Running head: AN INTEGRATIVE REVIEW: BREASTFEEDING AND NAS

An Integrative Review: Breastfeeding and Neonatal

Abstinence Syndrome (NAS)
Dahlia Rose
Nursing Research
NUR 4122
05-01-2016

I pledge
I have never given nor received aid, other than acknowledged, on this assignment or test, nor
have I seen anyone else do so.

AN INTEGRATIVE REVIEW: BREASTFEEDING AND NAS

Abstract
The goal of this integrative review is to evaluate the literature regarding the impact of
breastfeeding on neonatal abstinence syndrome (NAS). NAS rates tripled between the years
2000 and 2009 due to the current epidemic of opioid abuse in the United States (Pritham, 2013).
The research design is an integrative review. The search for literature was conducted using
computer based search engines PubMed and the Nursing Reference Center within the EBSCO
database. The results and findings of five articles support the implementation of breastfeeding as
an intervention in NAS to improve neonatal outcomes. Findings showed that breastfeeding
decreases the need for pharmacological treatment for NAS and hospital length of stay.
Limitations to the review include the nursing students lack of experience, time constraints, and
limits on the number of articles used for the review. Future research should include larger sample
sizes, especially regarding the benefit of breastfeeding on buprenorphine-exposed neonates, to
further establish the correlation of breastfeeding on neonatal outcomes.

AN INTEGRATIVE REVIEW: BREASTFEEDING AND NAS

Introduction/Background
The purpose of this integrative review is to search the literature regarding the impact of
breastfeeding on neonatal abstinence syndrome (NAS). Opioid addiction continues to be a
growing concern in the United States and nearly one-third of those being treated for opioid
addiction are women of childbearing age (OConnor, Collett, Alto, & OBrien, 2013) As a result,
twenty-one to ninety-four percent of neonates with in utero exposure to opioids experience NAS,
which is characterized by central nervous system hyperirritability, gastrointestinal dysfunction,
respiratory distress, and vague autonomic symptoms such as yawning, sneezing, mottling and
fever (Pritham, Paul, & Hayes, 2012). Additional adverse effects of opioid use during pregnancy
include intrauterine growth restriction, placental insufficiency, preterm rupture of membranes,
premature birth, postpartum hemorrhage and perinatal mortality (OConnor, Collett, Alto, &
OBrien, 2013). This topic interests the researcher due to the growing prevalence of opioid
dependence during pregnancy and the serious implications it has on the morbidity and mortality
of the neonates. Therefore, the proposed PICO question by the researcher is as follows: In
neonatal abstinence syndrome, what is the effect of breast feeding over not breastfeeding or
formula-feeding on the length of hospital stay and the need for pharmacological treatment for
NAS.
Design/Search Methods
The research design is an integrative review. The search for research articles was
conducted using the computer-based search engines PubMed, EBSCO, and the Nursing
Reference Center databases. The search terms included: opioid dependency in pregnancy,
neonatal abstinence syndrome, breastfeeding, neonatal length of stay, buprenorphine, and

AN INTEGRATIVE REVIEW: BREASTFEEDING AND NAS

methadone. To maintain a current approach to the issue, the search was limited to peer-reviewed
qualitative and quantitative nursing research journal articles, published in English, and written
between the years of 2011 and 2016. The articles were individually screened by the author and
only the articles that met the inclusion criteria and pertained to the PICO question were reviewed
and the others were excluded. The screening produced four quantitative articles and one
literature review.
Findings/Results
In order to determine whether breastfeeding is an appropriate intervention in this
population, it is important to consider certain maternal factors. Breastfeeding is supported by the
American College of Obstetricians and Gynecologists (ACOG) as long as the women have a
negative screening for human immunodeficiency virus (HIV) infection; are able to abstain from
using using alcohol, illicit drugs, and amphetamines; and have no other contraindications
(Pritham, 2013). The American Academy of Pediatrics (AAP) and the Academy of Breastfeeding
Medicine (ABM) also endorse breastfeeding as long as certain criteria are met (Pritham, 2013).
Additionally, the ACOG and the American Academy of Addiction Medicine indicate that patient
stabilization with opioid-assisted therapy is compatible with breastfeeding (OConnor, Collett,
Alto, & OBrien, 2013).
To further support those organizations, four of the articles additionally discuss that the
concentrations of methadone or buprenorphine that is passed to the neonate via breast milk is
low (OConnor et al., 2013, Pritham et al., 2012, Pritham, 2013, & Welle-Strand et al., 2013).
Breastfeeding has also been found to be beneficial in neonates with NAS in each of the articles

