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Neonatal abstinence syndrome (NAS) is a growing public health problem in the United States, as it is related to the opioid epidemic. NAS is the leading problem of medical and developmental issues in newborns and can have harmful long-term outcomes.  Nurses, especially those who frequently work with neonates and their mothers, need to be aware of this vulnerable population and the specific care that they need.  This course will examine the incidence of NAS, the clinical presentation, how to assess NAS, treatments, and long-term outcomes based on research and clinical practice guidelines.  

Introduction   

What is neonatal abstinence syndrome (NAS)?   

NAS is a diagnosis given to newborns who are actively withdrawing from a substance after birth. It is a postnatal withdrawal symptom, meaning the neonate was exposed in-utero to an addictive substance and is now “abstaining” from such substance after birth since they are no longer exposed (4). NAS comprises a constellation of symptoms in the newborn, including central nervous system (CNS) irritability, gastrointestinal dysfunction, and temperature instability, to name a few. We will go over the whole myriad of symptoms shortly. While other drugs have been implicated, NAS is most often attributed to maternal opioid use. NAS can be caused by both illegal substance abuse and prescribed medications, such as oxycodone for chronic pain or methadone for addiction management (4). NAS often requires hospitalization of the infant for monitoring and medication weaning. This course will mainly discuss opioid withdrawal, as it is the most common.  

Incidence of Neonatal Abstinence Syndrome 

The incidence of NAS has been increasing significantly in the United States, especially with the ongoing opioid crisis (4). According to data from the Centers for Disease Control and Prevention, 7% of women self-reported using prescription pain relievers during their pregnancy in 2019. Furthermore, the number of documented cases regarding opioid use during pregnancy increased by 131% from 2010 to 2017.

The number of reported cases of newborns with NAS during the same period increased by 82%. In addition, data collected from the Healthcare Cost and Utilization Project in 2020 estimated that 6 in every 1,000 newborns in the United States were diagnosed with NAS (2). opioid use during pregnancy and newborns with NAS increases healthcare costs and hospital length of stay. Nurses need to be able to recognize the symptoms of NAS and be aware of the appropriate interventions to treat these vulnerable patients.  

Clinical Presentation 

The clinical presentation of NAS varies with the opioid, the maternal drug history (including the timing of the most recent use of the drug before delivery), maternal, infant, and placental metabolism, term of the pregnancy (i.e., preterm versus full-term) and net transfer of drug across the placenta (4).

For example, if the mother just used heroin an hour before delivery, the infant’s withdrawal symptoms may be worse than if the mother had not used in the past two weeks.

In addition, maternal use of other drugs and substances, such as cocaine, barbiturates, hypnotics, sedatives, and cigarettes, may influence the severity and duration of NAS. Polysubstance abuse of different classes of drugs can exacerbate and worsen NAS symptoms.

Because opioid receptors are concentrated in the CNS and the gastrointestinal tract, the predominant signs and symptoms of NAS will reflect CNS irritability, autonomic over-reactivity, and gastrointestinal tract dysfunction. Excess environmental stimuli and hunger will exacerbate the perceived severity of NAS (1, 4, 6). 

Neurological Symptoms 

NAS symptoms generally start to clinically present themselves one to three days after birth, depending on the specific drug and the factors previously mentioned. However, sometimes, they can take up to a week to appear (4). Many symptoms of NAS overlap with other medical conditions and can be initially mistaken for symptoms related to sepsis, hyperthyroidism, or gastrointestinal reflux (1). So, as nurses, what do we look for when we are assessing NAS?  

One of the most apparent clusters of symptoms is neurologic excitability. A baby experiencing withdrawal may exhibit tremors in their arms or legs, which may be seen after disturbing the infant or even while they appear to be sleeping. Another symptom is irritability; the baby may cry intensely for excessive time.

