Neonatal abstinence syndrome: building effective nonpharmacologic care bundles

Neonatal abstinence syndrome (NAS), also called neonatal opioid withdrawal syndrome (NOWS), describes the signs that may appear when a newborn has been exposed to opioids during pregnancy and then experiences reduced exposure after birth. Symptoms can include tremors, irritability, unsettled sleep, feeding difficulty, vomiting, loose stools, increased muscle tone and, in more severe cases, breathing problems or seizures. The pattern and severity vary widely between infants.

Medication may be needed for some babies, yet supportive care is the foundation for every infant at risk. A carefully designed nonpharmacologic care bundle reduces sensory stress, supports feeding and sleep, strengthens parent–infant attachment and helps clinicians recognise when additional treatment is required. It should begin before birth and continue through discharge planning.

Australian maternity and neonatal services are adapting this work to different settings, from tertiary hospitals in Sydney and Melbourne to smaller regional units and remote services. Families may be managing housing pressures, transport barriers, child protection involvement, mental health concerns or their own recovery from substance dependence. A respectful, consistent approach can make clinical care safer and more acceptable.

The principles also sit within the wider perinatal research community. The FAOPS congress archive reflects the scientific focus on perinatal and neonatal medicine that brought clinicians and researchers together in the Asia-Pacific region, even though the planned Tokyo meeting was cancelled in 2020.

Why supportive care comes first

The newborn’s nervous system can become highly reactive during withdrawal. Bright lights, loud voices, repeated handling and frequent interruptions may intensify crying and make it harder for the infant to feed or settle. A calm environment is therefore a clinical intervention, rather than a comfort measure added after medical care is complete.

A bundle usually starts with low-stimulation nursing. Staff can dim lights, reduce noise, cluster essential care, use slow and contained handling, and offer swaddling or facilitated tucking when appropriate. Skin-to-skin contact, gentle rocking and non-nutritive sucking may help an infant regulate. Care should be paced around the baby’s cues instead of following a rigid schedule whenever clinical safety allows.

Parents are central to this approach. The person who knows the baby’s usual cues best should be supported to provide holding, settling, feeding and comfort. If parental presence is limited, the team should identify other safe, consistent carers rather than leaving the infant exposed to repeated unfamiliar handling.

Keeping parents beside the baby

Rooming-in allows parents and babies to remain together and can reduce separation, unnecessary stimulation and missed feeding cues. It also gives families more opportunity to learn practical soothing skills. Where a hospital has the staffing and environment to provide it safely, rooming-in may reduce the need for pharmacological treatment and shorten the hospital stay.

In Australia, implementation may look different in a busy metropolitan women’s hospital, a regional maternity unit or a neonatal intensive care service receiving transfers from across a state. A private room is useful but not essential. A quiet bay, flexible visiting arrangements, recliner chairs for skin-to-skin care and clear escalation pathways can support the same principles.

Language matters, especially when parents fear that disclosure of drug use will lead to judgement or loss of custody. Staff should use person-first, non-stigmatising terms such as “opioid exposure” or “a parent receiving medication treatment”. Asking what helps the baby settle and acknowledging the parent’s expertise can build trust quickly.

For Aboriginal and Torres Strait Islander families, culturally safe care should be embedded rather than treated as an optional referral. Services can involve Aboriginal health workers or liaison officers, support the family’s chosen decision-makers and consider the effects of distance from Country and community. These steps are relevant to clinical safety because trust influences attendance, communication and discharge follow-up.

Supporting feeding, sleep and regulation

Feeding difficulties are common in infants with withdrawal. The baby may suck urgently, tire quickly, have a disorganised suck–swallow–breathe pattern or struggle with reflux and loose stools. A feeding plan should focus on adequate intake, energy conservation and the infant’s ability to remain calm, rather than treating every unsettled period as hunger.

Breastfeeding is often encouraged when it is clinically appropriate and the parent is stable on prescribed opioid agonist treatment, with advice tailored to the individual situation. The team should assess other medicines, ongoing non-prescribed substance use, infections and the parent’s capacity to feed safely. Expressed breast milk, paced bottle feeding or temporary alternative feeding plans may be needed. These decisions should be explained without shame and reviewed as circumstances change.

Small, frequent feeds can be helpful, although excessive feeding may worsen vomiting or fatigue. Occupational therapists, speech pathologists, lactation consultants and neonatal nurses can assess oral-motor function and develop practical strategies. In some Australian hospitals, access to these professionals varies, so staff should identify which skills are available locally and when a referral or transfer is necessary.

