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Neonatal Abstinence Syndrome (NAS) Symptoms, Diagnosis, and Treatment

3 min read · 8 sections
Over 50-80% of infants exposed to opioids in the fetus develop neonatal abstinence syndrome (NAS). Additionally, the number of infants diagnosed with NAS grew nearly 7-fold between the years 2000-2014, a trend that parallels an increase in the number of pregnant women struggling with opioid use disorder (OUD) in that same timeframe.1

Despite the potential danger of this condition, women who are pregnant and suffering from OUD can take actionable measures to treat their opioid addiction as well as safely manage NAS, should it arise, to prevent or minimize harm to their newborn infant. Though this condition demands urgent medical attention, women who are pregnant can reduce potential complications with their newborn’s health and birth with the proper treatment interventions. This page will provide information regarding neonatal abstinence syndrome and what pregnant women who are struggling with OUD can do to protect their health and the health of their child.2

What Is Neonatal Abstinence Syndrome?

Neonatal abstinence syndrome (NAS) is a collection of physiological and neurobehavioral signs of withdrawal that occur in newborns after they are repeatedly exposed to opioid drugs while in utero.2 NAS is a nonspecific term that labels the presentation of various withdrawal symptoms in infants after they’re born.2 More specifically, neonatal abstinence syndrome may now be referred to as neonatal opioid withdrawal syndrome (NOWS) in some medical literature.2  Some symptoms of NAS can be serious but this condition is treatable.3

Causes and Risk Factors of NAS

Neonatal abstinence syndrome may develop in association with intrauterine exposure to certain drugs and/or medications and the newborn’s abrupt withdrawal from those substances upon birth.4 Though several neonatal withdrawal syndromes may result from various types of drug exposure, the term NAS often designates the abstinence syndrome that specifically arises in connection with maternal opioid drug use.4

Common causes and risk factors of NAS may include:5

  • Using illicit opioid drugs during pregnancy (with specific opioid type and average dose used further altering this risk).
  • Concurrent exposure to additional substances during pregnancy—such as nicotine and benzodiazepines—may also alter the onset and severity of NAS.
  • Maternal factors such as poor nutritional status and stress.
  • Environmental factors, such as quality of neonatal care, adequate stimulation, and maternal contact.
  • Genetic variables and other physiological differences such as rates of placental opioid metabolism.

Symptoms of Neonatal Abstinence Syndrome

After intrauterine opioid exposure, many infants will develop symptoms of NAS in the first 24-48 hours after they are born. 6 However, symptoms are sometimes slower to appear, with first presentation as many as 5 to 10 days after birth.6 The severity and length of symptoms will vary based on the type of drugs used during pregnancy, when the last use occurred, and the gestational age of the infant.6

Symptoms of neonatal abstinence syndrome will be closely monitored and graded in terms of severity. Such symptoms may manifest across a variety of organ systems and physiological functions—for example, metabolic, vasomotor, central nervous system, respiratory system, and gastrointestinal issues.4

Symptoms of NAS may include the following: 4,5,6

  • High-pitched crying.
  • Sleep disturbances.
  • Tachypnea or rapid breathing.
  • Tachycardia or increased heart rate.
  • Sweating.
  • Mottled skin.
  • Projectile vomiting.
  • Diarrhea.
  • Gastric regurgitation.
  • Poor-feeding, possibly leading to weight loss and failure to thrive.
  • Hyper-irritability.
  • Increased muscle tone.
  • Myoclonus (muscle jerks).
  • Tremors.
  • Seizures.

Neonatal Abstinence Syndrome Diagnosis

Establishing a good relationship with a doctor or midwife who is experienced in working with pregnant women that have substance use disorders will be particularly important for proper diagnosis and treatment of neonatal abstinence syndrome.7

Early prenatal care can help prevent complications, and doctors may also encourage certain behaviors to help women stay healthy throughout their pregnancies.2 Ensuring that a woman with OUD is living in a safe, stable environment can promote success in both recovery and family planning.2

Providing women with information about labor, delivery, and post-natal care before the baby is born can help empower new mothers. Topics they may want to discuss with their doctors include establishing safe options for pain management during delivery, the benefits of breastfeeding, safe sleeping practices for infants, hormonal changes, and the possibility of postpartum depression and how to treat it.2

Benefits of breastfeeding include:2

  • A decrease in the severity of withdrawal symptoms.
  • A reduction in the need for medical intervention.
  • A decrease in the length of treatment and hospitalization.