This accompanies increased wakefulness, where most newborns sleep most of the day; the infant with NAS may be awake for long periods. High-pitched crying is another neurological symptom, along with increased muscle tone. The baby may also exhibit hyperactive deep tendon reflexes and an exaggerated Moro reflex.

One of the more subtle signs is frequent yawning and sneezing. A severe and life-threatening neurological symptom of withdrawal is seizures. Care must be taken to recognize withdrawal before the onset of seizures, as they can result in the infant’s death. Neurological symptoms are considered the hallmark triad of signs of NAS and are often the most identifiable (1, 6).   ​

Gastrointestinal Symptoms 

One of the other main clusters of symptoms of the baby with NAS is gastrointestinal dysfunction (1).   

• Poor feeding, such as having a poor latch on the breast or bottle or not taking enough volume to maintain adequate weight gain, may result in the infant needing a temporary feeding tube to supplement the required calories and nutrients (1). Constant, excessive, or uncoordinated sucking may contribute to poor feeding and the increased wakefulness described earlier. Regurgitation and vomiting may be seen as a form of gastrointestinal dysfunction, sometimes exacerbated by excessive crying and irritability.   
• Diarrhea may be exhibited as frequent loose or watery stools and may contribute to diaper rash and the baby being even more irritable.   
• Dehydration can be caused by a combination of poor feeding, vomiting, diarrhea, and maybe another indication for tube placement or even intravenous fluids.   
• Electrolyte imbalances may be caused by excessive vomiting and diarrhea, especially for newborns withdrawing from heroin. 
• Poor weight gain and failure to thrive are typical in infants with NAS, and as a result, the baby’s formula may need to be fortified with extra calories (1).   

Gastrointestinal dysfunction symptoms are more subjective than neurological symptoms. For example, most babies will spit up, especially within the first few days of life when they are just learning to eat. Babies also do not need large volumes of milk in the first few days of life, so judging their feeding intake may be tricky. It is also sometimes normal for babies to lose weight during the first week of life, so care must be taken to analyze all the symptoms of one another. 

Autonomic Symptoms 

The last central cluster of symptoms of NAS is autonomic nervous system signs. Some of these symptoms may be persistent for months, especially for newborns withdrawing from buprenorphine (1).  

• Increased sweating is one, which is exacerbated if the infant is very irritable (1). Thus, ensure the infant is not overdressed, and the room should be warm enough.  
• Nasal stuffiness is another symptom where the infant may appear to be congested. Nasal suctioning generally does not relieve the stuffiness and may make it worse.   
• Fever is a common symptom, one for which infection may need to be ruled out depending on maternal history and if any other symptoms of infection are present. The fever from withdrawal is generally not reduced with medications such as Acetaminophen. 
• Temperature instability is a related sign where the baby may have been hyperthermic at one moment and then hypothermic an hour later. Mottling, where the skin may have a discolored or streaky, vein-like appearance, may also be seen and is related to temperature instability. Again, the infant should be appropriately dressed so as not to exacerbate these symptoms (1).   
• Tachypnea, or breathing faster than usual even while at rest, may be exhibited in babies with NAS and may contribute to other problems, such as poor feeding (1).   

Scoring NAS 

The Finnegan Neonatal Abstinence Scoring System (FNASS)  is a clinical drug withdrawal assessment tool used by healthcare providers to determine the severity of withdrawal signs exhibited by infants exposed to opioids in utero. It is the most frequently used NAS scoring tool in the United States (1). The tool comprises 21 withdrawal signs that are scored and assessed throughout the withdrawal period.  

The signs are grouped into three subcategories: those related to CNS disturbances, metabolic, vasomotor, and respiratory disturbances, autonomic system disturbances, and gastrointestinal disturbances.  

Notice that these three subcategories are the same as the clusters of symptoms we just talked about. Under each subcategory are several symptoms to which you will assign a score. Each sign is weighted a numerical score based on the severity of the observed sign. Infants scoring an eight or greater are recommended for pharmacologic treatment. The baby is scored every 3-4 hours, usually 30 minutes after a feeding. The healthcare team examines the infant’s scoring trends to determine treatment and its success (1). 

