Neonatal Abstinence Syndrome, also called in short NAS, is a condition that may affect babies who were exposed to opioid substances while “in utero” (during pregnancy). After such exposure, babies may develop opioid withdrawal symptoms and, as a result, require prolonged observation in hospitals and sometimes treatment with medications.
Introduction
Due to the opioid crisis that we have currently in the USA, approximately 22000 newborn babies have been reported to be affected by this condition every year. Unfortunately, the number of affected babies increased fivefold over the last 12 years. The opioid crisis affects all areas of the USA, including inner cities and rural regions.
Examples of opioid substances that can cause this condition include commonly prescribed narcotic pain relievers such as Percocet, Oxycodone, Oxycontin, and Vicodin. Of course, illegally obtained illicit drugs such as heroin can be a culprit, as well. There is an ongoing debate on whether barbiturates and anti-depressant medications can cause NAS.
One study reported that among 744 opioid exposed mothers, 54% were on at least one additional psychiatric medicine, and 32% were on at least two other psychotropic medications (Link to source). Babies exposed to those psychiatric medications had a longer length of stay in the hospital after birth and required more days on medication, treating their withdrawal symptoms.
Marijuana, amphetamine, and cocaine do not cause withdrawal symptoms in babies. Obviously, it does not mean that these substances are safe for a baby to take during pregnancy.
Frequently, pregnant women who suffer from opioid addiction are being treated with Methadone or Buprenorphine during pregnancy. It is essential to know that these treatments are recommended to them because they increase the chances of delivering healthier babies close to term. But, they also result in the birth of a baby that is likely to have withdrawal symptoms. The reason for that is that these two medications interact with opioid receptors hence are capable of causing withdrawal symptoms in a baby.
What are the effects of maternal opioid use during pregnancy?
Maternal opioid abuse can influence three types of outcomes: the mother’s health, her pregnancy, and her baby. (Link to scientific article)
Effects on mother’s health:
- More STD (sexually transmitted diseases)
- HIV, Hepatitis
- Endocarditis (inflammation in the heart – often very severe condition)
- Osteomyelitis (infection in the bones)
- Sepsis (multi-organ infection)
- Cellulitis (infection in soft tissues under the skin)
- Less use of health care
- Decreased social interactions
Effects on the pregnancy:
- The smaller size of the fetus
- Problems with the detachment of the placenta
- Premature labor
- Abnormal heart patterns in a baby
- Death of the fetus
Effects on a newborn baby:
- Low birth weight
- Preterm delivery of the baby
- Small head circumference
- Sleep myoclonus (muscle jerks)
- Opioid withdrawal symptoms (Neonatal Abstinence Syndrome)
Opioid Withdrawal Symptoms in babies.
The central nervous system, autonomic nervous system, and gastrointestinal system are the most affected organs by opioid exposure.
Withdrawal symptoms in the baby suffering from NAS are somewhat similar to those symptoms observed in adults. Babies will be agitated, crying a lot, have difficulties with feedings, present with diarrhea, increased sweating, increased heart rate, and blood pressure, and even fever. They may have increased muscle tone, muscle cramps, and in rare circumstances, possibly even seizures.
Evaluation of opioid exposed newborn babies after birth.
When making a diagnosis of Neonatal Abstinence Syndrome, we should remember that other conditions than NAS can sometimes mimic withdrawals. Examples of those conditions are low glucose levels, low calcium levels, hyperactivity of thyroid gland, infections, neurologic abnormalities, and conditions causing excruciating pain in a baby (fracture or twisted testicle).
Evaluation of each baby suspected of having Neonatal Abstinence Syndrome should rely on obtaining full maternal history, physical examination of the baby, and getting biologic samples from the baby if necessary.
Maternal History:
During each delivery, full maternal history, including all risk factors that can influence the health of the baby, should be given to pediatric providers. Unfortunately, many times, births occur unexpectedly, and that is not available. After each delivery, a pediatrician should try to obtain a maternal history from the obstetrician, mother’s nurse, and in-person from the mother.
