Nonpharmacological Care in Neonatal Abstinence Syndrome Infants: An Integrative Review

Leeba Matthew, Johns Hopkins University

Ivy Pacis, Johns Hopkins University

Valerie T. Cotter, Johns Hopkins University

DOI: 10.58117/eh0f-6a41

Introduction

Neonatal Abstinence Syndrome (NAS) refers to withdrawal symptoms experienced by newborns following intrauterine exposure to maternal substance use. NAS remains a significant healthcare concern because affected infants often require prolonged hospitalization, intensive monitoring, and specialized treatment, contributing to increased healthcare resource utilization (Zyoud et al., 2022). The early postnatal period is critical for neonatal brain development, and studies have demonstrated that prenatal substance exposure can contribute to long-term cognitive and developmental delays in childhood (MacMillan et al., 2019).

Nonpharmacological interventions are considered a foundational component in the management of infants with NAS and play a critical role in improving both short- and long-term developmental outcomes (Adrian et al., 2020). Evidence suggests that interventions such as minimizing environmental stimulation, swaddling, holding, skin-to-skin care, and feeding on demand can reduce withdrawal severity, decrease the need for pharmacological treatment, shorten hospital length of stay, and improve maternal-infant outcomes (Adrian et al., 2020).

Despite growing evidence supporting these interventions, consistent implementation of nonpharmacological care remains variable in clinical practice. Standardized protocols for both pharmacological and nonpharmacological management can help healthcare teams provide individualized and evidence-based care for infants affected by NAS (Chin Foo et al., 2021). However, gaps in nurses’ knowledge, confidence, assessment skills, and understanding of NAS management may contribute to inconsistent application of these interventions at the bedside.

Nurse education plays an essential role in improving nurses’ self-efficacy, strengthening knowledge of both pharmacological and nonpharmacological interventions, enhancing NAS assessment skills, and fostering empathy toward affected infants and their families (Adrian et al., 2020). Addressing these knowledge and practice gaps through targeted education may improve the consistent integration of nonpharmacological care and ultimately enhance the quality and safety of care delivered to infants with NAS.

Methods

An integrative review methodology was selected because it enables synthesis of evidence from diverse methodologies, including qualitative, quantitative, mixed-methods, quality improvement, and review studies, thereby providing a comprehensive understanding of a complex clinical issue (Whittemore & Knafl, 2005). This integrative review was conducted as part of a formal evidence-based practice (EBP) project to fulfill the scholarly requirements of a Doctor of Nursing Practice (DNP) program. The purpose of the review was to synthesize existing evidence regarding the utilization of nonpharmacological interventions for infants with NAS and to identify factors that influence their implementation in neonatal care settings.

The search was done through electronic databases, including PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Embase. The search strategy included Medical Subject Headings (MeSH) and related keywords: complementary therapies, breastfeeding, kangaroo care method, nonpharmacological measures, swaddling, feeding on demand, skin-to-skin, rooming-in, decreased stimuli, holding, neonatal abstinence syndrome, neonatal substance withdrawal, and nursing staff. The Boolean operator OR was used when searching for each MeSH term with synonyms. The articles relevant to the question were identified using the Boolean operator AND to combine the search results from each MeSH term.

Using the database searches, 216 articles were identified, and 87 duplicate records were removed using the web-based platform, Covidence. A total of 129 articles were screened using the title and abstract screening tool. Nineteen articles were excluded based on predefined exclusion criteria, including studies that focused exclusively on pharmacological interventions, patient populations beyond the neonatal period, or were conducted in cultural and geographical settings not applicable to the review. A total of 110 articles were identified for full-text screening. Ninety articles were excluded during full-text screening based on the exclusion criteria of inappropriate study design and setting, non-English language, and articles older than 10 years. Twenty articles were identified for data extraction using the guidelines of the Johns Hopkins Evidence-Based Practice Model (Dang et al., 2022).

The Johns Hopkins Evidence-Based Practice Model was selected because it is a nursing-focused framework specifically designed to guide the translation of evidence into clinical practice, making it particularly well suited for DNP scholarly projects aimed at practice improvement. Unlike traditional appraisal tools such as JBI, CASP, or COREQ that primarily focus on methodological evaluation of individual studies, the Johns Hopkins model provides a structured approach for integrating diverse levels of evidence and translating findings into practice recommendations. The model’s Practice Question, Evidence, and Translation (PET) process guided the development of the review question, critical appraisal of evidence, and interpretation of findings for clinical application. The search results are shown in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart in Figure 1.