Since the FNASS has some limitations, new scoring tools are also being researched regarding screening and scoring for neonatal abstinence syndrome. These tools include the Neonatal Withdrawal Inventory (NWI) and the Neonatal Narcotic Withdrawal Index. However, most U.S. hospitals are still utilizing the FNASS (3). Nurses should use the screening tool outlined by their healthcare facility’s protocols and practice standards. 

Nonpharmacological Interventions 

If a neonate is found to have NAS, they will typically be admitted to the neonatal intensive care unit (NICU) for supportive treatment. Upon admission, the baby may not be scoring high enough to start pharmacological therapies, so in the meantime, and after the medication is started, the nurse can employ many different nonpharmacological interventions to help console the baby. Nonpharmacological treatment is considered the first-line therapy for neonatal abstinence syndrome (1). 

One intervention is to decrease the environmental stimuli, such as keeping the room quiet and dimly lit, and handling the infant slowly (1). If available, the baby may need to be placed in a private room in order to keep the environment non-stimulating. Another nursing intervention is to offer frequent small feedings on demand. This may help infants with motor or tone dysregulation to take quality feedings and feel soothed.

Holding the infant may help the baby with NAS to regulate poor motor control symptoms such as thrashing and flailing by providing gentle head and limb restraint. Nonnutritive sucking, such as with a pacifier, helps organize the infant and is naturally soothing. Swaddling the infant helps self-soothe and better tolerate stimulation such as diaper changes. You can keep the baby’s arms swaddled while changing the diaper or performing a lab draw to help cut down on excessive yet necessary stimulation.

Containment is gentle pressure on the infant’s limbs and trunk to support motor and tone control. For example, while the mother changes the diaper, the nurse can place his or her hands on the infant’s crossed arms and trunk to provide gentle containment. Rubbing is often better than patting when burping the infant to avoid triggering the Moro reflex. Vertical rocking helps to facilitate relaxation and eye contact and is more soothing than rocking side to side (1). Swings such as Mamaroos provide gentle swaying in different patterns that may be helpful. 

Other options for nonpharmacologic interventions may be available, depending on policies and availability in each NICU. One intervention is kangaroo care, or skin-to-skin holding, with the infant’s mother or father. However, more research is still needed to improve outcomes regarding this topic (1, 5). The baby, wearing only a diaper, is placed on the mother or father’s bare chest.

Kangaroo care helps the infant feel comforted and sleep better while promoting bonding with the parents. Infant massage is often provided by a licensed massage therapist or physical therapist and can be taught to the parents. Infant massage provides relaxation to the infant and helps to decrease stress behaviors.

Aromatherapy, such as adding lavender to the bathwater, may help reduce stress and promote sleep in the infant. Music therapy, such as soft singing by the mother, white noise, heartbeat, and fluid sounds, such as in the womb, may improve heart rate and feeding behaviors. Loud or irritating music should not be used. Non-oscillating water beds are a newer option that helps to promote sleep and decrease NAS symptoms (1).  

Pharmacological Interventions 

The goal of pharmacologic intervention is to alleviate distressing and possibly painful withdrawal effects so that the infant may become comfortable enough to eat, sleep, and recover from physical dependence (1). Opioid withdrawal is best treated with opioids, given the opioid mechanisms of action. Most providers in the United States and the United Kingdom use an opioid (usually morphine or sometimes methadone) as the first drug of choice to treat confirmed opioid-induced NAS.