AN INTEGRATIVE REVIEW: BREASTFEEDING AND NAS

reviewed (Isemann et al., 2011; OConnor et al., 2013; Pritham et al., 2012; Pritham, 2013; &
Welle-Strand et al., 2013). A synopsis of the compiled research articles is presented on page 12.
The quantitative study conducted by Welle-Strand et al. (2013), examined the rate and
duration of breastfeeding in a cohort of women in an opioid maintenance treatment (OMT) in
Norway, as well as the effect of breastfeeding on the incidence and duration of NAS. A total of
124 women treated with either methadone or buprenorphine during pregnancy and their neonates
born between 1999 and 2009 were evaluated in three study parts. A standardized questionnaire
was completed by medical professionals in the first part of the study. In parts two and three of
the study, data was collected via personal and telephone interviews in the third trimester and
again following delivery, and then telephone interviews were conducted again a median number
of 332 days after the child was born. The findings revealed that 74% of women in methadone
maintenance therapy (MMT) and 78% of women in the buprenorphine maintenance therapy
(BMT) initiated breastfeeding of their infants after delivery. The median length for breastfeeding
was 12 weeks for women in MMT and 7 weeks for women in BMT. The methadone-exposed
newborns being breastfed had a significantly lower incidence of NAS needing pharmacological
treatment (53%) than those who were not breastfed (80%). There was a shorter duration of
pharmacological NAS treatment for the neonates of women in OMT who were breastfeeding
compared to those who were not (28.6 vs 46.7 days). There was a shorter duration of NAS
treatment for methadone-exposed neonates linked to lactation status (31 vs 48.9 days). There was
no decrease in incidence or shorter duration of pharmacological NAS treatment among the
buprenorphine-exposed neonates which was indicated may be related to the small sample size.
Pritham et al. (2012), also examined opioid replacement therapy in pregnancy and its
effect on neonatal outcomes, including hospital length of stay for NAS. In the authors

AN INTEGRATIVE REVIEW: BREASTFEEDING AND NAS

retrospective chart review, 152 opioid dependent women on MMT (n=136) or BMT (n=16)
during pregnancy and their neonates born between January 1, 2015 and December 31, 2007 at
the Eastern Maine Medical Center (EMMC) were evaluated. After the medical records were
queried and analyzed it was discovered that women on MMT who breastfed their neonates,
shortened their length of stay as compared to those who formula fed. Neonates exposed to BMT
experienced less severe NAS and shorter length of stay than those exposed to methadone. In
addition, the MMT group had significantly smaller head circumference and smaller for
gestational age (SGA) and BMT had more neonates with large for gestational age (LGA).
Pritham (2013), further examined the topic at hand by individually screening 61 articles
between the years of January 1990 and April 2013 to determine the relationship between
breastfeeding and NAS severity, need for pharmacological treatment for NAS, and length of stay
in neonates with exposure to methadone and buprenorphine opioid therapy. The author
discovered that neonates who were breastfed were less likely to require pharmacological
treatment for NAS and therefore experienced a significantly shorter length of stay than those that
were formula fed. Lower initiation rates and early cessation of breastfeeding are also common
among opioid-dependent women related to a number of factors. Some reasons that opioiddependent women do not breastfeed include embarrassment to feed in public, dislike in the act of
breastfeeding and fear of the associated nipple pain. Additionally, lack of public knowledge on
its benefits, societal norms, inadequate support systems, maternal employment, childcare issues
and insufficient prenatal education were also found to be deterrents to breastfeeding. Unlike the
other articles, this author also discussed that rooming-in, skin-to-skin contact, and swaddling are
also effective strategies in the care of neonates with NAS in addition to breastfeeding and
pharmacological treatment.

