Neonatal Abstinence Syndrome

What is Neonatal Abstinence Syndrome?

More and more cases are coming to light where substance use during pregnancy is resulting in a condition called neonatal abstinence syndrome (NAS). This condition is increasingly seen with both legal prescription drugs and illegal opioids. NAS is a multi-faceted disorder that happens when a baby is no longer exposed to a substance the mother used or abused during the pregnancy. The symptoms mostly affect the baby’s nervous system, digestive system, and body’s automatic processes, but the exact causes of the condition are not wholly known. Various factors, including the age of the baby at birth, the baby’s sex, genetics, and the mother’s substance abuse habits affect the severity of the symptoms.

Diagnosis is made by taking note of the mother’s history while pregnant and observing the baby’s symptoms. This can also include biological testing. There are many tools doctors use to assess a baby’s condition; one such tool is the Finnegan scoring system, which is used to evaluate and plan the treatment for a baby showing symptoms of NAS. Some basic ways to initially manage the symptoms include having the baby stay in the same room as the mom, controlling the baby’s environment, and practicing breast feeding (unless the mother is still abusing substances or has a disease like HIV or hepatitis). If the symptoms continue and these strategies are not successful, medication could be considered.

There isn’t full agreement on which medication is the best, but morphine is used most often. Newer studies suggest methadone or buprenorphine could be beneficial for treating NAS, as they have been associated with shorter hospital stays and less time spent on medication. Phenobarbital and clonidine may also be used as additional treatments. Consistently using both non-medication and medication treatments is essential for helping these babies. A new approach to management, called “eat, sleep, and console”, focuses on the baby’s basic functioning, standard care, and increased involvement of the family in care. This new approach has been showing positive results.

Managing NAS also involves taking a look at the mother’s overall condition and situation, such as mental health, exposure to violence, and access to healthcare. These factors are critical for maintaining a healthy relationship between mother and baby, which is necessary for the baby’s normal development. NAS has been linked to long-term issues like developmental delays, behavioral problems, and early death. There isn’t enough data yet to fully understand the long-term impacts of NAS. However, about 13% of child welfare cases are related to cases where the baby is exposed to substances. There’s also been an increase in cases where children exposed to substances are involved with child welfare services. This increase is up to 240%, from 3.79 to 12.90 per 1,000 births. There’s a significant need to address NAS from a public health perspective to reduce these cases and the economic burden they cause.

The Mainstreaming Addiction Treatment (MAT) Act has been put into effect to expand evidence-based treatments for the rising issue of opioid use. This Act allows health care providers with a standard controlled substance license to prescribe a specific medication, buprenorphine, for opioid use disorder. This is intended to help blend substance use disorder treatment across healthcare settings and reduce the stigma surrounding opioid use disorder treatment.

As of December 2022, the MAT Act has removed the requirement of the DATA-Waiver (X-Waiver) program. All DEA-registered healthcare providers with permission to prescribe Schedule III drugs can prescribe buprenorphine for opioid use disorder if the state’s law allows it. The Substance Abuse and Mental Health Services Administration (SAMHSA) supports and encourages this change. There are now no limits on how many patients a healthcare provider can treat with buprenorphine. They are no longer required to keep track of patients treated with buprenorphine separately.

Pharmacy staff can now fill prescriptions for buprenorphine using the prescribing healthcare provider’s DEA number without needing a DATA 2000 waiver. However, healthcare providers still need to comply with applicable state laws regarding treating patients with opioid use disorder. Should you need them, you can find the contact information for State Opioid Treatment Authorities here: https://www.samhsa.gov/medication-assisted-treatment/sota.

What Causes Neonatal Abstinence Syndrome?

Neonatal Abstinence Syndrome (NAS), also called neonatal withdrawal syndrome, is a group of problems a newborn experiences if exposed to addictive illegal or prescription drugs while in the mother’s womb. NAS occurs when a baby adapts to drugs in the womb and then goes through drug withdrawal after birth.

Several drugs can potentially cause NAS, but opioids are traditionally the ones most frequently responsible. These include illegal drugs such as heroin, as well as prescription medications like hydrocodone, oxycodone, and other drugs containing opioids. Semi-synthetic opioids, such as methadone and buprenorphine, are also noted.

Please note that these latter drugs are often used as part of a medication-assisted treatment (MAT) for pregnant women who are trying to overcome opioid addiction. Women are actually advised to continue MAT during their pregnancies since stopping opioid use suddenly could introduce higher risks to both the mother and the unborn baby.

