A Gentler Way to Care for Newborns Going Through Opioid Withdrawal

What a large national study called Eat, Sleep, Console found for babies exposed to opioids before birth

A large U.S. study found that a calm, family-centered way of caring for newborns going through opioid withdrawal—called Eat, Sleep, Console—let babies leave the hospital ready for discharge about a week sooner than the older method, and cut the number of babies who needed medication by more than half. Just as importantly, the gentler approach appeared just as safe in the months after the babies went home. The findings suggest that keeping families close, dimming the lights, and focusing on whether a baby can feed, rest, and be comforted can do much of the work that medicine used to do.

Why This Research Matters

When a baby is exposed to opioids during pregnancy—often because the mother is taking prescribed medication to treat opioid use disorder, which is the recommended and responsible thing to do—the newborn can go through withdrawal after birth. Doctors call this neonatal opioid withdrawal syndrome. The baby may be irritable, have trouble feeding and sleeping, tremble, or have loose stools, and needs careful watching and comforting. During the height of the opioid epidemic, the number of affected newborns rose sharply across the country, and caring for them became one of the most common reasons for long newborn hospital stays [1]. These long stays are hard on babies, exhausting for families, and costly for the health system [2].

The central question parents and clinicians face is simple but consequential: does this baby need medicine to get through withdrawal safely, or can comfort and care be enough? For decades, the answer leaned heavily toward medicine. This study asked whether a different, gentler starting point could safely help more babies recover without it.

How Babies Used to Be Cared For

For almost fifty years, hospitals judged how severe a baby's withdrawal was using a checklist called the Finnegan score, first created in 1975 [3]. A nurse would observe the baby every few hours and add up points for signs like trembling, crying, and poor feeding. If the score crossed a certain line, the baby was started on an opioid medicine, usually morphine or methadone, and the dose was raised or lowered based on later scores. For many years this was the standard, and a major pediatric guideline built around it in 2012 [4].

Over time, doctors grew uneasy with this method. The checklist was long, demanding, and based on a nurse's judgment of each sign, and research suggested it often pushed babies toward medication they might not truly need—so much so that a much shorter version of the checklist worked about as well [5]. There was another problem: care looked completely different from one hospital to the next. A baby with the same exposure might be medicated and stay for weeks at one hospital, or be comforted and go home in days at another, with no clear reason for the difference [6]. Families had no way of knowing which approach their baby would receive.

In 2017, a team led by Dr. Matthew Grossman proposed a different idea: instead of scoring symptoms, ask three practical questions—can the baby eat, can the baby sleep, and can the baby be consoled (comforted)? [7], [8]. If the answer is yes, the baby is doing well, even if they have some withdrawal signs. This "Eat, Sleep, Console" approach puts gentle, non-medicine care first: a quiet, dimly lit room, skin-to-skin holding, feeding on demand, keeping the baby with the parents, and—above all—bringing families in as the main source of comfort. Early reports from individual hospitals and statewide programs were striking, with fewer babies needing medicine and going home sooner [9]. But these early reports were not strict experiments, and some experts worried that the new approach might send babies home too soon or miss a baby who really needed treatment [10]. A careful national trial was needed to know for sure.

What the Researchers Did

The study, called ESC-NOW, was run by a national research network and was carefully designed to give a trustworthy answer [11]. It took place at 26 hospitals across the United States—big university hospitals and smaller community hospitals alike—so the results would apply to many kinds of places. Every hospital started by using the old Finnegan method. Then, at a randomly chosen time, each hospital switched over to Eat, Sleep, Console after a few months of staff training. Because the timing of each hospital's switch was decided by chance, the researchers could fairly compare the babies cared for each way. In total, 1,305 babies took part, all born at 36 weeks of pregnancy or later.

The researchers' main measure was how long it took until each baby was medically ready to go home, using a careful definition that required the baby to be feeding well, off any breathing support, and past a safe waiting period after any medicine. They chose this "ready for discharge" measure on purpose, so the comparison would reflect how the babies were truly doing rather than how quickly a particular hospital happened to send babies home. They also tracked how many babies needed opioid medicine and, importantly, watched the babies' safety for three months after they left.

What They Found

The gentler approach made a large difference. Babies cared for with Eat, Sleep, Console were ready for discharge in about 8.2 days, compared with 14.9 days under the old method—roughly a week sooner [11]. The number of babies who needed opioid medicine dropped from about 52 out of 100 to about 20 out of 100. In plain terms, with the gentler approach, most opioid-exposed babies got better with comfort and family care alone, and only about one in five needed medicine.

There were other encouraging signs. Babies in the Eat, Sleep, Console group were more likely to be breast-feeding directly when they went home, which fits with an approach that keeps mothers and babies together. And the safety results were reassuring: in the three months after discharge, the two groups had nearly identical rates of emergency visits and hospital readmissions, and serious events were rare in both. The worry that babies might be sent home too soon and get into trouble did not come true over the period studied.

