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Outpatient pharmacologic weaning for neonatal abstinence syndrome: a systematic review

  • Jodie Murphy-Oikonen (a1) and Karen McQueen (a2)

The purpose of this systematic review was to assess the literature regarding the effectiveness and safety of outpatient pharmacologic weaning for infants with neonatal abstinence syndrome (NAS).


NAS is a multi-system disorder observed in infants experiencing withdrawal from opioid exposure in utero. Infants requiring pharmacologic treatment to manage withdrawal, traditionally receive treatment as a hospital inpatient resulting in lengthy hospitalization periods. However, there is evidence to suggest that some healthcare institutions are continuing outpatient pharmacologic weaning for select infants in a home environment. As there is no standard of care to guide outpatient weaning, assessment of the safety and effectiveness of this approach is warranted.


A systematic review of outpatient weaning for infants with NAS was conducted using the electronic databases PubMed, Nursing and Allied Health, CINAHL, Evidence-Based Medicine, Web of Science, Medline, and PsychINFO. Studies were eligible for inclusion in the review if they fulfilled the following criteria: (1) reported original data on outcomes related to the effectiveness or safety of outpatient weaning for infants with NAS, (2) infants were discharged from hospital primarily receiving opioid pharmacologic treatment for NAS, (3) the method included quantitative designs that included an inpatient comparison group, and (4) articles were published in English in a peer-reviewed journal.


The search identified 154 studies, of which 18 provided information related to NAS and outpatient weaning. After reviewing the remaining full-text studies, six studies met all inclusion and exclusion criteria. All studies identified that outpatient weaning for select infants was associated with shorter hospitalization compared with infants weaned in-hospital only and may be potentially effective in reducing associated healthcare costs. However, duration of pharmacologic treatment was longer in the outpatient weaning groups in the majority of the studies. Furthermore, adverse events were rare and compliance to follow-up treatment was high among those who received outpatient weaning.

