Neonatal Abstinence Syndrome was recognized over 40 years ago at Harlem Hospital. NY where they pioneered many treatment approaches: quiet non-stimulating environment, swaddeling, low voices, skin-to-skin contact, and the use of volunteer cuddlers. They were one of the first to use Morphine to ease symptoms in infants with severe withdrawal symptoms inconsolable by swaddeling, intolerable to touch, difficulty feeding, etc.
Neonatal abstinence syndrome (NAS) is a treatable condition that newborns may experience as a result of prenatal exposure to certain substances, most often opioids. Neonatal opioid withdrawal syndrome (NOWS) is a related term used today that refers to the symptoms that infants may experience as a result of exposure to opioids specifically.
The Four Categories For Pregnant Women Who May Use Opioids:
Those taking medication for pain due to a medical condition who are being monitored by a physician and are not addicted.
Those on medication-assisted treatment (MAT) who are in recovery from a substance use disorder and are managed by a physician.
Those misusing opioid pain medications with or without a prescription and who are addicted.
Those using illicit opioids (e.g., heroin) and who are addicted.
Prior to birth, engaging pregnant women with opioid use and other substance use disorders in substance use treatment and other services during prenatal care can decrease or prevent negative birth outcomes associated with NAS and NOWS. A supportive, nonjudgemental attitude with support from Social Work staff as part of a treatment team and nursing follow-up post hospital discharge leads to better outcomes.
Symptoms of NAS and NOWS
The signs a newborn has NAS depend on what drugs the mother used, how much and how often she took them during pregnancy. One or more of the following can be signs of withdrawal:
Hard to get or keep asleep
Diarrhea or frequent stools
Severe diaper rash
Stuffy nose or sneezing
Skin irritation of face, heels
Poor weight gain
Patchy color of skin
Image from the American Nurse: Caring for infants and families affected by neonatal abstinence syndrome
The onset of the symptoms varies. Newborns exposed to heroin or other short-acting opioids will typically show symptoms within the first 48–72 hours after birth. Those exposed to methadone or buprenorphine, which are longer acting opioids, will often present symptoms later than 72 hours, but usually within the first 4 days. The severity and duration of the withdrawal symptoms can be influenced by exposure to other substances, including tobacco and barbiturates along with poly-substance use.
Pathophysiology of Neonatal Opioid Withdrawal
From: FDA ADVISORY COMMITTEE: Neonatal Opioid Withdrawal Syndrome
Infants with NAS and NOWS are treated through non-pharmacological methods (such as rooming-in with mothers after birth, breastfeeding, swaddling, skin-to-skin time, and minimizing stimuli in the environment), as well as pharmacologic methods (medication) when warranted. There are numerous scoring systems to help identify severity NAS and guide medication treatment: Finnegan NAS -most extensively used, Lipsitz Neonatal Drug-Withdrawal, Neonatal Narcotic Withdrawal Index, Neonatal Withdrawal Inventory, and MOTHER NAS Scale. A new Eat, Sleep, Console (ESC) NAS assessment scoring method has been introduced using regular assessments of the infant’s ability to eat, sleep, and be consoled to determine the need for pharmacologic treatment, a family friendly approach.
Substance use contributes to parenting challenges and has the risk of impeding development of the nurturing parent-child relationships. At the extreme, NAS can lead to infant abuse due to a parent being overwhelmed with a screaming, unconsolable infant. In the U.S., the National Rate of NAS per 1,000 Newborn Hospitalizations in 2017 ( lists rate per state) was 7.3, while in my state - PA, the rate is more than doubled to 14.8.
As a prior Home Health Central Intake Manager serving the Philadelphia 5 county area, my staff processed 300+ Maternal Child referrals monthly with ~ 50 having + drug screens on referral. Our Mom Baby nurses were successful in teaching parents how to care for their infants; few required rehospitalization. Registered Nurses link moms and babies for followup at OB and Pediatrician appointments along with other resources as needed: free cribs, diapers, formula, shelter resources and counseling through Philadelphia's Maternity Care Coalition.
The Michael Smerconish daily newsletter 5/25/21, published the following article whose authors are Registered Nurses associated with the School of Nursing at the University of Pennsylvania. They recommend a Nursing First Approach to caring for infants with NAS.
Treating Newborns in Opioid Withdrawal: A Nursing-First Approach
National Center on Substance Abuse and Child Welfare: Neonatal Abstinence Syndrome
Caring for infants and families affected by neonatal abstinence syndrome
Neonatal Abstinence Syndrome (NAS) Toolkit
Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants - able to download.
HRSA’s Home Visiting Program: Supporting Families Impacted by Opioid Use and Neonatal Abstinence Syndrome
Video: Advances in Neonatal Care -EBP Brief on Eat, Sleep, Console
EATING, SLEEPING, CONSOLING NEONATAL ABSTINENCE SYNDROME CARE TOOL