Key messages
• Due to a lack of evidence, we are unable to draw any conclusions about the benefits and risks of acupuncture for babies with neonatal abstinence syndrome caused by being exposed to drugs while in the womb.
• Large studies that are well-designed and reported are needed to find out more about the benefits and risks of acupuncture, including studies that make comparisons of acupuncture techniques, sites, timing and application.
What is neonatal abstinence syndrome?
Neonatal abstinence syndrome is a drug-withdrawal syndrome, mostly occurring after being exposed to opoid drugs (such as heroin and methadone) while still in the womb. A neonate may be born physically dependent on a drug, which causes withdrawal symptoms after birth, for example, high-pitched crying, a disrupted sleep-wake cycle and tremors. Neonatal abstinence syndrome is diagnosed with a standardised withdrawal assessment, such as the Finnegan score.
How is neonatal abstinence syndrome treated?
Newborns developing neonatal abstinence syndrome require medical treatment and longer hospital stays after birth than neonates without this condition. Treatments for neonatal abstinence syndrome include multiple multimodal treatments to ease symptoms of withdrawal, such as swaddling, 'rooming in' and breastfeeding. If the standardised assessment exceeds a certain threshold, newborns are treated pharmacologically with an orally administered opioid. However, optimal neonatal abstinence syndrome management continues to be debated. Acupuncture has been proposed as a potential intervention. Acupuncture involves stimulation of specific points on the body, either through the insertion of thin metal needles ('invasive') or using techniques that do not penetrate the skin ('non-invasive'), such as acupressure and laser.
What did we want to find out?
Our goal was to determine the benefits and risks of acupuncture in babies with neonatal abstinence syndrome (NAS). The primary outcomes were the duration of pharmacological treatment (medication), adverse events (harm) and length of hospital stay.
What did we do?
We searched for studies comparing acupuncture to no treatment, medications or other types of acupuncture (e.g. needle acupuncture versus laser acupuncture). Acupuncture could be given alone or in combination with conventional medical treatment for NAS ('standard care'), as long as the latter was administered to all participants in the study.
What did we find?
We found two studies including 104 infants in total. Both studies compared acupuncture (with techniques that do not penetrate the skin) added to standard care versus standard care.
The two studies used different acupuncture techniques. One study of 28 infants, which was conducted in Austria between 2009 and 2014, used daily laser acupuncture on ear and body acupuncture points until the morphine used to treat the NAS symptoms in both groups was stopped. The other study, conducted in the USA between 1992 and 1996, included 76 babies and used acupressure with herbal seeds taped to ear acupoints that were massaged for 30 to 60 seconds, along with standard NAS care.
Main results
The evidence is very uncertain about the effects of adding acupuncture to standard care on how long infants need to take medication or stay in hospital. The evidence is also very uncertain about whether acupuncture can reduce the highest score an infant is given when a doctor assesses their neonatal abstinence syndrome.
No adverse events were reported for any of the infants in either study, but as there were only 104 babies, it is not possible for us to draw any conclusions about the safety of acupuncture from these results.
No studies provided information about pain or infant death. Nor did they follow up on the infants' progress in the longer term.
What are the limitations of the evidence?
The main limitation is that only two small studies were analysed. Some of the outcomes were not reported at all. Moreover, the studies could have been better designed. It is unclear whether there are studies on this topic that have been conducted but have not been published. As far as we are aware, there are no studies currently taking place.
How up to date is this evidence?
The evidence is up-to-date as of August 2023.
The limited available evidence is insufficient to establish the benefits and harms of acupuncture for the management of NAS in newborn infants. Both studies we included in this review assessed non-invasive acupuncture and reported no adverse effects; however, data are drawn from a very small sample. In light of current limitations, clinicians are urged to approach the use of acupuncture in newborn infants with NAS cautiously, as there is currently no evidence to support its routine application.
This systematic review highlights the need for well-conducted, large randomised controlled trials to achieve an optimal information size to assess both the benefits and harms of acupuncture for NAS. In addition, comparisons of acupuncture techniques and sites should be made to assess effectiveness and feasibility.
