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Evidence Based Practice: Non-Pharmacologic Interventions for Neonatal Abstinence Syndrome

Madelyn Kamin
Regis College School of Nursing
Professor Sawyer
Evidence Based Practice in Nursing
11 November 2021



Evidence Based Practice: Non-pharmacologic Interventions for Neonatal Abstinence
Problem Statement
Neonatal Abstinence syndrome is identified as one of the severe health issues that are
affecting infants. It is a syndrome that entails the withdrawal of the supply of opioid substances,
occurring in the postpartum period. Once a woman is pregnant, whatever goes into her body is
moved to the fetus’s bloodstream through the placenta. Women who take illicit drugs, much like
alcohol, often lead to dependence. In the same way, the mother’s addictions have an impact on
her children. They become dependent on these illicit drugs after birth and suffer withdrawal
when no longer receiving them from the mother. As a result, the child’s central nervous system
becomes too active, leading to withdrawal symptoms. Pregnant women who abuse illicit drugs
expose their unborn children to many health issues. At the same time, these women do not seek
health attention during pregnancy for prenatal care that is paramount to the fetus (Allen et al.,
There are more challenges that the child faces once they are born that include poor
intrauterine development, low birth weight, convulsions, and congenital disabilities. Abuse of
illicit drugs during pregnancy puts the mother and child at high risks; hence women should
abstain from such substances (Allen et al., 2018). The majority of pregnant women who use
illicit drugs repeatedly, especially opioids, have increased NAS frequency. The outcomes are
based on the past 15 years, whereby substance abuse among pregnant women has not been given
significant attention. In the future, opioid abuse among women should be addressed to prevent
the high rate of NAS among infants. Apart from opioids, tobacco and alcohol consumption have
been on the rise, which risks the health and growth of infants. Prenatal education to the women



population exposed to opioid consumption is crucial in ensuring they are informed on the risks
predisposed to their infants. Mothers abstaining during pregnancy and after delivery is vital in
reducing the NAS incidences among children after birth (Cook & Fantasia, 2019).
Notably, NAS is be managed both pharmacologically and non-pharmacologically in less
severe cases. Research indicates that non-pharmacological interventions target withdrawal issues
and leave no side effects for the child. These non-pharmacological interventions include
breastfeeding the baby, positioning the infant, putting the child in quiet and dimly lit rooms,
stochastic vibrotactile stimulation, skin-to-skin contact, and swaddling. This study investigates
recent research outcomes that focus on non-pharmacological therapies relevant to NAS
management by referring to peer-reviewed articles from 2016 onwards.
Background and Significance
Most pregnant women are dependent on drugs or alcohol before becoming pregnant,
making it difficult for them to receive prenatal care (Allen et al., 2018). Illicit drug abuse among
pregnant women is attributed to social and economic factors well known to them. Substances
such as alcohol, tobacco, and opioids directly affect the unborn child as use progresses. The level
of misinformation leads them to expose their unborn child to the consequences of addiction. In
addition, some educated mothers know the impacts of the drugs on these unborn babies but
progress to taking the illicit drugs when pregnant. It is the proportion of uneducated women
which has been identified to be rampant in the USA. NAS has been a health burden to the
economy of the USA over the last 15 years due to the high rate of uneducated women who are
opioid addicts. When a pharmacological mechanism is used in conjunction with nonpharmacological therapies, the results can be more effective. Even in the most severe cases of
NAS, non-pharmacological treatments alone cannot be relied upon to treat the disease (Cook &



