PAS 2026
As‑needed dosing helps infants with opioid withdrawal go home sooner
Clinical takeaway: For infants with moderate to severe neonatal opioid withdrawal syndrome (NOWS) managed using the Eat, Sleep, Console (ESC) approach, consider symptom-based (“as-needed”) opioid dosing to reduce treatment duration and time to discharge.
Efforts to minimize pharmacologic exposure and length of stay remain central to improving care for infants with NOWS. Traditional scheduled opioid tapers may overtreat some newborns, prompting interest in more individualized strategies.
In the OPTimize NOW randomized trial published in JAMA and presented at PAS 2026, investigators enrolled 383 infants (≥36 weeks gestation) with moderate to severe NOWS cared for using the ESC model. Infants were randomized to symptom-based opioid dosing (as-needed when symptoms crossed prespecified thresholds; n=189) or to a standard scheduled opioid taper (n=194).
Infants receiving symptom-based dosing reached medical readiness for discharge a mean of 2 days earlier than those on scheduled tapers. They also discontinued opioid therapy sooner, reflecting lower cumulative medication exposure. Importantly, guardrails were built into the protocol to prevent undertreatment, and outcomes didn't suggest increased risk among infants managed with as-needed dosing.
Benefits were observed specifically in infants managed with ESC. The same advantages were not seen in infants cared for using Finnegan‑based protocols, which rely on frequent scoring of neurologic, gastrointestinal, and autonomic signs to drive treatment—often prompting earlier initiation and longer continuation of opioids. These findings highlight how dosing strategies and care models interact, and suggest symptom‑based dosing is most effective when paired with function‑focused approaches.
In an accompanying editorial, the authors caution that scheduled opioid tapers—long considered standard—may expose some infants to unnecessary medication despite fluctuating symptoms that respond to supportive care and intermittent dosing. They note that symptom‑based treatment aligns closely with ESC by targeting distress only when feeding, sleeping, or consolability are impaired, while emphasizing that success depends on clear thresholds, close monitoring, and experienced teams to avoid undertreatment.
Source: Devlin LA, et al. (2026, April 25). JAMA. Symptom-Based Dosing for Neonatal Opioid Withdrawal: The OPTimize NOW Randomized Clinical Trial