A study conducted in 2023 showed that babies born to mothers on MAT had shorter hospital stays when the babies did not require any medication management for withdrawal symptoms. Babies of mothers using a combination of buprenorphine and naloxone also had lower risks of developing NAS. On the other hand, babies of mothers taking methadone were six times more likely to need more than one medication for withdrawal treatment.

There are also cases where non-opioid psychiatric medications, like certain types of antidepressants and antipsychotics, could cause withdrawal-like symptoms in newborns. Other substances like benzodiazepines, nicotine, alcohol, methamphetamines, and inhalants can produce similar symptoms, but are less studied and have fewer treatment guidelines.

It is also essential to note that substances such as gabapentin, benzodiazepines, cocaine, and nicotine can make NAS symptoms worse. Consumption of multiple substances during pregnancy can intensify the severity. Marijuana is commonly used during pregnancy, and its impact on NAS severity is still unclear.

While there is no definite withdrawal syndrome associated with marijuana, THC (the psychoactive compound in marijuana) can impact the development of a fetus’ central nervous system. Babies exposed in the womb can exhibit hyperactivity, memory problems, and learning difficulties later in childhood.

Risk Factors and Frequency for Neonatal Abstinence Syndrome

Understanding the spread of Neonatal Abstinence Syndrome (NAS) needs knowledge of maternal substance use during pregnancy. As of 2016, substance abuse disorders were most prevalent in Australia and Asia, while opioid dependence disorder was most seen in North America. Opioid Use Disorder (OUD) globally increased by 47% from 1990 to 2016, the most significant rise among substance abuse disorders. Even though men are more affected, about one-third of all substance use disorders (SUDs) occur in women. Roughly 10 million women suffered from opioid dependence in 2016.

In the US, opioid use during pregnancy surged by 333% from 1999 to 2014 and continues to grow. About 1 in 4 women on Medicaid were prescribed opioids during pregnancy. The rise in substance abuse, especially opioids, during pregnancy has led to an increase in NAS cases. From 2004 to 2014, NAS incidents among babies on Medicaid increased fivefold. This data equates to 1 newborn diagnosed with NAS every 25 minutes. Studies from 24 tertiary care hospitals have reported an incidence of NAS as high as 23 per 1000 births.

A survey of 28 states found regional differences in NAS cases with the highest rates found in West Virginia, Vermont, and Kentucky. It is challenging to determine the exact number of NAS cases due to variances in definitions and necessary data among states even where reporting NAS is compulsory. Therefore, there needs to be a standardized definition of NAS across states to better address the opioid crisis.

• NAS cases have led to higher admission rates to Neonatal Intensive Care Units (NICU), increasing from 7 per 1000 to 27 per 1000.
• Hospital costs for managing NAS have increased nearly seven times, costing $462 million in 2014 for those covered by public insurance.
• NAS hospital admissions in Tennessee increased fivefold over a decade.
• The time frame from 2012 to 2016 saw an increase of NAS cases from 21,732 to 32,128, while hospital charges tripled to $2.5 billion.
• Over the same time frame, the rate of NAS also rose from 4.6 to 6.7 per 1000 in-hospital births.

A recent study from Wisconsin found a link between maternal opioid use disorder and infant mortality, regardless of NAS and opioid treatment during pregnancy. Given the long-term impacts of NAS, both medical and social, lawmakers must address the opioid and resulting NAS epidemic.

Signs and Symptoms of Neonatal Abstinence Syndrome

NAS, or Neonatal Abstinence Syndrome, refers to a group of symptoms affecting various body systems that newborns can experience if they were exposed to addictive substances before birth. The symptoms that show up can fall into various categories, like those affecting the Central Nervous System (CNS), breathing, digestion, and automatic body processes.

Every baby’s experience with NAS can be different, but some common tell-tale signs include increased muscle stiffness, shaking while at rest, and an exaggerated startle response. Other early symptoms might be high-pitched crying, irritability, sneezing, and diarrhea, mainly due to the body’s heightened response to the absence of certain substances. The severity and timing of these symptoms can depend on which drug the mother used during pregnancy, how often she used it, the baby’s gestational age during exposure to the drug, along with several other factors.

CNS-related symptoms often seen in NAS include:

• Hyperirritability
• High-pitched crying
• Shivering
• Jerky movements and potentially seizures
• Problems with sleep and maintaining calmness

Changes in automatic processes due to NAS can lead to:

• Heart rate changes
• Rapid breathing
• Temperature changes
• Skin color changes and sweating
• Frequent yawning, blocked nose, excessive sneezing

Digestive system signs of NAS include having trouble with feeding, regurgitation, vomiting, and diarrhea. These might cause the baby to lose weight and not grow as expected, requiring an increased calorie intake.