Findings

Twenty articles published between 2014 and 2024 were identified for further analysis (Table 1). The level and quality of the evidence were evaluated by the Johns Hopkins Evidence-Based Practice Model (Dang et al., 2022). Thirteen articles were Level III with a quality rating of B, and seven articles were Level V with a quality rating of B (see Table 1). The included studies represented a variety of methodologies, including literature reviews (n = 6), retrospective chart reviews (n = 5), mixed-methods studies (n = 2), quality improvement projects (n = 2), qualitative studies (n = 2), cohort studies (n = 2), and one ethnographic study. Analysis of the literature revealed three overarching themes related to the utilization of nonpharmacological interventions for infants with NAS: (1)healthcare provider knowledge, attitudes, and perceptions influenced the implementation and utilization of nonpharmacological care practices; (2) family-centered interventions contributed to improved outcomes for both infants and mothers; and (3) nonpharmacological interventions were associated with improved infant outcomes, including reduced length of hospital stay and decreased need for pharmacological treatment. Across studies, organizational support, staff education, standardized protocols, and interdisciplinary collaboration were identified as important facilitators of successful implementation.

Healthcare Provider Knowledge, Attitudes, and Perceptions

Healthcare provider knowledge, attitudes, and perceptions emerged as important factors influencing the implementation and effectiveness of nonpharmacological care practices. Studies consistently emphasized the importance of staff education, training, and organizational support in facilitating evidence-based care for infants with NAS. Following implementation of the ESC approach, healthcare providers identified environmental modifications, increased education, and ongoing competency development as essential components of successful NAS management (Cooney et al., 2024).

The literature also highlighted the importance of interdisciplinary collaboration and team-based care models. Effective communication, shared decision-making, and mutual respect among healthcare professionals and families contributed to improved implementation of nonpharmacological interventions (McDaniel et al., 2021). In addition, provider attitudes toward substance-exposed infants and their families were found to influence care delivery. Studies emphasized the need to establish nonjudgmental partnerships with parents and caregivers to foster trust, engagement, and participation in care (Grisham et al., 2019). Education programs aimed at addressing stigma and unconscious bias were associated with stronger therapeutic relationships and increased adoption of family-integrated care practices (Shuman et al., 2020). Furthermore, providing clinicians with knowledge and resources related to developmental and neuroprotective care enhanced their ability to deliver evidence-based nonpharmacological interventions effectively (Piccotti et al., 2019). Together, these findings suggest that organizational support, ongoing education, and interdisciplinary collaboration are essential to successful implementation.

Family-Centered Interventions and Improved Outcomes for Infants and Mothers

Family-centered interventions were consistently identified as a key component of successful NAS management and were associated with improved outcomes for both infants and mothers. Across studies, interventions that actively engaged parents in the care process promoted infant comfort, strengthened parent-infant bonding, and enhanced maternal confidence and involvement. Family-centered approaches commonly included rooming-in, breastfeeding, skin-to-skin care, caregiver participation, and parent education.

Rooming-in programs were associated with increased maternal engagement, improved bonding, and reduced severity of withdrawal symptoms when combined with education, social support, and follow-up services (Newman et al., 2015). Increased parental presence during hospitalization was also associated with shorter hospital stays, fewer days of pharmacological treatment, and lower NAS scores (Howard et al., 2017). Several studies highlighted the importance of educating parents and family members about NAS and the ESC approach to encourage active participation in nonpharmacological care practices (Grisham et al., 2019).

Interventions such as skin-to-skin care, swaddling, holding, and prompt responsiveness to infant cues were shown to reduce infant stress, promote sleep, and support neurodevelopment (Piccotti et al., 2019). Family involvement further contributed to improved social development and stronger parent-infant attachment (Gadomski et al., 2018). Overall, the literature supports the integration of family-centered approaches into NAS treatment protocols and highlights the critical role of families as active partners in care.