Corresponding author
Author for correspondence: J. Murphy-Oikonen, Lakehead University School of Social Work, 955 Oliver Rd, Thunder Bay, ON, Canada P7B5E1. E-mail:
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Abdel-Latif, ME, Oei, J, Craig, F Lui, K, NSW and ACT NAS Epidemiology Group (2013) Profile of infants born to drug-using mothers: a state-wide audit. Journal of Paediatrics and Child Health 49, E80E86.
Abrahams, RR, MacKay-Dunn, MH, Nevmerjitskaia, V, MacRae, GS, Payne, SP Hodgson, ZG (2010) An evaluation of rooming-in among substance-exposed newborns in British Columbia. Journal of Obstetrics and Gynaecology Canada 32, 866871.
Ailes, EC, Dawson, AL, Lind, JN, Gilboa, SM, Frey, MT, Broussard, CS Honein, MA , Centers for Disease Control and Prevention (CDC) (2015) Opioid prescription claims among women of reproductive age-United States, 2008-2012. MMWR. Morbidity and Mortality Weekly Report 64, 3741.
Backes, CH, Backes, CR, Gardner, D, Nankervis, CA, Giannone, PJ Cordero, L (2012) Neonatal abstinence syndrome: transitioning methadone-treated infants from an inpatient to an outpatient setting. Journal of Perinatology 32, 425430.
Bagley, SM, Wachman, EM, Holland, E Brogly, SB (2014) Review of the assessment and management of neonatal abstinence syndrome. Addiction Science & Clinical Practice 9, 19.
Burns, L, Mattick, RP, Lim, K Wallace, C (2007) Methadone in pregnancy: treatment retention and neonatal outcomes. Addiction 102, 264.
Chau, KT, Nguyen, J, Miladinovic, B, Lilly, CM, Ashmeade, TL Balakrishnan, M (2016) Outpatient management of neonatal abstinence syndrome: a quality improvement project. The Joint Commission Journal on Quality and Patient Safety 42, 506515.
Cicero, TJ, Ellis, MS Harney, J (2015) Shifting patterns of prescription opioid and heroin abuse in the United States. The New England Journal of Medicine 373, 17891790.
Cleary, BJ, Donnelly, JM, Strawbridge, JD, Gallagher, PJ, Fahey, T, White, MJ Murphy, DJ (2011) Methadone and perinatal outcomes: a retrospective cohort study. American Journal of Obstetrics and Gynecology 204, 139.e1–9.
Crouch, M Manderson, L (1995) The social life of bonding theory. Social Science & Medicine (1982) 41, 837844.
Davies, H, Gilbert, R, Johnson, K, Petersen, I, Nazareth, I, O’Donnell, M, Guttmann, A Gonzalez-Izquierdo, A (2016) Neonatal drug withdrawal syndrome: cross-country comparison using hospital administrative data in England, the USA, Western Australia and Ontario, Canada. Archives of Disease in Childhood. Fetal and Neonatal Edition 101, 2630.
Edwards, L Brown, LF (2016) Nonpharmacologic management of neonatal abstinence syndrome: an integrative review. Neonatal Network 35, 305313.
Epstein, RA, Bobo, WV, Martin, PR, Morrow, JA, Wang, W, Chandrasekhar, R Cooper, WO (2013) Increasing pregnancy-related use of prescribed opioid analgesics. Annals of Epidemiology 23, 498503.
Finnegan, LP, Connaughton, JF, Kron, RE Emich, JP (1975) Neonatal abstinence syndrome: assessment and management. Addictive Diseases 2, 141158.
Flacking, R, Lehtonen, L, Thomson, G, Axelin, A, Ahlqvist, S, Moran, VH, Ewald, U Dykes, F The SCENE Group (2012) Closeness and separation in neonatal intensive care. Acta Paediatrica 101, 10321037.
Hall, ES, Wexelblatt, SL, Crowley, M, Grow, JL, Jasin, LR, Klebanoff, MA, McClead, RE, Meinzen-Derr, J, Mohan, VK, Stein, H Walsh, MC, OCHNAS Consortium (2015) Implementation of a neonatal abstinence syndrome weaning protocol: a multicenter cohort study. Pediatrics 136, e803e810.
Hudak, ML Tan, RC, Committee on Drugs, Committee on Fetus and Newborn and American Academy of Pediatrics (2012) Neonatal drug withdrawal. Pediatrics 129, e540e560.
Jansson, LM, Velez, M Harrow, C (2009) The opioid-exposed newborn: assessment and pharmacologic management. Journal of Opioid Management 5, 4755.
Joanna Briggs Institute (2014) Reviewers manual. Adelaide: Author.
Kaltenbach, K Jones, HE (2016) Neonatal abstinence syndrome: presentation and treatment considerations. Journal of Addiction Medicine 10, 217223.
Kelly, LE, Knoppert, D, Roukema, H, Rieder, MJ Koren, G (2015) Oral morphine weaning for Neonatal Abstinence Syndrome at home compared with in-hospital: an observational cohort study. Pediatric Drugs 17, 151157.
Kocherlakota, P (2014) Neonatal abstinence syndrome. Pediatrics 134, e547e561.
Kraft, WK, Stover, MW Davis, JM (2016) Neonatal abstinence syndrome: pharmacologic strategies for the mother and infant. Seminars in Perinatology 40, 203212.
Krans, EE, Cochran, G Bogen, DL (2015) Caring for opioid-dependent pregnant women: prenatal and postpartum care considerations. Clinical Obstetrics & Gynecology 58, 370379.
Lee, J, Hulman, S, Musci, M Stang, E (2015) Neonatal abstinence syndrome: influence of a combined inpatient/outpatient methadone treatment regimen on the average length of stay of a Medicaid NICU population. Population Health Management 18, 392397.
