Understanding Neonatal Abstinence Syndrome (NAS)

Neonatal abstinence syndrome (NAS) is a set of signs and symptoms that can occur in a baby whose mother has used opioid medicines or other substances. Because the baby has been exposed to drugs in the womb, they may show signs of drug withdrawal after birth. Neonatal opioid withdrawal syndrome(NOWS) is used to refer specifically to withdrawal from opioids only. NAS will be used here to cover both opioid or other substances and opioid-only exposure.

What causes NAS?

Most drugs and medicines that a mother takes pass from her bloodstream to her unborn baby. Some are more likely to cause NAS than others. They include:

  • Opioid drugs such as heroin

  • Opioid medicines such as codeine and oxycodone. Or medicines used to treat opioid use disorder such as buprenorphine or methadone.

  • Products of a type of plant called kratom. This plant has opioid-like effects.

  • Medicines to treat depression, such as fluoxetine, sertraline, or citalopram

  • Nicotine from tobacco use

Alcohol use can also cause a different set of problems. These are called fetal alcohol spectrum disorders.

Signs of NAS

Signs of withdrawal may start 24 to 48 hours after birth. Or they may start as late as 5 to 10 days after birth. The timing depends on the substance involved. The signs in a full-term baby may include:

  • Trembling

  • Too much crying or high-pitched crying

  • Sleep problems

  • Tight muscle tone

  • Overactive reflexes

  • Seizures

  • Yawning, stuffy nose, and sneezing

  • Poor feeding or uncoordinated sucking

  • Vomiting or diarrhea

  • Sweating

  • Fever or unstable temperature

A preterm baby may have signs that are less severe. They may also get better faster. This may be because their nervous system is less mature, or because they were exposed to less drug than a full-term baby.

Diagnosing NAS

The healthcare provider will ask about your history of medicine or substance use. Be as accurate and detailed as you can. Note the time you last took the medicine or drug. The healthcare provider may use a scoring system. This is to keep track of how severe the baby’s withdrawal is. This scoring may also help to plan treatment. The healthcare provider may check your baby’s meconium, urine, and umbilical cord tissue. Some birth centers routinely screen all babies.

Treatment for NAS

Treatment will depend on how severe the symptoms are as well as on your baby's age and general health.

A baby with withdrawal is fussy and unhappy. They may be hard to comfort. Wrapping the baby snugly in a blanket may help give comfort and make babies feel more secure. Your baby may also need extra calories added to feedings. This is because increased activity and fussing uses more energy. Babies may also need IV fluids if they are dehydrated or have severe vomiting or diarrhea.

Some babies may need medicines. These can prevent severe withdrawal signs such as seizures. Medicines may also help ease the discomfort of withdrawal. If medicine is needed, a baby will likely be given a medicine that is in the same family of drugs as the one causing withdrawal. Once the signs of withdrawal are under control, the amount of the medicine is slowly decreased. This helps wean the baby off the drug. Talk with your baby's healthcare provider to learn which treatments might work for your baby.

Treatment decisions may be based on the baby's ability to eat, sleep, and be consoled ("ESC"). Evidence suggests that babies spend less time in the hospital and/or on medicine when their caregivers or families are present and involved in this care.

Possible complications of NAS

Other problems may include:

  • Poor growth in the womb

  • Being born too soon

  • Seizures

  • Birth defects

Even without NAS, prenatal drug exposure can be related to later developmental delay. Some drugs have been linked to specific problems. These include:

  • Opioids. These can cause serious withdrawal in the baby. Some signs can last as long as 4 to 6 months. Seizures may also occur in babies born to opioid users.

  • Amphetamines. These can lead to low birth weight and preterm birth.

  • Cocaine. This can cause poor growth. It also makes problems such as placental abruption more likely.

  • Marijuana. This may cause lower birth weight. It may also cause later problems with learning and behavior.

  • Alcohol. This can have major effects on babies before and after birth. It can slow growth during pregnancy and after birth. It can also cause problems of the head and face, heart defects, learning problems, and mental problems.

  • Cigarette smoking. This may cause low birth weight. It may also put babies at higher risk for preterm birth and stillbirth.

When to call the healthcare provider

Call the healthcare provider if your baby has any of these:

  • Signs that don’t get better, or get worse

  • New signs

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