NAS is also thought to cause an imbalance in neurobehavioral regulation – the baby’s ability to regulate its own attention, automatic processes, sensory processing, and muscular tone. This might lead to increased muscle stiffness and problems focusing attention. Problems with consoling the infant and other potential long term effects on development can also occur because of this imbalance.

The severity and timing of NAS’s symptoms can differ greatly between babies. Factors influencing this include the type of drug the mother was using, when the last dose was taken before birth, the total dosage the baby was exposed to, and exposures to other drugs. Withdrawals can begin as soon as the first day of life for short-acting drugs like heroin, while those from long-acting substances like buprenorphine and methadone can present within the first three days. However, withdrawal syndromes can continue as late as four weeks after birth. While factors like breastfeeding, which involves only minimal amounts of opioids in breast milk, and genetic factors are also likely to influence the severity of NAS symptoms.

Testing for Neonatal Abstinence Syndrome

Neonatal Abstinence Syndrome (NAS) is a condition diagnosed in babies who show symptoms related to drug withdrawal following exposure while in the womb. Symptoms can be identified based on maternal history of drug use during pregnancy, collected in a supportive and respectful manner. In cases where this history is not easily available, a baby may undergo testing to confirm the diagnosis.

Several testing methods are available to detect any drug exposure that took place before a child’s birth. Medical experts may test the baby’s urine, meconium (a newborn’s first bowel movement), cord blood or hair. Urine and meconium testing are the most common because they provide results quickly and are easy to conduct. Urine tests can identify drugs that were taken a few days prior to delivery, typically able to detect them in the infant’s urine between 2 and 4 days. Meconium tests can identify drug exposure dating back up to 20 weeks of pregnancy. However, these tests may sometimes result in false positives or negatives, especially when testing for synthetic and semisynthetic drugs, and should be interpreted cautiously.

See, certain substances, like common household items (like soap or alcohol), and even painkillers taken by the mother during labor can affect test results. Furthermore, storage and collection mistakes , like contaminated meconium or delayed urine collection, can also lead to false negatives. In such cases, a combination of maternal urine and infant meconium testing, followed by confirmatory testing using gas chromatography-mass spectrometry, can provide more precise results. Despite these tests, management and treatment of the infant should be primarily based on the baby’s symptoms rather than the test results.

Starting immediately after birth, babies suspected to have been exposed to drugs in the womb are assessed using various tools. The Finnegan Neonatal Abstinence Scoring System (FNASS) is widely used, typically involving assessments every 3 to 4 hours based on 21 different signs and symptoms. However, this system does have limitations due to its subjective nature and the need for consistent application by trained medical personnel. Additionally, it was primarily designed for full-term babies exposed to opioids, limiting its application for premature babies or those exposed to other substances. Several modified versions of FNASS have been developed to overcome these limitations, but their usage is still not widespread.

More recently, a new approach called the “Eat, Sleep, Console” (ESC) model has been developed. This approach evaluates basic functions of the baby and family involvement in the baby’s care, prioritizing non-medical treatments before considering prescription medications. Although promising, this approach is still relatively new and requires further research, particularly through randomized clinical trials, to validate its effectiveness.

Treatment Options for Neonatal Abstinence Syndrome

Treatment options for Neonatal Abstinence Syndrome (NAS), a condition in newborns caused by withdrawal from certain drugs they were exposed to in the womb, can be broadly categorized into non-drug, alternative and drug-based approaches.

Non-drug Treatment

This type of treatment aims to be comforting and supportive towards the newborn, and involves changes to the physical environment, like darkening the room, lowering noise levels and reducing visual stimuli. We also use gentle comforting techniques such as rocking, swaddling (wrapping the baby in a blanket), and skin-to-skin contact. We take care to bundle up nursery care actions to reduce unnecessary touching of the baby, which can be disturbing. For babies with NAS, they may need frequent feeding in small amounts. Applying a barrier cream for diaper rash can help reduce irritability.

We also encourage the mother to be actively involved in caring for her baby. Breastfeeding is also highly endorsed as it can aid in the infant’s neurodevelopmental outcomes. A supportive approach from healthcare professionals is vital to maintain the mother-infant relationship and helps the non-drug treatment be more effective.

Alternative Treatment

Several non-conventional therapies have been studied for potential effectiveness in NAS. These include massage therapy, acupressure therapy, and Reiki which have shown to have calming effects. Other therapies being studied include aromatherapy and music therapy.