The information that we need to get should cover the time before and during pregnancy. We want to know if the mother used any prescribed and un-prescribed medications or substances. We want to know what were the names, dosages, and frequencies of use. The more information we can gather, the better idea we will have what to expect in the baby after birth.
Finally, it would be useful to talk to mother’s doctors treating her for her addiction during pregnancy or receive (with her permission) medical records, if that applies to her.
Physical examination of the baby with suspected Neonatal Abstinence Syndrome.
While conducting a physical examination, doctors look for any signs and symptoms of withdrawal. First, they check vital signs such as temperature, heart rate, respiratory rate, and blood pressure. Frequently, in babies with withdrawal symptoms, those vital sign values are elevated and abnormal.
Then we examine all organs with particular attention to the nervous system and gastrointestinal system. We check the baby for any presence of abnormal neurological symptoms such as tremors, or seizures, increased muscle tone, agitation, or abnormal reflexes. We also inquire about the quality of feedings, sucking reflex, and any presence of diarrhea or vomiting.
During our examination, we can utilize specific scoring systems useful in the assessment of babies with Neonatal Abstinence Syndrome such as Finnegan’s Scoring system or ESC method. Finnegan’s scoring used to be very popular among health care providers until very recently. This scale has 21 items that need to be assessed at regular intervals, and the assessment ends with assignment of final total numerical score that would guide our treatment decisions.
If the baby had consistent scores eight or more, we would decide to escalate treatment to control the baby’s symptoms better. Escalation could include non-pharmacologic approaches or medications for NAS. Many providers complained about Finnegan’s scoring system that it was too labor-intensive, subjective, and not based on adequate data. Thus, the new approach has been developed, called ESC.
ESC stands for Eat, Sleep, and Console. Doctors decided that the best approach in the assessment of babies suffering from withdrawal symptoms is to make sure that the baby behaves like a baby. And, the baby should sleep an adequate amount of time, the baby should eat a certain amount of milk at regular intervals, and the baby should be able to be consoled.
For the purpose of the ESC method, it was decided that a baby who can breastfeed well or eat at least one ounce, sleep for at least one hour, and console within 10 minutes has well-controlled withdrawal symptoms and does not need additional intervention (Scientific article on ESC).
During daily and ongoing evaluations of each baby with Neonatal Abstinence Syndrome, doctors take into account parents’ and nurses’ input as these individuals spend more time with a baby every day than anybody else.
Biologic samples:
There will be situations when maternal history is incomplete or in doubt, and it is useful to get a sample from a baby and send for toxicology testing. Some institutions do not want to be judgmental or accused of bias against anybody, and they test routinely all babies affected or all babies born in their institutions.
You need to know that depending on a state where you live, findings on neonatal toxicology screening may have legal consequences for the mother and the father of each affected baby.
Sample materials useful for toxicology testing come from:
- meconium (first stool)
- urine
- umbilical cord
- hair
- nails
Urine can be quickly obtained in a baby, but the disadvantage of this sample is that only first or second voids are useful, and urine indicates only exposure to substances within the last few days before delivery.
Meconium and umbilical cord will prove exposure to toxic substances for several weeks or even months before the delivery.
Testing of hair and nails is not done routinely in clinical practice. It can turn out to be useful in forensic examinations when a legal proof is needed 2-3 weeks after birth, and meconium, urine, and umbilical cord samples are no longer available for testing.
Treatment of Neonatal Abstinence Syndrome.
Treatment of NAS should always include non-pharmacologic supportive measures, but in some cases, it may also require medications.
Non-pharmacologic measures to treat opioid withdrawal symptoms in newborns.
Ideally, during hospitalization baby should be bonding with the mother in a separate room, be held frequently, and kept in a quiet, calm environment with the minimal amount of stimulation to decrease distractions and discomfort of the baby.
It has been shown in some studies that babies who stay with their mothers and receive breast milk while having withdrawal symptoms tend to require shorter hospitalizations. The beneficial effect of breast milk was particularly significant for babies who were exposed in utero to methadone.
Mothers who are HIV positive, who are still using illicit substances, or are not in addiction treatment programs may not be good candidates to provide breast milk for their babies.