Fantasia, 2019). However, non-pharmacological modalities are crucial in reducing reliance on
medical therapies, which have side effects on these newborns. Hence, non-pharmacological
therapies in NAS treatment should prioritize managing the symptoms, especially when the
newborn is dealing with a less severe case.
Reports from the pediatric unit identify that the severity of the withdrawal symptoms can
be reduced by rooming in and a high level of parental involvement in infant care. Due to parents’
involvement in non-pharmacological therapies that help reduce hospitalizations for NAS
patients, NAS cases are decreasing. (Howard et al., 2017). Once the child suffers from NAS,
women are encouraged to have skin-to-skin breastfeeding sessions that increase the bonding. It
translates to improved outcomes for the babies with NAS as the bond tends to lessen the
withdrawal symptoms and length of stay. The article postulates that hospitals should not be
barriers towards the room in or parental care of the child as it is a non-pharmacological therapy
that accelerates the recovery of the babies.
Moreover, newborn babies that suffer from NAS require gentle care, which provides a
calming effect to the child. Once the newborn is placed in a quiet room that is dimly lit, it
increases their comfort. Some strategies soothe the child, including wrapping the baby with a
cloth that ensures they get better sleep and protects them from a startling effect (Cook &
Fantasia, 2018). Once the baby is comfortable in the wrapping, they tend to be free from anxiety.
After birth, the mother must maintain the proper nutrition with the baby in mind for their
developmental milestones. The baby’s body will change from addiction to the current inflow of
nutrients reducing the withdrawal symptoms.
Literature indicates that stochastic vibrotactile stimulation (SVS) uses a crib mattress as a
complementary intervention in managing the NAS in newborn infants. The SVS can be lowered



by increasing the baby’s movement while using a mattress to keep the child in one position
(Zuzarte et al., 2017). The strategy of SVS aids in improving the functioning of the cardiac and
respiration in NAS babies through regulation of anatomic functioning. SVS reduces the
hyperirritability and pathophysiological weaknesses present in infants with NAS at birth through
pharmacological intervention. As a result, the respiratory and cardiac functions are enhanced
through reduced movements of the child.
Further, it is vital to focus on quality improvement initiatives that lower the need for
pharmacological treatments. This approach eliminates agents to use, reduces the length of
hospital stay, reduces opioid treatment days, and lowers hospital costs. The quality improvement
strategy is evaluated in line with the babies’ functionality by assessing the number of
pharmacological treatments with parental engagement (Wachman et al., 2018). The success of
the function-based facet is linked to the presence of the mother. How function-based strategy
works include prioritizing sleeping, decreasing pharmacological intervention rates (Wachman et
al., 2018). Notably, the article points out that many care institutions towards NAS management
require selecting a multidisciplinary QI approach. Increased adoption of the strategy will reduce
the hospital stay of the mother and the infant since it is easier to implement and has quick results
(Wachman et al., 2018). Health care should focus on increasingly integrating the QI approach
that reduces treatment costs, hospitalization, and a need for pharmacological treatment.
NAS is a health issue that prevalently affects newborns in the USA and becomes
problematic with the economic burden. It is one of the leading causes of medical and growth
problems identified among newborn babies. Health care facilities are dealing with the problem
whereby the majority of the women do not have the necessary insurance to cater for such costs.
The number of women abusing substances is on the rise leading to social, economic, and legal



constraints in dealing with the outcomes (Whalen, Holmes & Blythe, 2019). NAS and substance
abuse by pregnant women requires attention and solutions. Nurses have been dealing with NAS
through creating public awareness of the prevalently affected regions. Civic education to the
women on the impacts of opioids and other illicit substances is crucial towards alleviating the
number of cases of NAS among newborns. The non-pharmacological approach is critical for
such regions since it incurs low costs and is efficient in less severe situations (Whalen, Holmes
& Blythe, 2019). Nurses will provide the needful support to these women, especially on how to
provide care and nutritional support.
Additionally, educating pregnant women on the efficiency of prenatal care is crucial.
NAS symptoms can be lowered by coordinating the mother-based programs, especially addicts
and non-pharmacological facets aligning the child’s need. The health care sector aims to reduce
the costs of hospitalization; hence, choosing the non-pharmacological aspects is critical in
attaining the latter.
The focus of the study is to analyze the effectiveness of the non-pharmacological
interventions in curbing NAS in infants.
EBP Model-Rosswurm & Larabee
Evidence-based practice in health care has become pertinent to the optimization of the
outcomes significantly towards patients. Health care providers, especially nurses, cannot rely on
clinical experience and support quality care through defined frameworks. An evaluation of their
practice and seeking alternative ways of improving health care procedures is paramount. The
foundation of evidence-based practice is through a systematic approach towards clinical issues
where clinical practitioners focus on consistent evaluations and using emerging evidence that