Sleep is another important treatment target. The aim is to help the infant achieve longer periods of quiet sleep while following safe-sleep guidance. Swaddling must allow hip movement and should stop when the baby shows signs of rolling. The infant should sleep supine on a firm, clear surface, with skin-to-skin care provided only while the adult is awake and able to supervise.

Assessing progress without overhandling

Traditional withdrawal scores can draw attention to individual symptoms such as tremor, sneezing or high-pitched crying. They may also require frequent disturbance and can produce inconsistent results between observers. A functional approach, such as Eat, Sleep, Console, considers whether the infant can eat effectively, sleep for an appropriate period and be consoled within a reasonable time.

No assessment method replaces clinical judgement. Staff must still check temperature, respiratory effort, hydration, weight, blood glucose when indicated and neurological status. Sepsis, hypoglycaemia, hypocalcaemia, gastrointestinal disease and other causes of irritability can resemble withdrawal. A baby with poor feeding, lethargy, fever, respiratory distress, abnormal movements or rapidly worsening symptoms needs prompt medical assessment.

A shared record helps the whole team see whether the care bundle is working. Documentation can include the infant’s longest sleep, feeding volumes or breastfeeding effectiveness, consolability, weight trend, stooling, parent involvement and any environmental triggers. Reviewing these measures during handover makes care more consistent across shifts.

The Australian context requires attention to local protocols and medication pathways. Hospitals should agree in advance on when to involve neonatology, pharmacy, social work and child and family health services. Clinical guidance differs between jurisdictions and institutions, so teams should use current state or territory policy rather than relying on an old score sheet or informal custom.

Building a reliable hospital bundle

A successful bundle is a system, not a list placed in a folder. It needs executive support, staff education, suitable space, access to parent accommodation and a process for measuring outcomes. Useful measures include time to first skin-to-skin contact, proportion of eligible infants rooming-in, use of pharmacological treatment, length of stay, breastfeeding at discharge and readmission.

Education should include nurses, midwives, doctors, allied health professionals, Aboriginal health staff and security or reception teams whose interactions can shape a family’s experience. Simulation and bedside coaching are often more effective than a single online module. Staff need practice in cue-based care, trauma-informed communication, safe swaddling, feeding support and escalation.

Hospitals should also examine whether policies unintentionally separate families. Restricted visiting, automatic admission to a special care nursery or inflexible medication administration times may undermine the bundle. Safety requirements remain essential, but they can often be balanced with supervised rooming-in, family accommodation and coordinated appointments.

Discharge planning begins early. Families need a clear explanation of expected settling patterns, feeding concerns, safe sleep, medication instructions if applicable and signs that require urgent review. In Australia, follow-up may involve a GP, child and family health nurse, Aboriginal Community Controlled Health Service, hospital outpatient clinic, opioid treatment program and social support agency. A named contact and practical transport plan are more useful than a generic list of phone numbers.

Extending care beyond the newborn unit

Withdrawal symptoms often change after discharge. Some infants remain unsettled, while others improve as feeding and sleep mature. Parents may be exhausted and managing their own treatment, pain, mental health needs or family responsibilities. Follow-up should therefore assess the baby and the caregiver together.

Community nurses can observe a feed, review weight and hydration, reinforce safe sleep and help parents interpret cues. A written plan should state who will review the infant, when the appointment will occur and how to obtain help after hours. Families living outside Brisbane, Perth, Adelaide or other major centres may need telehealth, outreach visits or coordinated appointments to avoid repeated long-distance travel.

Care must also account for privacy and stigma. Notes should be factual and relevant, and clinicians should explain who may receive information and why. Mandatory reporting obligations vary in application and must be followed, but transparent communication is preferable to vague warnings. Parents are more likely to seek help when they understand the process and are treated as partners in keeping the infant safe.

Quality improvement should include family feedback, not just hospital statistics. Ask whether parents felt listened to, whether they could stay with their baby, whether feeding advice was practical and whether discharge information made sense. Reviewing these experiences alongside clinical outcomes can reveal barriers that a dashboard misses.

A nonpharmacologic bundle works best when every part of the service sends the same message: the infant deserves calm, responsive care, and the parent is an important part of providing it. Begin with a local audit, agree on a small set of evidence-informed practices, train the multidisciplinary team and make room for family participation from the first assessment. Strengthen referral links with maternity, neonatal, alcohol and other drug, Aboriginal health and community services so that support continues after the hospital doors close.