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Neonatal abstinence syndrome

Neonatal abstinence syndrome (NAS) is a group of problems that occur in a newborn who was exposed to addictive opiate drugs while in the mother’s womb.

Causes

Neonatal abstinence syndrome may occur when a pregnant woman takes drugs such as heroin, codeine, oxycodone (Oxycontin), methadone or buprenorphine.

These and other substances pass through the placenta that connects the baby to its mother in the womb. The baby becomes dependent on the drug along with the mother.

If the mother continues to use the drugs within the week or so before delivery, the baby will be dependent on the drug at birth. Because the baby is no longer getting the drug after birth, withdrawal symptoms may occur as the drug is slowly cleared from the baby's system.

Withdrawal symptoms also may occur in babies exposed to alcohol, benzodiazepines, barbiturates, and certain antidepressants (SSRIs) while in the womb .

Babies of mothers who use other addictive drugs (nicotine, amphetamines, cocaine, marijuana,) may have long-term problems. While there is no clear evidence of a neonatal abstinence syndrome for other drugs, they may contribute to the severity of a baby's NAS symptoms.

Symptoms

The symptoms of neonatal abstinence syndrome depend on:

  • The type of drug the mother used
  • How the body breaks down and clears the drug (influenced by genetic factors)
  • How much of the drug she was taking
  • How long she used the drug
  • Whether the baby was born full-term or early (premature)

Symptoms often begin within 1 to 3 days after birth, but may take up to a week to appear. Because of this, the baby will most often need to stay in the hospital for observation and monitoring for up to a week.

Symptoms may include:

  • Blotchy skin coloring (mottling)
  • Diarrhea
  • Excessive crying or high-pitched crying
  • Excessive sucking
  • Fever
  • Hyperactive reflexes
  • Increased muscle tone
  • Irritability
  • Poor feeding
  • Rapid breathing
  • Seizures
  • Sleep problems
  • Slow weight gain
  • Stuffy nose, sneezing
  • Sweating
  • Trembling (tremors)
  • Vomiting

Exams and Tests

Many other conditions can produce the same symptoms as neonatal abstinence syndrome. To help make a diagnosis, the health care provider will ask questions about the mother's drug use. The mother may be asked about which drugs she took during pregnancy, and when she last took them. The mother's urine may be screened for drugs as well.

Tests that may be done to help diagnose withdrawal in a newborn include:

  • Neonatal abstinence syndrome scoring system, which assigns points based on each symptom and its severity. The infant's score can help determine treatment.
  • Toxicology (drug) screen of urine and of first bowel movements (meconium).

Treatment

Treatment depends on:

  • The drug involved
  • The infant's overall health and abstinence scores
  • Whether the baby was born full-term or premature

The health care team will watch the newborn carefully for up to a week after birth for signs of withdrawal, feeding problems, and weight gain. Babies who vomit or who are very dehydrated may need to get fluids through a vein (IV).

Infants with neonatal abstinence syndrome are often fussy and hard to calm. Tips to calm the infant down include measures often referred to as "TLC" (tender loving care):

  • Gently rocking the child
  • Reducing noise and lights
  • Swaddling the baby in a blanket

Some babies with severe symptoms need medicines such as methadone and morphine to treat withdrawal symptoms. These babies may need to stay in the hospital for weeks or months after birth. The goal of treatment is to prescribe the infant a drug similar to the one the mother used during pregnancy and slowly decrease the dose over time. This helps wean the baby off the drug and relieves some withdrawal symptoms.

If the symptoms are severe, especially if other drugs were used, a second medicine such as phenobarbital or clonidine may be added. Breastfeeding may also be helpful if the mother is in a methadone or buprenorphine treatment program without other drug use.

Babies with this condition often have severe diaper rash or other areas of skin breakdown. This requires treatment with special ointment or cream.

Babies may also have problems with feeding or slow growth. These problems may require:

  • Higher-calorie feedings that provide greater nutrition
  • Smaller portions given more often

Outlook (Prognosis)

Treatment helps relieve symptoms of withdrawal. Even after medical treatment for NAS is over and babies leave the hospital, they may need extra "TLC" for weeks or months.

Possible Complications

Drug and alcohol use during pregnancy can lead to many health problems in the baby besides NAS. These may include:

Neonatal abstinence syndrome treatment can last from 1 week to 6 months. Even after medical treatment for NAS is over and babies leave the hospital, they may need extra "TLC" for weeks or months.

When to Contact a Medical Professional

Make sure your health care provider knows about all the drugs you take during pregnancy.

Call your provider if your baby has symptoms of neonatal abstinence syndrome.

Prevention

Discuss all medicines, and alcohol and tobacco use with your health care provider.

Ask your health care provider with help stopping as soon as possible if you are:

  • Using drugs non-medically
  • Using drugs not prescribed to you
  • Using alcohol or tobacco

If you are already pregnant and take medicines or drugs not prescribed to you, talk to your health care provider about the best way to keep you and the baby safe. Some medicines should not be stopped without medical supervision, or harm may result. Your health care provider will know how best to manage the risks.

Alternative Names

NAS; Neonatal abstinence symptoms

References

Bencke M, Smith VC, Committee on Substance Abuse, Committee on Fetus and Newborn. American Academy of Pediatrics. Prenatal substance abuse: short- and long-term effects on the exposed fetus (technical report). Pediatrics. 2013;131(3):e1009-24. PMID: 23439891 www.ncbi.nlm.nih.gov/pubmed/23439891.

Hudak ML, Tan RC, Committee on Drugs, Committee on Fetus and Newborn: American Academy of Pediatrics. Neonatal drug withdrawal. Pediatrics. 2012;129(2):e540-60. PMID: 22291123 www.ncbi.nlm.nih.gov/pubmed/22291123.

Lawn C, Aiton N. The baby of a substance-abusing mother. In: Rennie JM, ed. Rennie and Roberton's Textbook of Neonatology. 5th ed. London, UK: Elsevier Churchill Livingstone; 2012:chap 26.

Patrick SW, et al. Prescription opioid epidemic and infant outcomes. Pediatrics. 2015;135:842-850.

Wiles JR, Isemann B, Ward LP, et al. Current management of neonatal abstinence syndrome secondary to intrauterine opioid exposure. J Pediatr. 2014;165:440-446. dx.doi.org/10.1016/j.jpeds.2014.05.010.

Update Date 11/3/2015

Updated by: Kimberly G Lee, MD, MSc, IBCLC, Associate Professor of Pediatrics, Division of Neonatology, Medical University of South Carolina, Charleston, SC. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Isla Ogilvie, PhD, and the A.D.A.M. Editorial team. Editorial update: 4/19/2016.

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