What is neonatal abstinence syndrome

Neonatal Abstinence Syndrome (NAS) refers to symptoms of withdrawal that babies can develop after birth if their mothers have taken medications or drugs during their pregnancy that can be addictive.

Many drugs used by mothers can reach the baby while they are in the womb. Once the baby is born, they can no longer receive the drug from their mother’s body, and may develop symptoms of neonatal abstinence syndrome (symptoms of withdrawal). These symptoms may include irritability, poor feeding, fever, sweating, stuffy nose, vomiting, stiffness or seizures.

There are many drugs that can cause neonatal abstinence syndrome but some of the most common are:

• Narcotics: methadone, morphine, Oxycodone, Percocet and Vicodin
• Muscle relaxants and antidepressants: Valium (diazepam), Ativan (lorazepam), Xanax
• Other potentially addictive drugs: cocaine, heroin, ecstasy and methamphetamine

It is very important that you let your nurse and doctor know about any drugs used during your pregnancy. This will help your caregivers to give appropriate medicines to you and your baby, deliver the best care, and discharge your baby home as soon as safely possible after birth. Doctors cannot predict which babies will have neonatal abstinence syndrome (NAS). The amount of drugs or medicines that the baby receives in the womb does not always match the symptoms that each baby may have after they are born.

Figure 1. Neonatal abstinence syndrome guidelines

Neonatal abstinence syndrome 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 neonatal abstinence syndrome symptoms.

Neonatal abstinence syndrome prevention

Discuss all medicines, and alcohol and tobacco use with your doctor.

Ask your provider for help 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 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 provider will know how best to manage the risks.

Neonatal abstinence syndrome symptoms

Most infants begin to have symptoms of neonatal abstinence syndrome (NAS) between 1-3 days after their birth. However, some infants may have neonatal abstinence syndrome (NAS) earlier and others may not have them until up to 10 days of age. Because of this, the baby will most often need to stay in the hospital for observation and monitoring for up to a week. These symptoms may be mild and go away quickly or may continue for months.

Neonatal abstinence syndrome 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 (rare)
• Skin irritation
• Sleep problems
• Slow weight gain
• Sneezing
• Stuffy nose
• Sweating
• Trembling (tremors) or jitteriness
• Vomiting

Some things that can affect how long it takes for symptoms to develop include:

• 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)
• How long the medication or drug is active in the mother
• How recently the medication or drug was taken before the baby’s birth
• Whether other medications or drugs were used at the same time

Neonatal abstinence syndrome possible complications

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

• Birth defects
• Low birth weight
• Premature birth
• Small head circumference
• Sudden infant death syndrome (SIDS)
• Problems with development and behavior

Neonatal abstinence syndrome diagnosis

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 might be done to measure the presence of the drug in the baby’s system include testing drug levels in the first stool (called meconium). Tests might also be done on a sample of the baby’s urine.

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). A small piece of the umbilical cord may also be used for drug screening.

Neonatal abstinence syndrome scoring

The Finnegan Neonatal Abstinence Score ¹⁾ is for the assessment of infants exposed in utero to psychoactive drugs, particularly opioids/opiates. Evaluator should check signs or symptoms observed at various time intervals and add the scores to obtain a total score. Observation of the scores over the time interval provides the progression/diminution of symptoms.

• Assess/score infants every 3-4 hours 1/2 to 1 hour after each feed
• Infants with signs of withdrawal have signs in each of systems (CNS, gastrointestinal, other)
• Score designed for term infants, adjustments must be made for preterm infants or infants beyond the initial newborn period

Table 1. Finnegan Neonatal Abstinence Scoring Tool

Patient ID:

Name:

Today’s Weight:

DOB:

Date:

AM

PM

Signs & Symptoms

Time

Comments

Central Nervous System Disturbances

SCORE

Crying: Excessive High Pitched Crying: Continuous High Pitched

2 3

Sleeps < 1hr After Feeding Sleeps < 2hrs After Feeding Sleeps < 3hrs After Feeding

3 2 1

Hyperactive Moro Reflex Markedly Hyperactive Moro Reflex

2 3

Mild Tremors: Disturbed Mod/Severe Tremors: Disturbed

1 2

Mild Tremors: Undisturbed Mod/Severe Tremors: Undisturbed

3 4

Increased Muscle Tone

2

Excoriation (Specific Area)

1

Myoclonic Jerk

3

Generalized Convulsions

5

Metabolic, Vasomotor and Respiratory Disturbance

Sweating

1

Fever < 101 (37.2 to 38.3°C) Fever > 101 (38.4°C)