AN INTEGRATIVE REVIEW: BREASTFEEDING AND NAS

In the retrospective chart review conducted by OConnor et al. (2013), 85 maternal-infant

dyads treated in an integrated treatment plan within a family medicine residency in Maine
between December 2007 to August 2012 were identified. The integrated treatment plan provided
prenatal and obstetric care, medication-assisted treatment with buprenorphine, substance abuse
counseling facilitated by a Psychologist trained in addictions treatment, care for mother and child
during and after birth and social services as well. Findings showed that 76% of the women chose
to breastfeed during hospitalization and 66% were still breastfeeding at the 6-to-8 week
postpartum visits and/or the 2 month well child visit. Infants in the non-breastfeeding cohort
were significantly more likely to have been exposed to illicit substances during the third
trimester as compared to those breastfeeding as determined by urine toxicology reports.
Breastfed infants were less likely to require pharmacological treatment for NAS as compared
with the group that did not breastfeed (23.1% vs 30%). Breastfed infants were less likely than
infants who were not breastfed to score an 8 or above on the modified Finnegan Scoring System
(65% vs 75%) which measures the degree to which an infant is withdrawing. Symptoms of NAS
also started to resolve earlier in the breastfed cohort (76.1 vs 78.3 hours). However, there was no
link regarding the hospital length of stay and breastfeeding.
The final article is also a retrospective chart review to identify maternal and neonatal
factors that impact response to methadone therapy for NAS. Isemann et al. (2011), identified 128
infants that received methadone pharmacotherapy for opiate withdrawal in the Neonatal
Intensive Care Unit at The University Hospital in Cincinnati, Ohio between January 2002 and
December 2007. Data was collected through the hospitals pharmacy database which was crossreferenced to the electronic medication administration record and nursing flow sheets. Findings
revealed that there was no statistical difference in the hospital length of stay between neonates

AN INTEGRATIVE REVIEW: BREASTFEEDING AND NAS

exposed to methadone in utero compared to infants that were additionally exposed to other
classes of drugs (benzodiazepines, barbiturates, cocaine, SSRIs, marijuana, additional opiates or
tobacco). Infants that required adjunctive therapy with phenobarbital were born of mothers on
higher doses of methadone and had a longer length of stay compared to those on methadone
monotherapy. Breastfeeding was associated with a shorter median duration of methadone therapy
in both preterm and term infants. Compared with formula-fed infants, ingestion of maternal
breast milk was also independently associated with a shorter length of stay.
Discussion/Implications
The findings of the integrative review address the effects of breastfeeding on NAS.
Therefore, the review findings relate to and support the researchers PICO question. The
quantitative study by Welle-Strand et al. (2013), indicated a need for more support for the
women to initiate and continue breastfeeding which should ideally begin in early pregnancy. The
advice provided concerning breastfeeding should be consistent between providers which may
require continuous education on the matter. Additionally, it was indicated that there is a need for
more research concerning the effect of lactation on NAS of neonates of women in BMT. This
final note was additionally supported by OConnor et al. (2013), who reported that exposure to
buprenorphine in breast milk does not appear to suppress NAS symptoms but this may be due to
the poor oral bioavailability resulting in minimal infant exposure. Pritham et al. (2012), also
stated that neonates exposed to buprenorphine experienced less severe NAS and shorter length of
stay than those exposed to methadone but the buprenorphine study group was too small to detect
meaningful differences. While the buprenorphine groups may have been smaller, all five articles
are in consensus that breastfeeding has shown to have positive correlations to neonatal
abstinence syndrome.

