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Neonatal abstinence syndrome
Other Resources UpToDate PubMed

Neonatal abstinence syndrome

Contributors: Eric Ingerowski MD, FAAP
Other Resources UpToDate PubMed

Synopsis

Neonatal abstinence syndrome (NAS) is a withdrawal syndrome that manifests in neonates exposed in utero to opioids or other addictive substances, such as barbiturates, benzodiazepines, nicotine, caffeine, and alcohol (see fetal alcohol syndrome). This article will focus on NAS from opioid withdrawal. Opioid drugs are derived from poppy plants, or they may be semi-synthetic or synthetic. Examples are morphine and codeine (natural opiates); heroin, oxycodone, oxymorphone, hydrocodone, hydromorphone, and buprenorphine (semi-synthetic opioids); and meperidine (Demerol), fentanyl, and methadone (synthetic opioids). A second type of NAS, which is less common, is associated with the withdrawal of postnatal pain therapy medications that were administered to the infant.

NAS is characterized by neurologic, autonomic, and gastrointestinal dysfunction, most commonly tremors, hyperirritability, high-pitched crying, poor feeding, and disrupted sleep. Other signs and symptoms include mottling or pallor, vomiting, loose stools, poor weight gain, excessive yawning, dehydration, frantic sucking, flaring of nostrils, fever, sweating, sneezing, abnormal posture or movements, hyperreflexia, hypertonia, back arching, seizures, and abnormal eye movements. Opioid withdrawal symptoms begin within 48 hours of birth in more than half of opioid-exposed neonates, and they persist for weeks to months. Every 18 minutes, another infant is born in the United States with NAS.

If maternal drug addiction is suspected, a positive urine drug screen or meconium drug test from the infant or a positive drug screen from the mother can help but is not essential to establishing a diagnosis of NAS. Findings of NAS can vary greatly and depend on multiple factors, including the drug or combination of drugs used and how recently and for how long the drugs were used, as well as the newborn's gestational age at birth. Compiling an accurate medical history is difficult as many parents are reluctant to report drug use for fear of legal consequences or losing custody. Furthermore, the newborn of a drug-using mother is at risk for other health issues, such as low birth weight, sudden infant death syndrome, malnutrition, and infectious disease transmitted from the mother. All of these factors can affect the treatment plan of the infant undergoing withdrawal and recovery.

Diagnosis and management traditionally involved the use of standardized neonatal abstinence scoring tools such as the Finnegan or Modified Finnegan Neonatal Abstinence Scoring Tools and treatment protocols. Therapy is usually inpatient but can be outpatient, depending on the pros and cons of each case. These protocols often involved substituting transition drugs such as methadone or buprenorphine while providing comfort and symptomatic relief to the infant. Treatment of the birth parent's withdrawal is best done simultaneously. A newer approach entitled Eat, Sleep, and Console has been shown to reduce the need for narcotic administration to infants with NAS as well as decrease length of hospital stay by using a holistic approach that includes the birth parent (and family) as an integral and valued member of the treatment team. This approach uses a function-based assessment tool that evaluates the infant's ability to eat, sleep, and console (soothe) with first-line treatments consisting of nonpharmacologic interventions (skin to skin, breast feeding, rocking, etc) provided by the infant's birth parent or caregiver. This approach is gaining more traction in the United States each year.

Nonpharmacologic therapy involves creating a supportive, nonstimulating environment without bright lights or loud noises, and providing adequate rest while promoting parent / baby bonding activities. Breastfeeding should be encouraged if the mother is clear of opiates or on opioid-replacement therapy. Studies show benefits to breastfeeding and rooming-in when possible.

Multidisciplinary professionals should be consulted throughout the recovery period. These should include a pediatrician, neonatologist, neonatal nurse, dietician, social worker, and substance abuse or mental health counselor. When the birth parent is emotionally or physically unavailable, additional support services are needed, often family members and volunteers.

When nonpharmacologic therapy is ineffective, pharmaceutical therapies have been utilized to ease the more severe symptoms of fever, seizures, dehydration, weight loss, and failure to thrive. Methadone or buprenorphine are commonly used for opiate replacement therapy, utilizing the Lipsitz or Finnegan scoring tools to monitor and modify dosage, or the Eat, Sleep, and Console method. Infants with NAS often have increased caloric needs and may have difficulty feeding, often necessitating the use of a higher caloric density formula or supplements to maintain adequate weight gain.

Related topics: opioid use disorder, opioid withdrawal syndrome

Codes

ICD10CM:
P96.1 – Neonatal withdrawal symptoms from maternal use of drugs of addiction

SNOMEDCT:
414819007 – Neonatal Abstinence Syndrome

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

  • Neonatal seizures
  • Neonatal bacterial sepsis
  • Respiratory distress syndrome in the newborn
  • Gastroesophageal reflux disease (GERD)
  • Hyperthyroidism
  • Hypoglycemia
  • Hypocalcemia
  • Hypoxic ischemic encephalopathy (HIE)
  • Meningitis (see Bacterial meningitis, Fungal meningitis, Aseptic meningitis)
  • Hunger

Best Tests

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Management Pearls

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Therapy

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Drug Reaction Data

Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

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References

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Last Reviewed:07/25/2023
Last Updated:07/30/2023
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Neonatal abstinence syndrome
A medical illustration showing key findings of Neonatal abstinence syndrome (Neurologic) : Seizures, Hyperreflexia, Irritability, Tremor, High-pitched cry, Hypertonia, Increased sneezing
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