Drug-based Treatment

This approach is used when non-drug methods alone are not enough to control symptoms. Between 27% to 91% of infants with NAS may require drug-based treatment. The aim of this treatment is to ease the withdrawal symptoms of the baby. Short-acting opioids are the most commonly used medications. Longer-acting synthetic opioids have also been explored as alternatives. Other consideration for drug treatment includes phenobarbital and clonidine.

However, Naloxone, an opioid antagonist, is not recommended as it can worsen withdrawal symptoms. Specific dosages and duration of the medication will be adjusted based on the baby’s symptoms and responses.

Treatment location

Traditionally, babies with NAS have been treated in the neonatal intensive care unit (NICU). However, this can be overstimulating for these infants. A more favourable approach is the ‘rooming-in’ model, whereby the mother and baby stay in the same room, promoting bonding, and breastfeeding. This has been shown to effectively reduce the severity of NAS. It is therefore important to re-think the traditional approach of automatically admitting all infants to a critical care setting.

What else can Neonatal Abstinence Syndrome be?

It’s crucial to consider other possible reasons for a baby’s symptoms before concluding that they’re due to Neonatal Abstinence Syndrome (NAS), even if the baby was exposed to drugs before birth. In some situations, a baby’s symptoms might look like NAS, but could be caused by another health problem. For example, elevated heart rate, temperature changes, skin mottling, and sweating could be wrongly taken as signs of an infection. Nervousness might come from a brain injury or stomach reflux. Fever might be caused by an overactive thyroid or infection. Shaky movement might come from low blood sugar or low calcium. Eating problems could be from oral muscle troubles, birth defects, or being born too early. And even though it’s rare, a baby’s seizure might actually be due to withdrawals, infections, lack of oxygen to the brain, or imbalances in body salts.

Lastly, a baby’s jerky movements which can easily be mistaken for seizures, need to be accurately identified to avoid unnecessary worry and tests. Moreover, normal signs of a new baby adjusting to life outside the womb, like reacting to pain, hunger, rough handling, or an imperfect physical environment should also be considered.

When checking a baby for NAS, it’s important to rule out all other possible causes. Information on the mother’s wellness and habits during pregnancy are important, including any medicines taken, substance misuse, quality of prenatal care, unexpected baby loss, and mental health diagnoses. Also, details surrounding the baby’s birth, like gestational age, birth weight, any birth complications, or other birth defects must be thoroughly examined. When all signs point to NAS and there’s a history of maternal drug use, then running tests to confirm the diagnosis is advisable.

Here are key health conditions to remember when evaluating a baby for NAS:

• Infection (Sepsis)
• Injury during birth (Birth trauma)
• Stomach acid reflux (Gastrointestinal reflux)
• Overactive thyroid (Hyperthyroidism)
• Low blood sugar (Hypoglycemia)
• Low blood calcium (Hypocalcemia)
• Brain injury due to lack of oxygen (Hypoxic-ischemic encephalopathy)

What to expect with Neonatal Abstinence Syndrome

Babies exposed to opioids before birth are more likely to experience negative long-term impacts, according to research. These effects may include changes in brain development, thinking skills, school performance, behavior, and vision. Such babies are also at higher risk of death. However, it’s challenging to say definitively that prenatal opioid exposure is the only cause of these poor outcomes, as multiple other factors can play a role.

Comparative studies have shown that opioid-exposed infants can exhibit different developmental progression compared to normal infants, this starts to become noticeable from about one year old. Several tools have been used to measure these differences, such as the McCarthy Motor Scale and Vineland Social Maturity Scales. However, results from some measures like the Bayley Scales of Infant Development are not consistent. Visual-motor problems, such as eye misalignment (strabismus) and involuntary eye movements (nystagmus), are prevalent among infants with Neonatal Abstinence Syndrome (NAS, which is a set of problems a newborn experiences when withdrawing from drugs it was exposed to in the womb).

Significant cognitive problems, like lower overall IQ scores, difficulties with verbal tasks, short-term memory issues, and impaired executive functioning, have been observed among children more than three years old who had prenatal opioid exposure. These children often perform worse in school, with lower average test scores in every grade, with the most notable difference seen in seventh grade.

Opioid-exposed children are twice as likely to be diagnosed with attention-deficit/hyperactivity disorder, conduct disorders, and adjustment disorders. These kids tend to show aggressive behavior and are more likely to have anxiety disorders. This population is also at an increased risk of rehospitalization due to abuse, trauma, and behavior issues. Mortality rates among them are consistently higher. These children may also develop asthma and eczema and could suffer from infections, premature birth, and low birth weight.