It helps to picture why the gentler approach works. A baby withdrawing from opioids is, in a sense, overwhelmed—bright lights, noise, handling, and hunger all make the symptoms worse. The old method, with its frequent scoring and quick move to medicine, sometimes added to that stimulation. The Eat, Sleep, Console approach turns the room into a calmer place and treats a parent's steady presence as the first and best remedy. When a baby is held, fed when hungry, and allowed to rest undisturbed, many simply settle, and the few who cannot are the ones who truly need medicine. That is why the study could safely give far fewer babies opioids without babies doing worse: the care was not being withheld, it was being delivered in a different and, for most babies, more natural form.

What This Means for Families

If your baby was exposed to opioids before birth, this research carries a hopeful and practical message. The most powerful medicine is often you. Holding your baby skin-to-skin, feeding them, keeping the room quiet and dark, and simply being present are not a way of delaying treatment—in this care model, they are the treatment, and the study shows they work for most babies. Mothers taking prescribed medication for opioid use disorder can usually breast-feed, and doing so is part of the approach. It also helps to know that needing some medicine is not a failure; about one in five babies still does, and the team caring for your baby will watch closely and treat when it is truly needed [12].

It is worth being honest about what the study could not yet answer. It followed the babies for three months, which is reassuring for the short term, but the researchers are still studying how these children do at two years of age. So while the early news is very good, the longer story is still being written.

What Researchers Are Working On Next

The team behind ESC-NOW is now following the children to see how they grow, learn, and thrive over the next couple of years, and to confirm that the gentler approach stays safe over the longer term. Researchers are also studying why the approach helped more at some hospitals than others—differences likely tied to how many nurses are available, whether parents can stay overnight, and the kind of rooms babies are cared for in. Because the comfort an Eat, Sleep, Console approach depends on requires someone at the bedside, some hospitals are building volunteer "cuddler" programs and changing their spaces so families can remain close. The broad direction is clear: caring for these newborns is shifting away from checklists and medication and toward calm rooms, supported families, and babies who are simply allowed to eat, sleep, and be consoled.

References

  1. Hirai AH, Ko JY, Owens PL, Stocks C, Patrick SW. Neonatal abstinence syndrome and maternal opioid-related diagnoses in the US, 2010-2017. JAMA. 2021;325(2):146-155. doi:10.1001/jama.2020.24991 ↩
  2. Strahan AE, Guy GP Jr, Bohm M, Frey M, Ko JY. Neonatal abstinence syndrome incidence and health care costs in the United States, 2016. JAMA Pediatr. 2020;174(2):200-202. doi:10.1001/jamapediatrics.2019.4791 ↩
  3. Finnegan LP, Connaughton JF Jr, Kron RE, Emich JP. Neonatal abstinence syndrome: assessment and management. Addict Dis. 1975;2(1-2):141-158. PMID:1163358 ↩
  4. Hudak ML, Tan RC; Committee on Drugs and Committee on Fetus and Newborn. Neonatal drug withdrawal. Pediatrics. 2012;129(2):e540-e560. doi:10.1542/peds.2011-3212 ↩
  5. Gomez Pomar E, Finnegan LP, Devlin L, et al. Simplification of the Finnegan neonatal abstinence scoring system: retrospective study of two institutions in the USA. BMJ Open. 2017;7(9):e016176. doi:10.1136/bmjopen-2017-016176 ↩
  6. Young LW, Hu Z, Annett RD, et al. Site-level variation in the characteristics and care of infants with neonatal opioid withdrawal. Pediatrics. 2021;147(1):e2020008839. doi:10.1542/peds.2020-008839 ↩
  7. Grossman MR, Berkwitt AK, Osborn RR, et al. An initiative to improve the quality of care of infants with neonatal abstinence syndrome. Pediatrics. 2017;139(6):e20163360. doi:10.1542/peds.2016-3360 ↩
  8. Grossman MR, Lipshaw MJ, Osborn RR, Berkwitt AK. A novel approach to assessing infants with neonatal abstinence syndrome. Hosp Pediatr. 2018;8(1):1-6. doi:10.1542/hpeds.2017-0128 ↩
  9. Blount T, Painter A, Freeman E, Grossman M, Sutton AG. Reduction in length of stay and morphine use for NAS with the "eat, sleep, console" method. Hosp Pediatr. 2019;9(8):615-623. doi:10.1542/hpeds.2018-0238 ↩
  10. Patrick SW, Barfield WD, Poindexter BB; Committee on Fetus and Newborn, Committee on Substance Use and Prevention. Neonatal opioid withdrawal syndrome. Pediatrics. 2020;146(5):e2020029074. doi:10.1542/peds.2020-029074 ↩
  11. Young LW, Ounpraseuth ST, Merhar SL, et al; ACT NOW Collaborative. Eat, Sleep, Console approach or usual care for neonatal opioid withdrawal. N Engl J Med. 2023;388(25):2326-2337. doi:10.1056/NEJMoa2214470 ↩
  12. Kraft WK, Adeniyi-Jones SC, Chervoneva I, et al. Buprenorphine for the treatment of the neonatal abstinence syndrome. N Engl J Med. 2017;376(24):2341-2348. doi:10.1056/NEJMoa1614835 ↩