Nonpharmacological Interventions and Improved Infant Outcomes

The literature consistently demonstrated that nonpharmacological interventions contribute to improved outcomes for infants diagnosed with NAS. Across studies, interventions focused on promoting infant comfort, physiologic stability, and neurodevelopment while reducing the need for pharmacological treatment. Common strategies included swaddling, holding, rocking, minimizing environmental stimuli, breastfeeding when appropriate, and responding promptly to infant cues. These interventions supported infant sleep, self-regulation, and overall comfort during withdrawal (Nelson, 2016).

Several studies reported that implementation of the Eat, Sleep, Console (ESC) model was associated with reductions in hospital length of stay and decreased use of pharmacological therapy compared with traditional symptom-based approaches to NAS management (Cooney et al., 2024). Similarly, volunteer cuddler programs and the use of trained support personnel provided additional opportunities for soothing and comforting infants experiencing withdrawal symptoms. These interventions were associated with improved withdrawal management, reduced breakthrough medication administration, and more successful pharmacological weaning (Adrian et al., 2020; Hignell et al., 2020). Collectively, the findings support nonpharmacological interventions as effective first-line strategies for managing NAS while reducing healthcare utilization and promoting positive infant outcomes.

Collectively, the findings suggest that the successful implementation of nonpharmacological interventions for infants with NAS is influenced by a combination of provider, organizational, and family-related factors. Evidence consistently supports the use of interventions such as rooming-in, breastfeeding, skin-to-skin care, and the ESC model to improve infant outcomes and reduce healthcare utilization. Organizational support, staff education, standardized protocols, and active family engagement emerged as key facilitators of effective implementation across healthcare settings.

Discussion

The management of NAS requires a comprehensive understanding of its complex pathophysiology and the evidence-based interventions that support optimal infant outcomes. NAS is a multifaceted biological phenomenon resulting from immature neurologic development, impaired neurologic processing, and complex maternal-fetal placental pharmacokinetics (Piccotti et al., 2019). Given the complexity of the condition, the American Academy of Pediatrics recommends that neonatal care units implement standardized assessment and management protocols for infants with NAS. Effective use of assessment tools, such as the Finnegan Neonatal Abstinence Scoring System (FNASS), requires ongoing education and training of healthcare providers to ensure safe, consistent, and high-quality care (Piccotti et al., 2019).

Across the literature, nonpharmacological interventions were consistently identified as the foundation of NAS management and the recommended first-line treatment approach. Common interventions included rooming-in, minimizing environmental stimuli, feeding on demand, swaddling, holding, rocking, and clustered care activities designed to reduce infant stress and promote self-regulation (Cook et al., 2019; Piccotti et al., 2019). Studies emphasized that the timely and consistent implementation of these interventions can decrease withdrawal severity, reduce the need for pharmacological treatment, and improve overall infant outcomes.

Successful implementation of nonpharmacological care often requires a collaborative and family-centered approach. McDaniel et al. (2021) described a Team-Based Care (TBC) model that incorporates healthcare professionals and family members as active participants in the care process. This model addresses the physiologic, neurobiological, and psycho-emotional needs of the infant while simultaneously recognizing the needs of the family during the prenatal, inpatient, and post-discharge periods. The TBC model promotes effective communication, interdisciplinary collaboration, and shared decision-making between families and healthcare providers, thereby enhancing both the quality and consistency of care.

Family involvement emerged as a critical component of successful NAS management. Multiple studies demonstrated that parental participation in infant care was associated with reduced pharmacological treatment requirements and shorter hospital lengths of stay (Holmes et al., 2016; Howard et al., 2017). Rooming-in programs not only improved infant outcomes but also provided parents and family members with the knowledge and skills necessary to care for their infants following discharge. Increased parental presence at the bedside was associated with enhanced bonding, greater caregiver confidence, and improved understanding of infant cues and withdrawal symptoms (Howard et al., 2017). Furthermore, active engagement in nonpharmacological interventions created opportunities for mothers to participate in daily infant care under the guidance and support of healthcare professionals, fostering trust, empowerment, and compassionate, nonjudgmental relationships between families and providers (Shuman et al., 2020).