aligns with quality health care needs. The Rosswurm and Larrabee EBP model is a guiding
framework for this study of NAS management in infants. Its development targeted nurses
involved in the therapy sessions with infants who are experiencing withdrawal syndrome after
birth. It is a systematic approach that involves six steps towards problem-solving strategy
(Rosswurm & Larrabe, 1999). The model has been pertinent to nurses in NAS therapies and the
management process in health care.
First, identification of the problem enhances assessment of the need that requires to be
changed. NAS has become a concern in healthcare due to the growing number of infants who
suffer from withdrawal syndrome after birth. Nurses have to provide the needed care based on
the severity of the syndrome. The data collected in the past from mothers dependent on opioids
show a growth in the number of infants who suffer from NAS. The second step is identifying the
best evidence significantly acquired from pediatrician records (Rosswurm & Larrabee, 1999).
Secondary data also provides meaningful information through systematic reviews on the
prevalence of NAS management and incidences from childbirth. In step three, the analysis of the
evidence is done, and the meta-analysis points towards the growth of NAS among infants
fivefold in the past 15 years. The healthcare sector has had to deal with the high number as the
majority of the mothers do not attend prenatal care for such matters to be identified. The
feasibility of the EBP provides the basis for assessing the benefits and risks of NAS therapies to
these infants based on the severe and less severe instances (Rosswurm & Larrabee, 1999). Step
four involves planning and design changes in line with the observations and resources available.
Due to the high costs of hospitalization, non-pharmacological aspects have been considered
towards NAS management. The fifth step includes implementing and evaluating the approach
preferred to deduce conclusions and recommendations (Rosswurm & Larrabee, 1999). In this



case, the non-pharmacological approach is crucial and subject to continuous evaluations for its
significance in NAS management. The sampling process from the infants who are placed under
non-pharmacological therapies provides feedback necessary in evaluation. In the sixth step, NAS
management will be based on the recommendations and new optimal approaches for the infants.

Image retrieved from https://images.app.goo.gl/rnY6JR34eXgEPBGt9
Literature Review
Research Question
The research question under consideration for this project is: Do non-pharmacological
interventions aid in reducing the NAS symptoms in infants.

Search Strategy

The literature search was conducted on various databases such as MEDLINE, PubMed,
Embase, and CINAHL. Only the articles published after 2016 were considered. Priority in
including the articles involved selecting first primary sources such as randomized controlled
trials and observational studies. The critical search terminologies used to produce the most



relevant and significant results were: neonatal abstinence syndrome, non-pharmacological care,
and neonatal opioid withdrawal syndrome. The goal of the search strategy was to explore the
available information and recent studies regarding non-pharmacological interventions and
management of NAS.
Empirical Literature
After reviewing many articles, evidence shows that non-pharmacological interventions
can effectively manage NAS in infants and improve patient outcomes. Non-pharmacological
management entails; soothing techniques, therapeutic modalities, social integration, feeding
methods, vibrotactile stimulation, music, and environmental control. Research studies have
shown that several interventions such as skin to skin contact, swaddling, breastfeeding, roomingin, and environmental control have proven effective in managing NAS. Therefore, incorporating
them into standard care can improve patients’ outcomes (Allen et al., 2018). However, the
interventions can be offered either as stand-alone therapies for less severe NAS or in
combination with pharmacological therapies for severe cases (Finnegan score 37wks were used in the study. This was a non-pharmacological therapy for NAS
management. A crib mattress was specially constructed and used as a complementary strategy
for NAS in infants (Zuzarte et al., 2017). The mattress provided low-level SVS (30-60Hz) at 10–
12μm RMS, with 30 minutes alternations between continuous vibrations being on (ON) and
vibration being off (OFF) for a duration of 6–8 hr. Various parameters were calculated separately
for the ON and OFF including, heart rate, axillary temperature, respiratory rate, movement



activity, and blood-oxygen saturation (Zuzarte et al., 2017). Results with SVS at (pNEONATAL ABSTINENCE SYNDROME