AN INTEGRATIVE REVIEW: BREASTFEEDING AND NAS

Limitations
The researcher acknowledges that there are numerous factors that have influenced this
integrative review. Each of the five articles were individually reviewed by the researcher and
were utilized to complete this final class assignment. The researcher is a full-time nursing student
who additionally works part-time, therefore there was limited time to complete this assignment
related to other school or work obligations. The assignment criteria were limited to five, peerreviewed nursing journal articles within the last five years. The gap in literature regarding the
topic at hand, further limited the review. Additionally, there is also a lack of experience since this
is the researchers first attempt at writing an integrative review.
Conclusion
The findings of this integrative review emphasize the importance of implementing
breastfeeding as a modality in the treatment of NAS as long as the women are eligible to
breastfeed. Beneficial findings from the review include a decrease in the need for
pharmacological treatment for NAS and shortened hospital length of stay which addresses the
PICO question. There is a lack of statistically significant data regarding the benefits of
breastfeeding among buprenorphine-exposed neonates which may be related to the smaller
sample sizes and the fact that methadone is typically the first-line treatment. Therefore, further
research should be done to determine the correlation of breastfeeding and neonatal outcomes in
buprenorphine-exposed neonates. Additionally, most of the opioid-dependent women are
socioeconomically disadvantaged and tend to formula feed their neonates related to a lack in
knowledge or fears related to the act of breastfeeding and the associated nipple pain. Therefore,
there needs to be more education and more support from clinicians regarding the benefits of

AN INTEGRATIVE REVIEW: BREASTFEEDING AND NAS

10

breastfeeding. Nurses provide most of the patient teaching and therefore, it is imperative that
they take this opportunity advocate for a vulnerable population such as this and help improve the
future statistics regarding NAS.

AN INTEGRATIVE REVIEW: BREASTFEEDING AND NAS

11

References
Isemann, B., Meinzen-Derr, J., & Akinbi, H. (2011). Maternal and neonatal factors impacting
response to methadone therapy in infants treated for neonatal abstinence syndrome.
Journal of Perinatology, 31, 25-29.
OConnor, A. B., Collett, A., Alto, W. A., & OBrien, L. M. (2013). Breastfeeding rates and the
relationship between breastfeeding and neonatal abstinence syndrome in women
maintained on buprenorphine during pregnancy. Journal of Midwifery & Womens
Health 58(4), 383-388. doi 10.1111/jmwh.12009
Pritham, U. A., Paul, J. A., & Hayes, M. J. (2012). Opioid dependency in pregnancy and length
of stay for neonatal abstinence syndrome. JOGNN, 41, 180-190.
doi 10.1111/j.1552-6909.2011.01330.x
Pritham, U. (2013). Breastfeeding promotion for management of neonatal abstinence syndrome.
JOGNN, 42(5), 517-526. doi 10.1111/1552-6909.12242
Welle-Strand, G. K., Skurtveit, S., Jansson, L. M., Bakstad, B., Bjarko, L., & Ravndall, E.
(2013). Breastfeeding reduces the need for withdrawal treatment in opioid-exposed
infants. Acta Paediatrica, 102, 1060-1066. doi 10.1111/apa.12378

AN INTEGRATIVE REVIEW: BREASTFEEDING AND NAS

Appendix
First Author
(Year)/Qualifications
Background/Problem
Statement

Isemann
2011/Department of Pharmacy, The
University Hospital, Cincinnati, OH
To identify maternal and neonatal
factors that impact response to
methadone therapy for NAS.
Opioid dependent women are often
transitioned to a maintenance therapy
with methadone or buprenorphine in an
attempt to mitigate drug seeking
behaviors and ameliorating the adverse
effects on the fetus.
The incidence of NAS ranges from 2194% among infants exposed to opiates
in utero.

Conceptual/theoretic
al Framework

None identified.

Design/
Method/Philosophical
Underpinnings

Quantitative
Retrospective chart review

Sample/
Setting/Ethical
Considerations

128 infants that received methadone

pharmacotherapy for opiate withdrawal
in the Neonatal Intensive Care Unit at
The University Hospital in Cincinnati,
Ohio between January 2002 and
December 2007
The study was approved by the
University of Cincinnati Institutional
Review Board
IV: Degree of fetal drug
exposure/neonatal treatment,
breastfeeding status, gestational age,
tobacco and/or illicit drug use during
pregnancy
DV: onset, duration and severity of NAS