Liu, A, Juarez, J, Nair, A Nanan, R (2015) Feeding modalities and the onset of the neonatal abstinence syndrome. Frontiers in Pediatrics 3, 14.
Maguire, D (2014) Care of the infant with neonatal abstinence syndrome: strength of the evidence. Journal of Perinatal 28, 204211.
McQueen, K Murphy-Oikonen, J (2016) Neonatal abstinence syndrome. New England Journal of Medicine 375, 24682479.
Meyer, AS, McWey, LM, McKendrick, W Henderson, TL (2010) Substance using parents, foster care, and termination of parental rights: the importance of risk factors for legal outcomes. Children and Youth Services Review 32, 639649.
Moher, D, Liberati, A, Tetzlaff, J Altman, DG, PRISMA Group (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Medicine 6, e1000097.
Napolitano, A, Theophilopoulos, D, Seng, SK Calhoun, DA (2013) Pharmacologic management of neonatal abstinence syndrome in a community hospital. Clinical Obstetrics and Gynecology 56, 193201.
O’Donnell, M, Nassar, N, Leonard, H, Hagan, R, Mathews, R, Patterson, Y Stanley, F (2009) Increasing prevalence of neonatal withdrawal syndrome: population study of maternal factors and child protection involvement. Pediatrics 123, e614e621.
O’Grady, MJ, Hopewell, J, White, MJ, O’Grady, MJ, Hopewell, J White, MJ (2009) Management of neonatal abstinence syndrome: a national survey and review of practice. Archives of Disease in Childhood – Fetal & Neonatal Edition 94, F249F252.
Patrick, SW, Schumacher, RE, Benneyworth, BD, Krans, EE, McAllister, JM Davis, MM (2012) Neonatal abstinence syndrome and associated health care expenditures: United States, 2000-2009. JAMA 307, 19341940.
Patrick, SW, Schumacher, RE, Horbar, JD, Buus-Frank, ME, Edwards, EM, Morrow, KA, Ferrelli, AP, Picarillo, MG Soll, RF (2016) Improving care for neonatal abstinence syndrome. Pediatrics 137.
Pritham, UA (2013) Breastfeeding promotion for management of neonatal abstinence syndrome. Journal of Obstetric, Gynecologic, and Neonatal Nursing 42, 517526.
Reece-Stremtan, S Marinelli, KA (2015) ABM clinical protocol #21: guidelines for breastfeeding and substance use or substance use disorder. Journal of the Academy of Breastfeeding Medicine 10, 135141.
Saunders, C, King, T, Smith, S, Buchheit, J, Cook, K, Edds, J Mefford, L, Neonatal Abstinence Syndrome Task Force of East Tennessee Children’s Hospital (2014) Neonatal abstinence syndrome: evaluating the effectiveness of an evidence-based multidisciplinary care approach. Journal of Perinatal 28, 232240.
Shannon, J, Blythe, S Peters, K (2016) Neonatal abstinence syndrome and the attachment relationship. Australian Nursing & Midwifery Journal 24, 4242.
Smirk, CL, Bowman, E, Doyle, LW Kamlin, O (2014) Home-based detoxification for neonatal abstinence syndrome reduces length of hospital admission without prolonging treatment. Acta Paediatrica 103, 601604.
Stover, MW Davis, JM (2015) Opioids in pregnancy and neonatal abstinence syndrome. Seminars in Perinatology 39, 561565.
Tolia, VN, Patrick, SW, Bennett, MM, Murthy, K, Sousa, J, Smith, PB, Clark, RH Spitzer, A (2015) Increasing incidence of the neonatal abstinence syndrome in U.S. neonatal ICUs. The New England Journal of Medicine 372, 21182126.
Traube, DE (2012) The missing link to child safety, permanency, and well-being: addressing substance misuse in child welfare. Social Work Research 36, 8387.
Tsai, LC Doan, TJ (2016) Breastfeeding among mothers on opioid maintenance treatment. Journal of Human Lactation 32, 521529.
Uebel, H, Wright, IM, Burns, L, Hilder, L, Bajuk, B, Breen, C, Abdel-Latif, ME, Feller, JM, Falconer, J, Clews, S, Eastwood, J Oei, JL (2015) Reasons for rehospitalization in children who had neonatal abstinence syndrome. Pediatrics 136, e811e820.
Wachman, EM, Byun, J Philipp, BL (2010) Breastfeeding rates among mothers of infants with neonatal abstinence syndrome. Journal of the Academy of Breastfeeding Medicine 5, 159164.
Wachman, EM, Newby, PK, Vreeland, J, Byun, J, Bonganzi, A, Bauchner, H Philipp, BL (2011) The relationship between maternal opioid agonists and psychiatric medications on length of hospitalization for neonatal abstinence syndrome. Journal of Addiction Medicine 5, 293299.
Warren, MD, Miller, AM, Traylor, J, Bauer, A Patrick, SW, Centers for Disease Control and Prevention (CDC) (2015) Implementation of a statewide surveillance system for neonatal abstinence syndrome – Tennessee. MMWR. Morbidity and Mortality Weekly Report 64, 125128.
Welle-Strand, GK, Skurtveit, S, Jansson, LM, Bakstad, B, Bjarkø, L Ravndal, E (2013) Breastfeeding reduces the need for withdrawal treatment in opioid-exposed infants. Acta Paediatrica 102, 10601066.
Wiles, JR, Isemann, B, Ward, LP, Vinks, AA Akinbi, H (2014) Current management of neonatal abstinence syndrome secondary to intrauterine opioid exposure. The Journal of Pediatrics 165, 440446.
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