Morphine is a full opioid receptor agonist. It also binds and inhibits GABA-inhibitory interneurons. Oral daily doses of morphine typically start at 0.04 mg/kg/dose, and the maximum dosage is 0.2mg/kg. Dosages are usually administered every 3 hours, but this largely depends on the newborn and the severity of withdrawal symptoms (1). Morphine is initiated at the lowest possible dose and increased as needed based on the infant’s Finnegan scores until the infant is said to be “captured,” the appropriate dose is found, and scores are stable. Other medications, such as methadone and buprenorphine, may also be used (1).  

Once the infant is “captured” at the correct dose, the practitioner may leave the baby at this dose for several days and then begin weaning. The dosages of morphine (or methadone) are weaned according to the infant’s Finnegan scores. If the baby has had low scores for the previous day, the practitioner may begin weaning the dose and continue weaning every few days as the infant tolerates. The specific doses and weaning schedules are up to individual practitioners and unit protocols and may vary.

One point to note is that opioids are passed into the mother’s breast milk. Depending on your unit’s policies and the mother’s situation, the mother may or may not be permitted to breastfeed or feed pumped breastmilk. If the mother is in a treatment program and is committed to her baby’s treatment, it may be allowed. However, the mother must be able to provide enough breastmilk so that the baby is exposed to a steady level of opioids in the breastmilk.

For example, if she can only offer four feedings worth of breastmilk a day, the other four feedings would consist of a formula that obviously does not contain any opioids. This lack of consistent levels of opioids in the feedings may exacerbate withdrawal symptoms and prolong hospitalization (1).  

Second-line drugs are medications often used in combination with opioids to manage specific clinical signs. Still, these drugs are indicated only when the baby has been prenatally exposed to benzodiazepines or develops signs that are not well controlled by the opioid class of drugs (3). Phenobarbital is preferred to diazepam in the reduction of CNS symptom severity and to avoid treatment failure.

Phenobarbital, which causes sedation by activation of GABA receptors in the CNS, has been used to treat NAS due to the frequent combination of benzodiazepine and opioid abuse. There is also growing evidence of the safety and efficacy of clonidine in the NAS population, although it increases the risk of hypotension and bradycardia.

Clonidine is an α2-adrenergic receptor agonist that has been used in combination with an opioid or other drugs in older children and adults to reduce withdrawal symptoms (2). If needed to control symptoms outside of a healthcare setting, the baby can generally be discharged on these medications, although exceptional follow-up will most likely be required (1).  ​

Long-term Outcomes 

NAS and intrauterine drug exposure can cause children to suffer from problems later in life. Behavioral and cognitive problems were reported in children of all ages with a history of exposure to drugs or substances in utero (1, 7). These include a predisposition to ADHD and difficulty with memory, time management, and organization.

NAS may also lead to delayed language development and abnormal brain development, leading to lower performance in school and difficulty communicating. Children born exposed to drugs are also typically smaller in weight and have a smaller head circumference. They may also be born earlier with central and autonomic nervous system abnormalities. These babies may also have altered motor development, which has a ripple effect as the child grows in their developmental milestones. Hearing and vision may also be affected by drug exposure.

Otitis media is commonly reported in infants exposed to methadone. Overall visual development is delayed with drug exposure and reported vision problems include strabismus, nystagmus, reduced acuity, and refractive errors. Children exposed to drugs in utero are also more likely to engage in risky behaviors, such as early drug abuse. Some of these outcomes may also become more apparent in conjunction with the environment in which the child is raised. If the child’s parents continue to take part in drug abuse, the child’s needs may not be adequately supported or even identified (1, 7).  

Conclusion 

NAS is a diagnosis given to newborns who are actively withdrawing from a substance, such as an opioid, after birth. It is a postnatal withdrawal symptom, meaning the neonate was exposed in-utero to an addictive substance and is now “abstaining” from such substance after birth since they are no longer exposed (4).

NAS comprises a collection of symptoms in the newborn, including CNS irritability, gastrointestinal dysfunction, and temperature instability. It is essential for nurses caring for the mother and baby to be able to recognize NAS and be aware of the appropriate interventions to treat these vulnerable patients.  

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