Breastfeeding Promotion for Management of Neonatal Abstinence Syndrome



      To review the literature about the association between breastfeeding and neonatal abstinence syndrome (NAS) severity, need for pharmacologic treatment for NAS, and length of hospital stays in neonates with in‐utero exposure to methadone or buprenorphine opioid replacement therapy.

      Data Sources

      PubMed, CINAHL, and Medline were searched for articles published between January 1990 and April 2013 using the terms 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.

      Study Selection

      Inclusion criteria included studies written in English on the topic of breastfeeding for management of NAS.

      Data Extraction

      The author independently reviewed each article.

      Data Synthesis

      Breastfeeding can effectively decrease NAS symptoms because methadone and buprenorphine are transferred to the breast milk. Maternal contact while breastfeeding also plays a role in ameliorating the NAS symptoms. Interventions that also support breastfeeding in the treatment of NAS include skin‐to‐skin contact, swaddling, and rooming‐in.


      Understanding the benefits of breastfeeding for opioid‐dependent pregnant women and their neonates will enable clinicians to safely recommend breastfeeding for long‐term health of these high‐risk women and their infants. This review of the effects of in‐utero exposure to opioids on infant development can assist clinicians to more effectively support opioid‐dependent women to breastfeed their infants.
      To read this article in full you will need to make a payment
      AWHONN Member Login
      AWHONN Members, full access to the journal is a member benefit. Use your society credentials to access all journal content and features
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Abrahams R.R.
        • Kelly S.A.
        • Payne S.
        • Thiessen P.N.
        • Mackintosh J.
        • Janssen P.A.
        Rooming‐in compared with standard care for newborns of mothers using methadone or heroin.
        Canadian Family Physician. 2007; 53: 1722-1730
        • Academy of Breastfeeding Medicine
        ABM clinical protocol #21: Guidelines for breastfeeding and the drug dependent woman.
        Breastfeeding Medicine. 2009; 4: 225-228
        • Almario C.V.
        • Seligman N.S.
        • Dysart K.C.
        • Berghella V.
        • Baxter J.K.
        Risk factors for preterm birth among opiate‐addicted gravid women in a methadone treatment program.
        American Journal of Obstetrics & Gynecology. 2009; 201: 326.e1-326.e6
        • American Academy of Pediatrics
        Policy statement. Breastfeeding and the use of human milk.
        Pediatrics. 2012; 129: e827-e841
        • American College of Obstetricians and Gynecologists
        Opioid abuse, dependence, and addiction in pregnancy. Committee opinion No. 524.
        Obstetrics & Gynecology. 2012; 119: 1070-1076
        • Atchan M.
        • Foureur M.
        • Davis D.
        The decision not to initiate breastfeeding: Women's reasons, attitudes and influencing factors.
        Breastfeeding Review. 2011; 19: 9-17
        • Baby Friendly USA
        Guidelines and evaluation criteria for facilities seeking baby friendly designation.
        Author, Sandwich, MA2010
        • Ballard J.
        Treatment of neonatal abstinence syndrome with breast milk containing methadone.
        Journal of Perinatal Neonatal Nursing. 2000; 15: 76-85
        • Beake S.
        • Pellowe C.
        • Dykes F.
        • Schmied V.
        • Bick D.
        A systematic review of structured compared with non‐structured breastfeeding programmes to support the initiation and duration of exclusive and any breastfeeding in acute and primary health care settings.
        Maternal and Child Nutrition. 2012; 8: 141-161
        • Begg E.J.
        • Malpas T.J.
        • Hackett L.P.
        • Ilett K.F.
        Distribution of R‐and S‐ methadone into human milk during multiple, medium to high oral dosing.
        Journal of Clinical Pharmacology. 2001; 52: 681-685
        • Benningfield M.
        • Arria A.
        • Kaltenbach K.