Several innovative approaches have also been implemented to enhance the delivery of nonpharmacological care. The use of a volunteer cuddling program in Canada enhanced the delivery of nonpharmacological care for infants with NAS and was associated with improved clinical outcomes through individualized comfort measures provided by trained volunteers (Hignell et al., 2019). Volunteers were educated to recognize infant behavioral cues and signs of overstimulation, allowing them to provide developmentally supportive care tailored to each infant's needs. Similarly, the ESC model has gained widespread support as a functional and family-centered approach to NAS management. Unlike traditional symptom-based assessment methods, the ESC model focuses on the infant's ability to eat effectively, sleep adequately, and be consoled. The model emphasizes maximizing nonpharmacological interventions, encouraging parental involvement, and supporting breastfeeding when appropriate and not contraindicated (Grisham et al., 2019).

The literature consistently demonstrated that effective implementation of nonpharmacological interventions is influenced by healthcare provider knowledge, attitudes, and organizational support. Healthcare professionals must possess strong assessment skills and a comprehensive understanding of the NAS continuum of care to effectively identify withdrawal symptoms and implement appropriate interventions (Adrian et al., 2020). Increased provider knowledge and confidence were associated with greater self-efficacy, reduced stigmatization of the mother-infant dyad, and improved delivery of family-centered care. Organizational support was also identified as essential for successful implementation, including adequate staffing levels, ongoing education, standardized protocols, and continuity of care. These factors facilitate the development of therapeutic relationships between nurses and families and create a safe, supportive environment that encourages parental engagement in infant care (Adrian et al., 2020).

Collectively, the evidence suggests that nonpharmacological interventions are effective strategies for improving outcomes among infants with NAS. Successful implementation requires a combination of evidence-based clinical practices, interdisciplinary collaboration, organizational support, and active family engagement. When consistently applied, these interventions can reduce healthcare utilization, decrease reliance on pharmacological treatment, strengthen parent-infant relationships, and promote positive short- and long-term outcomes for infants and their families.

Limitations

This integrative review has several methodological limitations that may influence the interpretation and transferability of findings. First, the search strategy was limited to English-language publications, which may have introduced language bias and excluded relevant evidence from non-English sources. Second, the search was limited to selected databases and studies published within the previous 10 years, potentially resulting in the omission of relevant older studies or evidence indexed in other databases.

The body of evidence included in the review was methodologically diverse, consisting of qualitative, quantitative, mixed-methods, quality improvement, and review studies, which limited direct comparison across studies. In addition, the majority of included studies represented lower levels of evidence, with a limited number of higher-level experimental or controlled study designs, reducing the strength of conclusions regarding intervention effectiveness. The relatively small sample of 20 included studies may further limit the generalizability and transferability of findings across diverse neonatal care settings.

Despite these limitations, the review provides valuable insight into current evidence supporting nonpharmacological interventions for infants with NAS and highlights the need for more rigorous, large-scale studies to strengthen the evidence base and guide future clinical practice.

Conclusion

The use of nonpharmacological interventions in infants with NAS has been associated with reduced length of hospital stay and decreased need for pharmacological treatment. These findings support the use of evidence-based nonpharmacological strategies, including rooming-in, parental presence, and the ESC model, as first-line approaches in NAS management. However, further research is needed to strengthen the quantitative evidence supporting these interventions and to guide their consistent implementation across diverse clinical settings.

Implications for nursing practice include the need for standardized, evidence-based protocols to ensure consistent delivery of nonpharmacological care for infants with NAS. Nursing education should prioritize ongoing competency development in NAS assessment and the application of nonpharmacological strategies to improve clinical decision-making and confidence among bedside providers. Future research should focus on the development, implementation, and evaluation of standardized NAS care protocols, including comparative effectiveness studies to determine best practices across varied neonatal populations and settings.

Ethical Approval

This manuscript is an integrative review of previously published literature and did not involve human participants or animal subjects; therefore, ethical approval was not required.

Generative AI Statement

The authors did not use generative artificial intelligence tools in the preparation of this manuscript.

Funding

The authors received no external funding for this study.

Conflict of Interest

The authors declare no conflicts of interest.

References

Appendix

Figures

Figure 1. "PRISMA Flow Diagram." From Page, M.J., McKenzie, J.E., Bossuyt, P.M., Boutron, I., Hoffmann, T.C., Mulrow, C.D., et al. 'The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.' BMJ 2021;372:n71. doi: 10.1136/bmj.n71

Tables

Table 1. Table of Evidence

Search Strategies