Major Variables
Studied (and their
definition), if
appropriate

12

AN INTEGRATIVE REVIEW: BREASTFEEDING AND NAS

Measurement
Tool/Data Collection
Method

Data Analysis

Findings/Discussion

Data was collected through the

University of Cincinnati hospitals
pharmacy database which was crossreferenced to the electronic medication
administration record and nursing flow
sheets
Inclusion criteria: newborn infants
treated with at least one dose of
methadone according to the treatment
protocol for NAS
Exclusion criteria: Infants who were (1)
treated with other opiate agonists
before initiation of methadone protocol,
(2) transferred to another hospital, (3)
died before the methadone therapy
protocol was completed
Continuous data were reported as
means with standard deviations or
medians with ranges
T-tests or Wilcoxons sum rank test for
unadjusted differences for continuous
data between preterm and term infants
x2-analysis or Fishers exact test for
differences between categorical data
Spearmans correlation coefficients to
evaluate the relationship among factors
Multiple linear regression model to
determine the independent relationship
between the variables
SAS version 9.1 software
There were no significant differences in
the hospital length of stay between
neonates exposed to methadone in
utero compared to infants that were
additionally exposed to other classes of
drugs (benzodiazepines, barbiturates,
cocaine, SSRIs, marijuana, additional
opiates or tobacco).
Infants that required adjunctive therapy

13

AN INTEGRATIVE REVIEW: BREASTFEEDING AND NAS

Appraisal/Worth to
practice

First Author
(Year)/Qualifications
Background/Problem
Statement

with phenobarbital were born of

mothers on higher doses of methadone
and had a longer length of stay
compared to those on methadone
monotherapy.
Breastfeeding was associated with a
shorter median duration of methadone
therapy in both preterm and term
infants.
Compared with formula-fed infants,
ingestion of maternal breastmilk was
associated with shorter length of stay
(maternal breast milk to total intake was
determined to be independently
associated with length of stay).

This article additionally highlights a correlation

between breastfeeding and improved length of
stay and decreased duration of
pharmacological treatment for NAS.
OConnor
(2013)/DNP; Maine Dartmouth Family
Medicine Residency
To examine breastfeeding rates and the
relationship between breastfeeding and
neonatal abstinence syndrome (NAS) in
women maintained on Buprenorphine
during pregnancy and whether
breastfeeding is related to the duration,
severity and frequency of
pharmacologic treatment for NAS.
Methadone continues to be the
standard of care for opioid dependence
during pregnancy but there is growing
evidence that suggests buprenorphine
is a safe alternative and believe it
should be a first-line therapy.
Nearly one-third of those being treated
for opioid addiction are women of
childbearing age.
Adverse maternal-fetal effects of opioid

14

AN INTEGRATIVE REVIEW: BREASTFEEDING AND NAS

abuse and misuse during pregnancy
include intrauterine growth restriction,
placental insufficiency, preterm rupture
of membranes, premature birth,
postpartum hemorrhage, and perinatal
mortality
Conceptual/theoretic
al Framework

None identified

Design/
Method/Philosophical
Underpinnings

Quantitative
Retrospective chart review

Sample/
Setting/Ethical
Considerations

85 maternal-infant dyads were

identified; largely Caucasian women as
Maine is 95% white and almost all
(>95%) had Maines low income
insurance option called Mainecare
Treated in an integrated treatment plan
within a family medicine residency in
Maine between December 2007 to
August 2012
The integrated treatment plan provided
prenatal and obstetric care, medicationassisted treatment with buprenorphine,
substance abuse counseling facilitated
by a Psychologist trained in addictions
treatment, care for mother and child
during and after birth and social
services
IV: maternal and infant characteristics
(i.e. buprenorphine dose, tobacco
exposure in utero, antidepressant
exposure in utero, illicit substance use
during 3rd trimester, infant NAS scores)
DV: infants requiring NAS treatment
related to NAS score, infant hospital
length of stay, neonatal outcomes (i.e.
premature birth, infant birth weight), and
maternal outcomes (i.e. spontaneous