        • Heil S.
        • Stine S.
        • Coyle M.
        • Martin P.
        Co‐occurring psychiatric symptoms are associated with increased psychological, social, and medical impairment in opioid dependent pregnant women.
        American Journal on Addictions. 2010; 19: 416-421
        • Bigelow A.E.
        • Power M.
        The effect of mother–infant skin‐to‐skin contact on infants’ response to the Still Face Task from newborn to three months of age.
        Infant Behavior and Development. 2011; 35: 240-251
        • Binder T.
        • Vavrinkova B.
        Prospective randomized comparative study of the effect of buprenorphine, methadone and heroin on the course of pregnancy, birth weight of newborns, early postpartum adaptation and course of neonatal abstinence syndrome (NAS) in women followed up in the outpatient department.
        Neuroendocrinology Letters. 2008; 29: 80-86
        • Bogen D.L.
        • Perel J.M.
        • Helsel J.C.
        • Hanusa B.H.
        • Thompson M.
        • Wisner K.L.
        Estimated infant exposure to enantiomer‐specific methadone levels in breast milk.
        Breastfeeding Medicine. 2011; 6: 377-384
        • Brown M.
        • Hayes M.
        • LaBrie S.
        Breast feeding is associated with decreased risk and length of treatment for neonatal abstinence syndrome (NAS) in methadone and buprenorphine exposed infants.
        2011 (Boston, MA)
        • Burns L.
        • Conroy E.
        • Mattick R.
        Infant mortality among women on a methadone program during pregnancy.
        Drug & Alcohol Review. 2010; 29: 551-556
        • Dinges D.
        • Davis M.
        • Glass P.
        Fetal exposure to narcotics: Neonatal sleep as a measure of nervous system disturbance.
        Science. 1980; 209: 619-621
        • Dryden C.
        • Young D.
        • Hepburn M.
        • Mactier H.
        Maternal methadone use in pregnancy: Factors associated with the development of neonatal abstinence syndrome and implications for healthcare resources.
        British Journal of Obstetrics and Gynecology. 2009; 116: 665-671
        • Ebner N.
        • Rohmeister K.
        • Winklbaur B.
        • Baewert A.
        • Jagsch R.
        • Peternell A.
        • Fischer G.
        Management of neonatal abstinence syndrome in neonates born to opioid maintained women.
        Drug Alcohol Dependence. 2007; 87: 131-138
        • Farid W.O.
        • Dunlop S.A.
        • Tait R.J.
        • Hulse G.K.
        The effects of maternally administered methadone, buprenorphine and naltrexone on offspring: Review of human and animal data.
        Current Neuropharmacology. 2008; 6: 125-150
        • Hans S.L.
        • Jeremy R.J.
        Postneonatal mental and motor development of infants exposed in utero to opioid drugs.
        Infant Mental Health Journal. 2001; 22: 300-315
        • Hauck F.R.
        • Thompson J.
        • Tanabe K.O.
        • Moon R.Y.
        • Vennemann M.M.
        Breastfeeding and reduced risk of sudden infant death syndrome: A meta‐analysis.
        Pediatrics. 2011; 128: 103-110
        • Isemann B.
        • Meinzen‐Deer J.
        • Akinbi H.
        Maternal and neonatal factors impacting response to methadone therapy in infants treated for neonatal abstinence syndrome.
        Journal of Perinatology. 2011; 31: 25-29
        • Jansson L.M.
        ABM clinical protocol #21: Guidelines for breastfeeding and the drug‐dependent woman. The Academy of Breastfeeding Medicine Protocol Committee.
        Breastfeeding Medicine. 2009; 4: 225-228
        • Jansson L.M.
        • Choo R.E.
        • Harrow C.
        • Velez M.
        • Schroeder J.R.
        • Lowe R.
        • Huestis M.A.
        Concentrations of methadone in breast milk and plasmas in the immediate perinatal period.
        Journal of Human Lactation. 2007; 23: 184-190
        • Jansson L.M.
        • Choo R.
        • Velez M.L.
        • Harrow C.
        • Schroeder J.R.
        • Shakleya D.M.
        • Huestis M.A.
        Methadone maintenance and breastfeeding in the neonatal period.
        Pediatrics. 2008; 121: 1056-1114
        • Jansson L.M.