assessed using a multiple linear regression model. Results of the study indicated the parental
presence mean score to be 54.4% at a 95% confidence interval and 48.8%–60.7% for
hospitalized infants (Howard et al., 2017). The duration of hospitalization was reduced by 9
days for infants on the opioid therapy (Howard et al., 2017). The breastfeeding was adjusted, but
parental presence still indicated a significant reduction in NAS score and the duration of opioid
treatment. The study results suggested that spending more bedside time by the parent can
decrease the severity of NAS and reduce the length of stay (LOS) at the hospital. The study
shows important implications for guidelines in clinical practice for managing NAS on the
affected infants (Howard et al., 2017).
A quality improvement (QI) project was conducted to improve NAS in patient outcomes.
The study criteria included opioid-exposed infants≥36 weeks. The QI methodology utilized a
plan-do-study-act (PDSA) cycle and stakeholder interviews (Wachman et al., 2018). Various
NAS outcomes pre-and post- QI intervention were compared, including function assessments
prioritizing on symptoms and then the “Eat, Sleep, Console” (ESC) Tool, a non-pharmacologic
care bundle, and a switch to methadone for pharmacologic treatment (Wachman et al., 2018).
Results indicate decreased pharmacologic treatment by 33% and adjunctive agent use
from 33.6 to 2.4%. The duration of hospitalization decreased by 6 days, while opioid treatment
days were reduced by 4 days. Results also indicated the reduction of total hospital charges by
approximately $11,000 per infant. Consequently, parental presence increased by 20% (Wachman
et al., 2018). It was concluded that a comprehensive QI program that focuses on nonpharmacologic care would significantly improve NAS management outcomes. According to the
study, better practices for opioid-exposed newborns would reduce the costly pharmacological



impacts, minimize hospitalization duration and improve patient outcomes (Wachman et al.,
Summary of ROL
Non-pharmacological interventions have evidentially proven to be effective in reducing
hospital costs, reducing the duration of hospitalization, reducing the use of pharmacological
therapies, and improving patient outcomes during NAS management. The proven interventions
should therefore be universally incorporated into the care and management strategies of NAS.
Parental presence, Comprehensive quality improvement programs, and uses of SVS strategies
included in this study have proven effective in NAS management, concluding that
nonpharmacologic therapies have a great potential in curing the affected infants.
EBP Project Design
The proposed study on NAS management using non-pharmacological therapy aims to
ascertain its effectiveness in treating less severe withdrawal syndrome in infants. The project is
estimated to be carried out within a 4-6 months survey on infants born within the project
postulation. All infants subjected to different aspects of non-pharmacological therapy will be
assessed during the period based on their response rate, hospitalization period, and costs incurred
(MacMullen, Dulsk & Blobaum, 2017). Additionally, data on the preference of pharmacological
treatment will be indicated. The focus of the study outcomes is in line with infants who indicate
withdrawal syndrome after birth as an evidence-based project. During the mentioned research
period, data will be gathered on the effect of non-pharmacological treatment modalities. The
target population will be infants born with NAS. According to the study, this evidence-based
project is of great importance in showing the importance of non-pharmacological interventions in
managing NAS with less severe symptoms.



Setting and Sample
The proposed project will be taking place in a healthcare setup where maternal delivery is
provided. In addition, consideration will be made for a facility that provides NAS management
prevalently on pharmacological therapy (Whalen, Holmes & Blythe, 2019). A sample population
of 30 infants of both genders will be considered for the study. However, it is subjected to the
availability of infants that are put on NAS management. The participants must be diagnosed with
NAS to be considered. Consent will be sought from parents and the facility for the research
process. Participants who agree will be given a form of consent to fill out. Exclusions will be
made for those who do not speak English or are cognitively impaired and may have difficulty
using the technology. The confidentiality and integrity of the information thereby must be
The SVS approach will be used as one of the intervention measures when nonpharmacological therapy is done on the infants. The use of specifications on the mattresses is
integral towards determining the impact on the health improvement or distress. Its importance is
based on the choices of improving the NAS condition in the newborn child while assessing the
aspects of breathing, heart rate, and response to the movement (Whalen, Holmes & Blythe,
2019). In addition, integrating another mechanism that concerns non-pharmacological therapy
will be considered, such as the presence of the parents, breastfeeding, and rooming-in. The
monitoring process of the participants will be attained for 4 hours for consistent outcomes each