However, even though a lot of research indicates these negative outcomes, a major study called Maternal Opioid Treatment: Human Experimental Research (MOTHER) presented contradictory results. This study followed infants exposed to buprenorphine or methadone in the womb until three years old. Infants were regularly tested to monitor their development, and the researchers found no significant differences in development or growth outcomes among opioid-exposed babies. They suggested that opioid exposure did not negatively affect these children’s physical, mental, and behavioral development. However, it should be noted that these infants were closely monitored and offered consistent support, which could have positively affected their development.

Further, the study only examined women enrolled in medication-assisted treatment programs for opioid dependence. So, it’s important to consider that illicit opioid use and the factors related to it might result in different outcomes.

Possible Complications When Diagnosed with Neonatal Abstinence Syndrome

Babies exposed to opioids have a higher likelihood of being born prematurely, showing slowed growth in the womb, and having a low birth weight. This situation is commonly recorded in babies exposed to heroin. Due to a faster metabolism, challenges with feeding, and increased losses in the intestines, these infants are highly susceptible to growth failure. Neonatal Abstinence Syndrome (NAS) is a withdrawal syndrome that these babies suffer, which can be associated with potentially fatal complications like seizures. Seizures are specifically linked to opioid withdrawal and are most common in babies exposed to methadone, although still a rare event. Ultimately, babies with NAS have a higher risk of death.

Common Side Effects:

• Premature birth
• Slowed growth in the womb
• Low birth weight
• Problems with feeding and increased intestinal losses
• Potential growth failure
• Higher risk for Neonatal Abstinence Syndrome (NAS)
• Potential for life-threatening complications, like seizures
• Increased risk of death

Recovery from Neonatal Abstinence Syndrome

After a child is released from the hospital, it is very important to schedule regular check-ups with a children’s doctor to monitor for the return or late appearance of symptoms associated with Neonatal Abstinence Syndrome (NAS). Weight checks are crucial to check for potential issues with growth and ensure that caregivers are properly informed and supported. Depending on the case, additional follow-up appointments with specialist clinics can be necessary. These can include clinics focused on child development, child psychiatry, children’s eye care, children’s brain health, occupational therapy, physical therapy, and dietetics. These will help identify and manage any ongoing problems typically seen in babies with NAS.

It’s prudent to loop in early intervention services, which provide support to help babies develop to their fullest potential. It is also important to have a plan in place to ensure the baby is safe and well cared for. Not all mothers are able to care for their babies after they are born, and in the US, appropriate laws require that these babies are placed in foster care when needed.

Importantly, the medical provider should aim to build a positive, respectful relationship with the mother, providing her with nonjudgmental and supportive care. Involvement of child welfare services should only occur if there are concerning signs of neglect, abuse, or harm to the child.

Additional support for the mother may involve connecting her to a women’s clinic, mental health services, clinics specializing in substance use disorders, breastfeeding support programs, social workers who can help with finding suitable housing and financial/legal aid, and services to evaluate and address exposure to violence. This comprehensive care from various disciplines is vital to support the unique needs of both the mother and the baby.

Preventing Neonatal Abstinence Syndrome

It’s important that moms or caregivers and family members understand what to expect when a baby has neonatal abstinence syndrome (NAS), a condition that happens when a baby withdraws from drugs they were exposed to in the womb. Education should cover the condition’s natural course, how it’s treated, potential problems, and what the outlook might be.

Any woman who could possibly have a child needs to know that drug abuse can harm her baby, including causing NAS. This condition can be prevented if a woman stops using drugs before she becomes pregnant, and it may be preventable if a woman stops using drugs early in pregnancy. In some cases, doctors might recommend a woman join a safe, supervised medical program called Medication-Assisted Treatment (MAT) if quitting drugs would be dangerous during pregnancy.

NAS symptoms can appear within the baby’s first 24 to 48 hours or as late as one week after birth. That’s why it’s important to watch for these signs even after the baby leaves the hospital. While in the hospital, the baby will be given supportive care, and the mom can be actively involved in the baby’s care. Some babies may need medicine to ease withdrawal symptoms.

Breastfeeding is highly recommended because it has many benefits. However, there may be some reasons not to breastfeed. After leaving the hospital, it’s essential for the baby to have regular check-ups with a health provider to prevent complications from NAS.

For more information, check out the American Academy of Pediatrics website. It has resources and knowledge specifically curated for patients and their families.