        • Choo R.
        • Velez M.L.
        • Lowe R.
        • Huestis M.A.
        Methadone maintenance and long‐term lactation.
        Breastfeeding Medicine. 2008; 3: 34-37
        • Jansson L.M.
        • Dipietro J.A.
        • Velez M.
        • Elko A.
        • Williams E.
        • Milio L.
        • Jones H.E.
        Fetal neurobehavioral effects of exposure to methadone or buprenorphine.
        Neurotoxicology and Teratology. 2011; 33: 240-243
        • Jansson L.M.
        • Velez M.
        • Harrow C.
        Methadone maintenance and lactation: A review of the literature and current management guidelines.
        Journal of Human Lactation. 2004; 20: 62-71
        • Joanna Briggs Institute
        Clinical update: The management of nipple pain and/or trauma associated with breastfeeding.
        Australian Nursing Journal. 2009; 17: 32-35
        • Jones H.E.
        • Kaltenbach K.
        • Heil S.H.
        • Stine S.
        • Coyle M.
        • Arria A.M.
        • Fischer G.
        Neonatal abstinence syndrome after methadone or buprenorphine exposure.
        New England Journal of Medicine. 2010; 363: 2320-2331
        • Kahila H.
        • Saisto T.
        • Kivitie‐Kallio S.
        • Haukkamaa M.
        • Halmesmaki E.
        A prospective study on buprenorphine use during pregnancy: Effects on maternal and neonatal outcome.
        Acta Obstetriciaet Gynecologica Scandinavica. 2007; 84: 145-150
        • Lindemalm S.
        • Nydert P.
        • Svensson J.
        • Stahle L.
        • Sarman I.
        Transfer of buprenorphine into breast milk and calculation of infant drug dose.
        Journal of Human Lactation. 2009; 25: 199-205
        • Liu A.J.
        • Nanan R.
        Methadone maintenance and breastfeeding in the neonatal period.
        Pediatrics. 2008; 121: 869-870
        • McCarthy J.J.
        • Posey B.L.
        Methadone levels in human milk.
        Journal of Human Lactation. 2000; 16: 115-120
        • McQueen K.A.
        • Murphy‐Oikonen J.
        • Gerbach K.
        • Montelpare W.
        The impact of infant feeding method on neonatal abstinence scores of methadone‐exposed infants.
        Advanced Neonatal Care. 2011; 11: 282-290
        • Malpas T.J.
        • Horwood J.
        • Darlow B.A.
        Breastfeeding reduces the severity of neonatal abstinence syndrome.
        Journal of Paediatric Child Health. 1997; 33: A38, 16
        • Messinger D.
        • Bauer C.
        • Das A.
        • Seifer R.
        • Lester B.
        • LaGasse L.
        • Poole W.
        The maternal lifestyle study: Cognitive, motor, and behavioral outcomes of cocaine‐exposed and opiate‐exposed infants through three years of age.
        Pediatrics. 2004; 113: 1677-1685
        • Moore E.
        • Anderson G.
        • Bergman N.
        Early skin‐to‐skin contact for mothers and their healthy newborn infants.
        Cochrane Database of Systematic Reviews. 2007; 3: 1-63
        • Nagasawa M.
        • Okabe S.
        • Mogi K.
        • Kikusui T.
        Oxytocin and mutual communication in mother‐infant bonding.
        Frontier Human Neuroscience. 2012; 6: 31
        • National Institute on Drug Abuse
        Maternal opiate use and newborns suffering from opiate withdrawal are on the rise in the U.S.
        • Nettleton R.T.
        • Wallisch M.
        • Olsen G.D.
        Respiratory effects of chronic in utero methadone or morphine exposure in the neonatal guinea pig.
        Neurotoxicology and Teratology. 2008; 30: 448-454
        • Patrick S.
        • Schumacher R.
        • Benneyworth B.
        • Krans E.
        • McAllister J.
        • Davis M.
        Neonatal abstinence syndrome and associated health care expenditures.
        Journal of the American Medical Association. 2012; 307: 1934-1940
        • Pritham U.
        Effects of breast and formula feedings on neonatal abstinence syndrome.
        Poster] presented at Association of Women's Health, Obstetric and Neonatal Nurses 2012 Convention. 2012 (National Harbor, MD)
        • Pritham U.
        • Paul J.
        • Hayes M.