Neonatal abstinence syndrome (NAS) is a drug-withdrawal syndrome, mostly occurring after antenatal exposure to opioids. A neonate may be born physically dependent on opioid medications, which causes withdrawal symptoms (such as high-pitched crying, disruptions in the sleep-wake cycle and tremors) after birth. This is diagnosed with a standardised withdrawal assessment, such as the Finnegan score. Newborns developing NAS require medical treatment and longer hospital stays after birth than neonates without this condition. Treatments for NAS include multiple multimodal treatments to ease symptoms of withdrawal, such as swaddling, 'rooming in' and breastfeeding. If the standardised assessment exceeds a certain threshold, newborns are treated pharmacologically with an orally administered opioid. However, optimal NAS management continues to be debated. Acupuncture has been proposed as a potential intervention. Acupuncture involves stimulation of specific points on the body, either through the insertion of thin metal needles or with techniques that do not penetrate the skin, such as acupressure and laser.
To assess if acupuncture (acupressure, needle, laser) reduces the treatment duration of neonatal abstinence syndrome (NAS) in newborn infants, reduces adverse events and reduces length of hospital stay.
We used bibliographic databases (CENTRAL, PubMed, Embase) and trial registries, together with reference checking, citation searching and contact with study authors, to identify the studies that are included in the review. The latest search date was 25 August 2023.
We included randomised controlled trials (RCTs) or quasi-RCTs, and cluster-randomised trials. We included infants born at full term and late preterm who were diagnosed with NAS within the first 72 hours after birth (i.e. showing significant signs as assessed using a standardised NAS assessment tool, e.g. presenting with withdrawal syndrome and Finnegan score > 8). We included studies where acupuncture (using invasive or non-invasive techniques) was compared with: 1) no intervention; 2) placebo or sham treatment; 3) any pharmacological treatment; or 4) another type of acupuncture (e.g. penetration of the skin with a needle versus acupressure). Acupuncture could be given alone or in combination with conventional medical treatment for NAS ('standard care'), as long as the latter was administered to the control group as well.
We used the standard methodological procedures expected by Cochrane. Our primary outcomes were duration of any pharmacological treatment for NAS, adverse events and length of hospital stay. We used GRADE to assess the certainty of evidence.
We included two single-centre RCTs (104 infants). Both studies compared non-invasive acupuncture added to standard care versus standard care. There were no studies where acupuncture was compared with placebo or sham treatment, pharmacological treatment or with another type of acupuncture. We did not identify any ongoing studies.
One of the included studies was conducted with 28 babies in Austria, between 2009 and 2014; it was a prospective, blinded RCT of laser acupuncture, which was performed daily at ear and body acupuncture points, bilaterally, until morphine was discontinued. The other study was conducted with 76 babies in the USA between 1992 and 1996. It was a randomised, prospective, but unblinded study of acupressure: a small herbal seed was taped to an ear acupoint or acupoints, and the seed site was massaged for 30 to 60 seconds after each NAS scoring event.
The evidence is very uncertain about the effect of adding acupuncture to standard care on the following outcomes.
• Duration of any pharmacological treatment for NAS. In one study, the median duration was 28 days (interquartile range (IQR) 22 to 33) and 39 days (IQR 32 to 48) in the acupuncture and control groups, respectively; in the other study, the mean duration of any pharmacological treatment for NAS was 22.1 days (standard deviation (SD) 16.6) and 22.7 days (SD 13.8) in the acupuncture and control groups, respectively (mean difference (MD) -0.60, 95% CI -7.45 to 6.25; 1 study, 76 infants).
• Adverse events. Both studies reported that no adverse effects occurred (risk difference (RD) 0.00 95% CI -0.05 to 0.05; 2 studies, 104 infants; I2 = 0).
• Length of hospital stay in days. In one study (28 infants), the median and IQR were 35 (25 to 47) days and 50 (36 to 66) days in the acupuncture and control groups, respectively. In the other study (76 infants), the mean duration of any pharmacological treatment for NAS was 25.8 days (SD 16.4) and 26 days (SD 13.3) in the acupuncture and control groups, respectively (MD -0.20, 95% CI -6.90 to 6.50; 1 study, 76 infants).
• Highest score in a single standardised NAS assessment. One study (28 infants) reported median scores of 15 (IQR 13 to 18) and 16 (IQR 14 to 19) in the acupuncture and control groups, respectively; the other study (76 infants) reported that the average NAS score per scoring event was slightly lower (mean 4.95, SD 1.00) for the 'control' infants than for the infants assigned to acupuncture (mean 5.27, SD 1.04).
We judged the certainty of the evidence to be very low for all these outcomes. No studies reported data on all-cause mortality, pain or long-term follow-up.