Major Variables
Studied (and their
definition), if
appropriate

15

AN INTEGRATIVE REVIEW: BREASTFEEDING AND NAS

Measurement
Tool/Data Collection
Method

Data Analysis

Findings/Discussion

vaginal births)
Retrospective chart review

Descriptive statistics including mean

and standard deviation to describe
maternal and infant populations
Fishers exact tests to determine
differences between categorical data
T tests when distributional assumptions
were met
Mann-Whitney U test when distribution
was not approximately normal
Statistical analyses performed with
Stata software version 11
65 women (76%) chose to breastfeed
during hospitalization and 66% were still
breastfeeding at the 6-to-8 week
postpartum visits and/or 2 month well
child visit.
Infants in the non-breastfeeding cohort
were significantly more likely to have
been exposed to illicit substances
during the third trimester (p=0.004) as
compared to those breastfeeding as
determined by urine toxicology reports.
Breastfeeding may attenuate NAS but
findings not statistically significant
(p<0.05)
NAS score of breastfed infants was
lower than nonbreastfed infants (8.83 vs
9.65)
Breastfed infants were less likely to
require pharmacologic treatment for
NAS as compared with nonbreastfed
group (23.1% vs 30%).
Breastfed infants were less likely than
nonbreastfed infants to score 8 or

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AN INTEGRATIVE REVIEW: BREASTFEEDING AND NAS

above on the modified Finnegan

Scoring System (65% vs 75%), which
measures the degree to which an infant
is withdrawing (hospital policy
warranted pharmacologic treatment
when 3 or more scores were greater
than or equal to 8, 2 or more scores
were greater than or equal to 12, or
when the average of 2 scores were
greater than or equal to 12)
Symptoms of NAS started to resolve
about 2 hours earlier in the breastfed
cohort (76.1 vs. 78.3 hours)
No conclusions were made regarding
the length of hospital stay and
breastfeeding because many of the
extended hospital stays were a result of
complications unrelated to NAS
Most studies reviewed showed lower
initiation and early cessation rates of
breastfeeding among opioid-dependent
women and so the higher rates of this
study could be attributed to:
o Less stringent eligibility criteria
than other institutions for
breastfeeding
o Access to support services such
as lactation consultants
knowledgeable staff
o All care was accessed in a
single-care setting (less barriers,
safety)
Larger sample size needed to
determine the statistical significance
between breastfed infants and NAS
severity and need for pharmacologic
treatment
The nonbreastfed group was smaller
than the breast feed group which
contributed to standard error and limited
statistical significance.

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AN INTEGRATIVE REVIEW: BREASTFEEDING AND NAS

Appraisal/Worth to
practice

First Author
(Year)/Qualifications
Background/Problem
Statement

Conceptual/theoretic
al Framework
Design/
Method/Philosophical
Underpinnings

This article brings attention to the benefits of

breastfeeding on NAS specifically those with
in-utero exposure to buprenorphine which is
still very pertinent to my PICO question.
Further research is necessary however to
determine the statistical significance of the
discussed findings.
Pritham
2012/PhD, School of Nursing, Georgia
Southern University
To examine opioid replacement therapy
in pregnancy and effect on neonatal
outcomes, including length of hospital
stay for NAS.
To lower health risks, pregnant women
who are opioid dependent have been
treated with methadone maintenance
therapy (MMT). Buprenorphine has
additionally been used as maintenance
therapy (BMT).
21-94% of neonates with in utero
exposure to opioids experience
withdrawal symptoms characterized by
central nervous system hyperirritability,
gastrointestinal dysfunction, respiratory
distress, and vague autonomic
symptoms such as yawning, sneezing,
mottled color and fever
Prolonged hospitalization of neonates
with NAS may affect infant attachment,
disrupt families, and increase health
care costs. Long term effects remain
unclear.
None identified

Quantitative
Retrospective chart review

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AN INTEGRATIVE REVIEW: BREASTFEEDING AND NAS

Sample/
Setting/Ethical
Considerations

Major Variables
Studied (and their
definition), if
appropriate

Measurement
Tool/Data Collection
Method

Data Analysis

152 opioid dependent women on

methadone maintenance therapy
(MMT) (n=136) or buprenorphine (BMT)
(n=16) during pregnancy and their
neonates born between January 1,
2015 and December 31, 2007 at the
Eastern Maine Medical Center (EMMC).
Institutional Review Board approval was
obtained from EMMC.
IV=maternal factors: age, gravidity,
parity, gestational age when prenatal
care was initiated, number of prenatal
visits, form of maintenance treatment
(MMT or BMT) and dose, tobacco
and/or alcohol/substance use during
pregnancy, breastfeeding status
DV=neonatal factors: gestational age at
time of birth, birth weight, head
circumference, size for gestational age,
length of stay, need for NAS
pharmacotherapy
The electronic medical record (EMR) at
EMMC was queried
Inclusion criteria:
o Women on prescribed MMT or
BMT when admitted for labor and
delivery
o Neonates diagnosed with NAS
Exclusions criteria:
o Neonates fewer than 28 weeks
gestation
Statistical Package for the Social
Sciences version 19
Descriptive statistics for demographic
factors
Multiple linear regression statistics to
determine relationship between
maternal lifestyle and infant feeding