        Opioid dependency in pregnancy and length of stay for neonatal abstinence syndrome.
        Journal of Obstetric, Gynecologic & Neonatal Nursing. 2012; 41: 180-190
        • Ramussen K.
        • Geraghty S.
        The quiet revolution: Breastfeeding transformed with the use of breast pumps.
        American Journal of Public Health. 2011; 101: 1356-1359
        • Riordan J.
        • Wambach K.
        Breastfeeding and human lactation.
        4th ed. Jones and Bartlett, Boston, MA2010
        • Rivera A.
        • Torres D.
        • Dávila R.
        • Parrilla Rodríguez A.
        • de Longo I.
        • Gorrín Peralta J.
        Exploratory study: Knowledge about the benefits of breastfeeding and barriers for initiation in mothers of children with spina bifida.
        Maternal & Child Health Journal. 2008; 12: 734-738
        • Sanchez E.S.
        • Bigbee J.W.
        • Fobbs W.
        • Robinson S.E.
        • Sato‐Bigbee C.
        Opioid addition and pregnancy: Perinatal exposure to buprenorphine affects myelination in the developing brain.
        Glia. 2008; 56: 1017-1027
        • Saylor C.
        • Lippa B.
        • Lee G.
        Drug exposed infants at home: Strategies and support.
        Public Health Nursing. 1991; 8: 33-38
        • Seligman N.S.
        • Salva N.
        • Hayes E.J.
        • Dysart K.C.
        • Pequignot E.C.
        • Baxter J.K.
        Predicting length of treatment for neonatal abstinence syndrome in methadone‐exposed neonates.
        American Journal of Obstetrics & Gynecology. 2008; 199: e1-396.e7
        • Smith L.
        Why Johnny can't suck: Impact of birth practices on infant suck.
        in: Genna C.W. Supporting sucking skills in breastfeeding infants. 2nded. Jones & Bartlett, Woodhaven, NY2013: 66-68)
        • Tenfelde S.
        • Finnegan L.
        • Hill P.
        Predictors of breastfeeding exclusivity in a WIC sample.
        Journal of Obstetric, Gynecologic & Neonatal Nursing. 2011; 40: 179-189
        • Tilton T.C.
        Breastfeeding considerations of opioid dependent mothers and infants.
        American Journal of Maternal‐Child Nursing. 2012; 37: 236-240
        • Tronick E.Z.
        • Messinger D.S.
        • Weinberg M.K.
        • Lester B.
        • LaGasse L.
        • Seifer R.
        • Liu J.
        Cocaine exposure is associated with subtle compromises of infants’ and mothers’ social‐emotional behavior and dyadic features of their interaction in the face‐to‐face still face paradigm.
        Developmental Psychology. 2005; 41: 711-722
        • U.S. Department of Health and Human Services
        The surgeon general's call to action to support breastfeeding.
        Author, Washington, DC2011
        • van Sleuwen B.E.
        • Engelberts A.C.
        • Boere‐Boonekamp M.M.
        • Kuis W.
        • Schulpen T.
        • L'Hoir M.P.
        Swaddling: A systematic review.
        Pediatrics. 2007; 120: e1097-1106
        • van Sleuwen B.E.
        • L'hoir M.P.
        • Engelberts A.C.
        • Busschers W.B.
        • Westers P.
        • Kuis W.
        Comparison of behavior modification with and without swaddling as interventions for excessive crying.
        Journal of Pediatrics. 2006; 149: 512-517
        • Wachman E.M.
        • Byun J.
        • Philipp B.L.
        Breastfeeding rates among mothers of infants with neonatal abstinence syndrome.
        Breastfeeding Medicine. 2010; 5: 159-164
        • Wachman E.M.
        • Hayes M.J.
        • Brown M.S.
        • Paul J.
        • Harvey‐Wilkes K.
        • Terrin N.
        • Davis J.M.
        Association of OPRM1 and COMT single‐nucleotide polymorphisms with hospital length of stay and treatment of neonatal abstinence syndrome.
        Journal of the American Medical Association. 2013; 309: 1821-1827
        • Weddig J.
        • Baker S.
        • Auld G.
        Perspectives of hospital‐based nurses on breastfeeding initiation best practices.
        Journal of Obstetric, Gynecologic and Neonatal Nursing. 2011; 40: 166-178


      Ursula A. Pritham, PhD, WHNP‐BC, FNP‐BC, is an assistant professor in the School of Nursing, Georgia Southern University, Statesboro, GA.