Various means of screening or assessment may be used to help evaluate and monitor infant progress when managing NAS. The Finnegan Neonatal Abstinence Scoring Tool is one of the most widely used assessments for NAS and is recommended by the American Academy of Pediatrics. 5 It is designed to quantify the severity of symptoms of NAS in a newborn and determine the necessity for pharmacological interventions to help ease withdrawal symptoms.4

Because of the stigma and potential legal consequences often associated with substance abuse, it is important for doctors to take a compassionate, non-judgmental approach when evaluating a mother for risk factors of NAS in her unborn or newborn child.5 Doctors will take a thorough maternal history of substance use; however, in the absence of self-reporting, a doctor may also use toxicology tests for either the mother or infant.5

Neonatal Abstinence Syndrome Treatment

Treatment for a newborn with NAS will depend on the severity of symptoms, but it may include the following: 4

  • Swaddling.
  • Skin-to-skin contact.
  • Gentle rocking.
  • Pacifiers.
  • Frequent small feedings.
  • Massage.
  • Medication.

Finding Help for OUD & Neonatal Abstinence Syndrome

If a woman is pregnant and struggling with OUD, she should immediately seek the help of a medical professional. To do this, she may begin by contacting her general physician, a psychiatrist, an OBGYN, or a treatment center/clinic specifically designed to treat women who are pregnant.

Certain helplines also exist for mothers who are pregnant and struggling with OUD, including:

  • 1-800-662-HELP (4357). SAMHSA’s National Helpline for families. This phone line is free, confidential, and will help you find information regarding treatment.
  • 1-800-662-4357 (for Medicaid users) or 888-986-7502 (for private insurance users). AAC’s helpline.
  • 1-866-942-6466. American Pregnancy Helpline. This line offers free, confidential information and support for young women who are pregnant and using substances.
  • 1-800-622-2255. National Council on Alcoholism and Drug Dependence (NCADD). This provides resources and treatment connections for pregnant women using substances. Resources are also available specifically for underage teens.

There are various treatment interventions that may fit the needs of a woman who is pregnant and struggling with OUD, including medication-assisted treatment with opioid agonist agents such as buprenorphine or methadone to manage her opioid use.3

Women who are receiving OUD medications before or during pregnancy generally do not have to stop their OUD medications during pregnancy. In fact, women in treatment for OUD during their pregnancy, whether with pharmacological medications or medications in combination with behavioral interventions, tend to have healthier pregnancies than women who do not receive treatment for their OUD during pregnancy.3

A treating physician may also prescribe a woman who is pregnant and struggling with opioid addiction other medications for specific health issues, as well as encourage her to engage in behavioral treatment interventions like cognitive behavioral therapy to address the underlying causes of her OUD. 3

Remember, the treatment regimen prescribed to a someone during pregnancy to treat OUD is entirely specific to that person.3 If you are pregnant and struggling with opioid addiction, be sure to discuss the best options for you and your baby with your physician and follow the medical advice of your provider.

There are programs specifically designed to help pregnant women who are seeking treatment. For example, certain drug and alcohol treatment centers are capable of safely addressing the unique needs of expecting mothers.

The most important step is getting help if you or someone you love is struggling with a substance use disorder. Sometimes rehab is the best option for women who are pregnant and struggling with substance abuse, and American Addiction Centers can help guide you through the process. Call or click this link for more information on treatment programs of all kinds, including ones specifically designed for pregnant women.

Long-Term Effects and Outlook of NAS

Though the longer-term impact of NAS/NOWS continues to be an area of study, treatment interventions for both you and your newborn can make a decidedly positive impact on your health and your baby’s development.6

Pharmacological intervention, or the use of medications in treating a pregnant woman struggling with opioid addiction or an infant born with NAS, is a cornerstone in treating NAS and preventing or controlling severe symptoms of this condition. However, non-pharmacological interventions may also be helpful in treating infants born with NAS in conjunction with proper medications.6

Intervening early and offering integrated support and services can build trust between patient and provider and help prevent or reverse any potentially harmful  health effects of NAS.  Creating a safe environment for mother and child, with access to nutritious food, community support like parenting classes or new mother support groups can be protective factors that shape a child’s development throughout their lives.2

Facts and Statistics on NAS

Key points to remember about NAS include:6

  • NAS occurs when babies are exposed to drugs or certain medications while in the womb.
  • Symptoms of withdrawal can begin as soon as 24 hours after birth or as many as 10 days after birth.
  • Some babies will require medications to manage withdrawal symptoms and make them comfortable.
  • Medication is available for infants with severe symptoms of NAS.
  • NAS is also treatable for many infants with a variety non-pharmacological treatment interventions.
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