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AN INTEGRATIVE REVIEW: BREASTFEEDING AND NAS

Findings/Discussion

Appraisal/Worth to
practice

First Author
(Year)/Qualifications
Background/Problem
Statement

method
The MMT group had significantly
smaller head circumference, smaller
gestational age (SGA) and BMT had
more neonates with large for gestational
age (LGA).
Maternal methadone dose and
concomitant use of benzodiazepines
increased length of stay.
Women on MMT who breastfed their
neonates, shortened their length of stay
as compared to those who formula fed.
Neonates exposed to buprenorphine
experienced less severe NAS and
shorter length of stay than those
exposed to methadone but the
buprenorphine group was small in
comparison to the methadone group.
This study highlights how breastfeeding can
shorten the length of hospital stay in
comparison to formula-fed neonates. It also
highlights some of the differences between
MMT and BMT which is additionally pertinent
to my topic.
Pritham
(2013)/PhD, WHNP-BC, FNP-BC; Georgia
South University School of Nursing
To examine the relationship between
breastfeeding and neonatal abstinence
syndrome (NAS) severity, need for
pharmacologic treatment for NAS, and
length of stay in neonates with
exposure to methadone and
buprenorphine opioid replacement
therapy
There has been an increase in maternal
opioid dependence and treatment with
synthetic opioids, such as methadone
or buprenorphine, which has tripled the
number of neonates with NAS between
2000-2009

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AN INTEGRATIVE REVIEW: BREASTFEEDING AND NAS

Conceptual/theoretic
al Framework

None identified

Design/
Method/Philosophical
Underpinnings

Quantitative
Literature review

Sample/
Setting/Ethical
Considerations

61 articles/sources were utilized for this

literature review
Ethical considerations not applicable

Major Variables
Studied (and their
definition), if
appropriate

Measurement
Tool/Data Collection
Method

Data Analysis

Findings/Discussion

IV: socioeconomic status, age,

educational level, marital status, social
influence, knowledge about
breastfeeding, current physical and
mental health
DV: NAS severity, need for NAS
pharmacologic treatment, length of
hospital stay, breastfeeding status
Articles were obtained from PubMed,
CINAHL and Medline between the years
January 1990 and April 2013
Search terms included opioid
dependency in pregnancy, neonatal
abstinence syndrome, methadone,
buprenorphine, neonatal length of stay,
breastfeeding, methadone in breast
milk, buprenorphine in breast milk,
swaddling and rooming-in
All articles were individually reviewed by
the author
Inclusion criteria included studies
written in English and relevance to topic
of breastfeeding for management of
NAS
The amount of methadone or
buprenorphine that is passed to the
neonate via breastmilk is considered to
be small, regardless of maternal dose,

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AN INTEGRATIVE REVIEW: BREASTFEEDING AND NAS

and safe.
Neonates who were breastfed were less
apt to require NAS treatment and
therefore experienced a significantly
shorter length of stay than those that
were formula fed.
Breastfeeding is associated with a
decreased rate for withdrawal treatment
from prenatal methadone or
buprenorphine exposure.
Breastfeeding is supported by the
American College of Obstetricians and
Gynecologists (ACOG) as long as the
women have a negative screening for
human immunodeficiency virus (HIV)
infection; are able to abstain from
alcohol, illicit drugs, and amphetamines;
and there are no other
contraindications.
Lower initiation rates and early
cessation of breastfeeding are common
among opioid-dependent women.
Breastfeeding has protective effects
against sudden infant death syndrome
(SIDS) especially if it is done
exclusively.
There is lack of information regarding
long term benefits of breastfeeding on
NAS outside the initial newborn period.
Most opioid dependent women are
socioeconomically disadvantaged and
tend to formula feed their infants.
Reasons they do not breastfeed include
embarrassment to feed in public, dislike
the act of breastfeeding and fear
associated nipple pain.
Other deterrents to breastfeeding
include lack of public knowledge on its
benefits, societal norms, inadequate
support systems, maternal employment,
child care issues, and insufficient