Measurement Instruments
A qualitative method will be used in the project for the designated period. It will
encompass pediatricians, nurses, the sample population, and the parent. Descriptive data
measurements are applied in the project to identify changes like the approach’s implementation
(Whalen, Holmes & Blythe, 2019). The healthcare professionals will use the EBP model to
identify the differences. Since it will be an ongoing assessment, data collection will be carried
out subject to the timing indicated with consideration of hours of care administration.
Data Collection Procedures
Data collection will be collected through observation on changes in line with the
withdrawal syndrome. In addition, responses from the pediatrician will be carried out through
interviews to provide feedback over the identified period. The aim is to ensure that observations
and feedback from the clinical staff provide detailed data that can be recorded and analyzed as
Data Analysis
Qualitative analysis is pertinent to the data analysis and presentation processes. The
method will analyze the entire process of implementing NAS management using nonpharmacological therapy based on valuable techniques that worked and those that failed.
Statistical analysis will be used based on the descriptive method.
Non-pharmacological therapies that are accorded to infants who suffer from withdrawal
syndrome have proved to be effective. These procedures are safe, effective, and easily



administered to the infants with the coordination of the parents. The process is to optimize the
recovery process and reduce the side effects that may emanate from the pharmacological
approach (Mangat, Schmölzer & Kraft, 2019). High merit is based on the low cost incurred with
the non-pharmacological interventions, whereby the process is easy and attainable within a short
period. However, many facilities require the commitment of the parents who are opioid addicts
and require healthcare attention. As a result, stabilizing the mother’s conditions for them to
coordinate with nurses is critical.
Furthermore, some infants may not receive optimal skin to skincare which hampers the
evaluation process as a pharmacological design has to be integrated. The success of the nonpharmacological therapy aligns reasonable commitment of the parent for the designated period
(Mangat, Schmölzer & Kraft, 2019). Although the non-pharmacological design is efficient with
less severe cases of NAS, the pharmacological approach is crucial in controlling severe cases of
the latter. High-quality outcomes are achieved through medication despite the side effects that
may be encountered. The mothers subjected to the non-pharmacological approach risk their
infants by failing to adhere to the procedure (Grossman, Seashore, & Holmes, 2017). Future
research should be based on follow-up of the mechanism of such infants, especially where the
case of an addict mother is involved. For the pharmacological approach, there are
pharmacokinetics and pharmacodynamics prevalent in the children, whereby with an addicted
parent, there are risks involved to identify such outcomes. Hence the high significance of the
non-pharmacological approach as the primary therapy will attain optimal observation before
leaving the hospital.



The treatment of NAS contains both pharmacological and non-pharmacological care.
Non-pharmacological treatment can shorten hospital stays, reducing the need for medication and
the associated risks for infants. As long as the mother is receiving medication-assisted treatment
(MAT), breastfeeding should be encouraged. According to swaddling, limiting light or sound
exposure and keeping the baby fed are additional supportive measures for NAS babies. Nonpharmacological treatment for NAS should be included in the standard of care because of the
growing body of evidence supporting its effectiveness and ease of implementation.



Allen, N., Prunty, L., Babcock, C., Attarabeen, O., & Patel, I. (2018). Non-pharmacological
interventions for neonatal abstinence syndrome. Addiction (Abingdon, England),
Cook, C. E., & Fantasia, H. C. (2019). Interventions for the Treatment of Neonatal Abstinence
Syndrome. Nursing for Women’s Health, 23(4), 357–365.
Howard, M. B., Schiff, D. M., Penwill, N., Si, W., Rai, A., Wolfgang, T & Wachman, E. M.
(2017). Impact of parental presence at infants’ bedside on neonatal abstinence syndrome.
Hospital Pediatrics, 7(2), 63-69. https://doi.org/10.1542/hpeds.2016-0147
Wachman, E.M., Grossman, M., Schiff, D.M. et al. (2018). Quality improvement initiative to
improve inpatient outcomes for Neonatal Abstinence Syndrome. J Perinatol 38, 1114–
1122 https://doi.org/10.1038/s41372-018-0109-.
Whalen, B. L., Holmes, A. V., & Blythe, S. (2019, April). Models of care for neonatal abstinence
syndrome: what works?. In Seminars in Fetal and Neonatal Medicine (Vol. 24, No. 2, pp.
121-132). WB Saunders.
Zuzarte, I., Indic, P., Barton, B., Paydarfar, D., Bednarek, F., & Bloch-Salisbury, E. (2017).
Vibrotactile stimulation: A non-pharmacological intervention for opioid-exposed
newborns. PloS one, 12(4), e0175981. https://doi.org/10.1371/journal.pone.0175981



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