matter as much for long-term outcomes as the approach used in hospital.

Implications of Neonatal Abstinence Syndrome Evidence for Practice

Neonatal nurses should support rooming-in, encourage parental presence, breastfeeding where appropriate and skin-to-skin contact, swaddle and hold babies, reduce stimulation and use function-based assessment such as Eat, Sleep, Console. A calm, warm environment draws on principles of developmental care and thermoregulation, since withdrawing babies may sweat and lose heat.

Before discharge, parents should be taught safe sleep practices, because babies with withdrawal may be at increased risk, and preterm babies exposed to opioids may also need screening for conditions such as retinopathy of prematurity. Follow-up should support families after discharge.

Units introducing these changes should audit medication use, length of stay, readmissions and parents’ experiences, so that improvements can be measured and sustained, and so that staff can see the difference their care makes for families.

Conclusion

This systematic review examined the evidence on nursing and family-centred approaches to the care of infants with neonatal abstinence syndrome. Keeping mothers and babies together, prioritising non-pharmacological care and using function-based assessment reduce medication and length of stay without increasing harm, while opioid medication remains effective for babies who need it.

Neonatal nurses are at the heart of this change in care. By treating parents as partners and providing compassionate, non-judgemental support, they can help babies through withdrawal while strengthening the bond between mother and child.

References

MacMillan, K. D. L., Rendon, C. P., Verma, K., Riblet, N., Washer, D. B., & Volpe Holmes, A. (2018). Association of rooming-in with outcomes for neonatal abstinence syndrome: A systematic review and meta-analysis. JAMA Pediatrics, 172(4), 345–351. https://doi.org/10.1001/jamapediatrics.2017.5195

Tolia, V. N., Patrick, S. W., Bennett, M. M., Murthy, K., Sousa, J., Smith, P. B., Clark, R. H., & Spitzer, A. R. (2015). Increasing incidence of the neonatal abstinence syndrome in U.S. neonatal ICUs. New England Journal of Medicine, 372(22), 2118–2126. https://doi.org/10.1056/NEJMsa1500439

Wachman, E. M., Grossman, M., Schiff, D. M., et al. (2018). Quality improvement initiative to improve inpatient outcomes for neonatal abstinence syndrome. Journal of Perinatology, 38, 1114–1122. https://doi.org/10.1038/s41372-018-0109-8

Young, L. W., Ounpraseuth, S. T., Merhar, S. L., Hu, Z., Simon, A. E., Bremer, A. A., Lee, J. Y., Das, A., Crawford, M. M., Greenberg, R. G., Smith, P. B., Poindexter, B. B., Higgins, R. D., Walsh, M. C., Rice, W., Paul, D. A., Maxwell, J. R., Telang, S., Fung, C. M., … Devlin, L. A. (2023). Eat, Sleep, Console approach or usual care for neonatal opioid withdrawal. New England Journal of Medicine, 388(25), 2326–2337. https://doi.org/10.1056/NEJMoa2214470

Zankl, A., Martin, J., Davey, J. G., & Osborn, D. A. (2021). Opioid treatment for opioid withdrawal in newborn infants. Cochrane Database of Systematic Reviews, (7), CD002059. https://doi.org/10.1002/14651858.CD002059.pub4