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AN INTEGRATIVE REVIEW: BREASTFEEDING AND NAS

Appraisal/Worth to
practice

First Author
(Year)/Qualifications
Background/Problem
Statement

Conceptual/theoretic
al Framework

prenatal education.
Breastfeeding has the potential to lower
the risk of postpartum depression
Rooming-in, skin-to-skin contact, and
swaddling have additionally been found
to be an effective strategy in the care of
neonates with NAS

The information in this article is supportive of

my PICO question in showing how
breastfeeding can benefit NAS and also
suggests other beneficial modalities.
Welle-Strand
(2013)/Norwegian Centre for Addiction
Research; Norwegian Directorate of Health
To examine the rate and duration of
breastfeeding in a cohort of women in
an opioid maintenance treatment (OMT)
in Norway, as well as the effect of
breastfeeding on the incidence and
duration of neonatal abstinence
syndrome (NAS)
OMT with methadone or buprenorphine
is the treatment of choice for opioiddependent patients in general and for
those who are pregnant.
In-utero exposure to methadone or
buprenorphine is associated with NAS
in 40-90% of the neonates.
None identified.

Design/
Method/Philosophical
Underpinnings

Quantitative
Retrospective and prospective cohort
study

Sample/
Setting/Ethical
Considerations

124 treated with either methadone or

buprenorphine during pregnancy and
their neonates born between 1999 and
2009

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AN INTEGRATIVE REVIEW: BREASTFEEDING AND NAS

Major Variables
Studied (and their
definition), if
appropriate

Measurement
Tool/Data Collection
Method

Data Analysis

Findings/Discussion

Approval obtained from the National

Committee for Research Ethics and
Data Inspectorate in Norway
Questionnaires were anonymous
Written consent obtained from the
sample subjects
IV: Demographics (age, educational
level, opioid dependency prior to OMT,
parity, current pregnancy), use of
cigarettes and/or drugs, OMT treatment
(medication, dose), breastfeeding status
DV: birth outcomes (cesarean section,
gestational age at delivery, preterm
births), neonatal outcomes (birth weight,
length, head circumference), NAS
treatment, NAS duration, length of
hospital stay related to NAS
Three part data collection:
o Standardized questionnaire
o Personal and telephone
interviews during 3rd trimester
o Telephone interviews in 332 days
(mean) after child was born
T-tests, Mann-Whitney U-test
IBM SPSS Statistics 19
Multivariate linear regression
Most women in both methadone
maintenance treatment (MMT) (74%)
and buprenorphine maintenance
treatment (BMT) (78%) initiated
breastfeeding of their infants after
delivery.
The median length of breastfeeding was
12 weeks for women in MMT and 7
weeks for women in BMT.
More than 85% of the women smoked
cigarettes the last last month before
delivery and 12% of women
breastfeeding and 21% of women not
breastfeeding had used-opiates,

24

AN INTEGRATIVE REVIEW: BREASTFEEDING AND NAS

Appraisal/Worth to
practice

benzodiazepines, amphetamine, and/or

cannabis-during the same month.
The methadone-exposed newborns
being breastfed had a significantly lower
incidence of NAS needing
pharmacological treatment (53%) than
those who were not breastfed (80%).
There was a shorter duration of
pharmacological NAS treatment for the
neonates of women in OMT who were
breastfeeding compared to those who
were not (28.6 vs 46.7 days)
There was a shorter duration of NAS
treatment for methadone-exposed
neonates linked to lactation status (31
vs 48.9 days)
There was no decrease in incidence or
shorter duration of pharmacological
NAS treatment among the
buprenorphine-exposed neonates which
may be related to the small sample
group.
Women in the study who did not
breastfeed had significantly more
preterm babies (30) and a tendency
towards more cesarean deliveries (24).
This study supports my PICO in the benefits of
breastfeeding vs no breastfeeding in relation to
NAS.

25