1 2

Frequent Yawning (> 3)

1

Mottling

1

Nasal Stuffiness

1

Sneezing (> 3)

2

Nasal Flaring

1

Respiratory Rate (> 60/min) Respiratory Rate (> 60 Min With Retractions)

1 2

Gastrointestinal Disturbances

Excessive Sucking

1

Poor Feeding

2

Regurgitation Projectile Vomiting

2 3

Loose Stools Watery Stools

2 3

Score

Total Score

Average Daily Score

Inter-observer Reliability %

Initials of Scorer 1

Initials of Scorer 2

[Source ²⁾ ]

Table 2. Simplified Finnegan Neonatal Abstinence Scoring System

Item	Description	Value
Cry	Excessive or continuous	2
Tremors	Excessive or continuous	5
	Tremors disturbed (mild, moderate or severe)	1
Increased Muscle Tone	Yes	2
Sleep	< 1 hour	3
	< 2 or 3 hours	1
Nasal Stuffiness	Present	1
Respiratory Rate	Greater than 60/min	1
Excessive Sucking	Present	1
Poor Feeding	Present	2
Feeding Intolerance	Regurgitation or projectile vomiting	2
Stools	Loose or watery	2

[Source ³⁾ ]

Neonatal abstinence syndrome treatment

After delivery, your baby will be taken with you to the mother/baby unit for routine care, unless there are other medical reasons for admission to the special care nursery (SCN) or neonatal intensive care unit (NICU). All babies at risk of neonatal abstinence syndrome will be observed for a minimum of 72 hours for signs of withdrawal. If you had a vaginal delivery, you may be discharged before your baby.

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 (or more depending on the drug) 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).

There are different levels of care available in the nurseries within hospitals. Your doctor will decide which nursery is best for your baby. Some babies may be kept in the mother’s room after being born. Other infants need frequent observations by specially trained staff and may need to go to a special nursery to be watched more closely. Regardless of the type of nursery your baby is admitted to, staff will try to keep you and your baby together as much as possible.

Babies that have neonatal abstinence syndrome use a lot of energy that should otherwise be used to help them grow and develop normally. If they need treatment but do not receive it, they may fail to sleep or eat well, fail to gain weight, and can also become sick. Some babies can also have very serious symptoms such as seizures. The goal for treating your baby is to decrease your baby’s symptoms so that they can grow and develop normally, and go home as soon as it is safe.

Some babies stay in the hospital for less than one week. Other babies have more severe withdrawal symptoms and need to stay longer. While your baby is in the hospital, staff will observe your baby frequently to watch their symptoms. When babies have symptoms of withdrawal, a scoring system is used by staff to help them decide how severe the symptoms are. If your baby begins to have high scores and does not respond to comfort measures, your baby’s doctor may decide to give him or her medication to help decrease withdrawal symptoms so that your baby remains safe and comfortable. Common medications used to reduce neonatal abstinence syndrome symptoms include methadone or morphine.

Babies that need medication in the hospital often need to continue taking it once they go home. Before your baby goes home, staff will teach you how to carefully observe your baby for withdrawal symptoms, how to give medications if your baby needs them, and let you know who you can call if you have questions.

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 in an upright position
• Reducing noise and lights
• Swaddling the baby in a blanket
• Swaddle your baby with their hands close to their mouth
• Keep lights and sound low
• Hold baby skin to your skin
• Use gentle touch
• Speak softly
• Limit visitors
• Offer breast/bottle feeding and a pacifier often
• Allow more time for feedings if needed

Some babies with severe symptoms need medicines such as methadone or 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, such as 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 feedings given more often

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

Care at home

Once your baby is home, symptoms of withdrawal may still continue for several weeks. These symptoms will gradually decrease over time. Getting plenty of rest for you and your baby can help to reduce stress for both of you. Your baby will also need close follow up care in the clinic or with home care visits to evaluate the baby’s growth, observe your baby for symptoms of withdrawal, adjust medication doses as necessary and give you an opportunity to ask questions about your baby.

Neonatal abstinence syndrome prognosis

Neonatal abstinence syndrome responds very well to drug therapy and hence has a very good prognosis. Neonatal abstinence syndrome tend to be responding well to morphine or phenobarbitone. Neonatal abstinence syndrome itself tends to resolve over time. However if any complications related to illicit drug use occur, the prognosis might change dramatically depending on the complications. Even after medical treatment for neonatal abstinence syndrome is over and babies leave the hospital, they may need extra “TLC” for weeks or months.