Medical treatment of Neonatal Abstinence Syndrome:
In situations where, in the opinion of a team that is taking care of the baby, withdrawal symptoms are not well controlled, medications can provide additional help. I want to emphasize here that there is a lack of good evidence regarding many topics related to the treatment of Neonatal Abstinence Syndrome. Frequently, treatment decisions are made more based on personal experiences, beliefs, and word of mouth “evidence.”
In my opinion, we still do not have satisfactory answers to the following questions:
- When should treatment with medications be started?
- What is the best medication to use?
- What doses to use?
- How to go about increasing and decreasing medication doses?
- The usefulness of outpatient medical therapy?
If treatment with medications is needed, we usually use one of the four drugs: Morphine, Methadone, Phenobarbital, Clonidine. Buprenorphine may be the 5th choice available soon if some more data becomes available. I have heard some positive things about the use of Buprenorphine in neonates with NAS, but to my knowledge, at the moment, it is not yet used outside of research trials. (Link to scientific article)
Each medication has some positive and negative characteristics. Morphine is much easier to adjust doses because it is given at frequent intervals. Methadone is usually given only once a day, so advocates of outpatient therapy use it (Link to scientific article).
Phenobarbital can be used as a second-line medication and also be provided at home. However, it seems that, in some cases, it is continued after discharge for too long.
Doctors use Clonidine both in first-line and second-line therapy for NAS, but Clonidine may decrease blood pressure and requires careful monitoring.
When we analyze the length of hospitalization, there is data showing that at some institutions, it is more important to have one protocol that is followed by all providers regarding when to start medication and how to go about increasing and decreasing the doses, than a type of medication being used.
It is still unclear which of these medications is best suited for the treatment of NAS in babies. Usually, clinicians choose one or two that they are most familiar with and comfortable with and use them on a regular basis.
Outcomes of babies with opioid withdrawal symptoms.
Short term outcomes of babies exposed to opiates are good. All babies eventually overcome their withdrawal symptoms and can function well without opioid medication. Babies that require treatment with medicine may need to stay in a hospital for 2-6 weeks before they can be successfully weaned off the medication and go home.
Despite thousands of babies that have been treated for Neonatal Abstinence Syndrome over the last few decades, we do not have useful data on long term outcomes. Such studies are challenging to conduct due to privacy issues in these vulnerable populations and due to numerous legal and administrative factors.
Ultimately, the type of socioeconomic environment and the amount of social and developmental stimulation received will be the most critical factors shaping the future of each child with a diagnosis of neonatal abstinence syndrome. Some providers advocate that these children should be enrolled in early intervention programs and referred to development evaluation clinics, but experienced pediatricians will be able to follow the child’s development, too.
Action items and questions that parents need to ask.
Before the birth of your baby:
If you are still pregnant and have an opioid use problem, tell your obstetrician about it and ask to be referred to an addiction treatment program that is experienced in treating pregnant patients.
If you are concerned about the custody of your child, get familiar with the state and local county laws regarding pregnancy and addiction problems. Also, you may want to consider a legal advice.
Ask your obstetrician if the hospital where you are going to deliver your baby has enough experience in treating babies with Neonatal Abstinence Syndrome.
After the birth of your baby:
Ask pediatrician or neonatologist if you can stay with your baby until discharge regardless of how long it will take. If you stay with your baby, that is likely to facilitate sooner discharge home.
Ask if you can breastfeed or pump breast milk and provide it later to your baby. Again, that is likely to lead to a faster discharge home.
Ask: how are they going to evaluate your baby for withdrawal symptoms. It is a good idea for you to learn those techniques so that you can participate better in the care of your baby.
Ask how you can console your baby during times when your baby is agitated and crying a lot. (holding your baby, offering breast or pacifier or music may help).
You can also learn more about NAS from the videos I posted on my YouTube Channel.
Disclaimer:
This article is only for general information purposes. It should not be viewed as any medical advice. There is a small chance that information here may be inaccurate. You should always discuss all health-related matters with your doctor before making any decisions that may affect your health or health of your family members.