Understanding Neonatal Abstinence Syndrome (NAS)

What Is Neonatal Abstinence Syndrome?

Neonatal Abstinence Syndrome, or NAS, is a combination of symptoms that a newborn exhibits soon after birth as a result of withdrawal from being exposed to drugs, traditionally opioids, while in the mother’s uterus. Though NAS is often associated with heroin, it’s important to remember that there are many different circumstances and drugs that can cause NAS, says Jennifer Wallace, MSN, RN, in an interview with The Oaks. Wallace serves as an assistant professor in the Family Focused Nursing Practice at Lawrence Memorial Regis College and a nurse in the Special Care Nursery and Maternity Units at Melrose-Wakefield Hospital in Boston.

Potential drugs may be prescription pain relievers, such as Vicodin, morphine, OxyContin or Percocet; illegal substances, such as heroin; or opioid maintenance therapy drugs, including methadone and buprenorphine, which are used as a treatment for opioid use disorder. Healthy newborns who end up in the neonatal intensive care unit (NICU) sometimes are given fentanyl, an opioid, and that can also cause withdrawal symptoms, Wallace says.

The Centers for Disease Control and Prevention (CDC) says that it’s possible that cocaine, amphetamines (which are used in the treatment of attention deficit hyperactivity disorder) and barbiturates may also cause NAS.1 The March of Dimes includes antidepressants and benzodiazepines as potential causes of NAS as well.2

How NAS Affects Babies

Babies with NAS are more likely to be born prematurely, have a low birth weight and may also develop birth defects. Symptoms of drug withdrawal typically appear within 48-72 hours after the baby is born, but can show up immediately or within a few weeks after birth.

Withdrawal symptoms are different for each baby depending on a variety of factors, including what kind of drug the mother used, when it was last used, and whether or not the baby is born full-term. Symptoms may include difficulty breathing and/or feeding, tremors, seizures, irritability, sneezing, disrupted sleep, vomiting, dehydration, an inability to maintain a regular temperature, excessive crying, high-pitched crying, yawning, fever and stuffy nose. These difficulties can result in a longer hospital stay with the potential for NICU admission.

“It’s really important to be clear that babies are not born addicts; they are born dependent,” says Elizabeth Welch-Carre, a neonatal nurse practitioner at Children’s Hospital Colorado, in this interview with The Oaks. “Addiction is a behavior, so only somebody who’s external to the uterus and can walk and talk can actually engage in addictive behavior.”

Additionally, not every baby that’s exposed to opioid drugs ends up with NAS, Welch-Carre says. “You may have had somebody who was using opiates intermittently or it may have been that they were on a dose that wasn’t significant,” she says.

Incidents of NAS have skyrocketed in recent years. Every 25 minutes, a baby is born with opioid withdrawal.3 In the 28 states with data available, the CDC reports that the number of cases of NAS nearly tripled between 1999 and 2013, from 1.5 to 6.0 per 1,000 hospital births.4

In 2000, 2,920 infants in the United States were born with NAS, while in 2012, that amount jumped to 21,732 infants with NAS.5 West Virginia, in particular, showed a spike in the number of babies with NAS, from 0.5 per 1,000 babies in 2000 to 33.4 per 1,000 babies in 2013.6 Clearly, NAS is becoming a major public health issue that needs to be addressed.

Why the Increase in NAS cases?

One reason for the increase in neonatal abstinence syndrome is likely the high rate of prescriptions being written for opioid painkillers.7 These NAS statistics also reflect the increasing number of adults with prescription opioid use dependence or disorders.8 The CDC estimates that one-third of women of childbearing age have filled a prescription for an opioid drug and 14-22% of women have filled a prescription for an opioid while pregnant.9

Another factor may be that almost half of pregnancies are estimated to be unplanned and many women don’t initially realize they are pregnant while taking an opioid. Similarly, the CDC reports that 86% of pregnancies are unplanned in women with opioid use disorders.10

Treatment for NAS

Treatment depends on considerations such as the severity of the baby’s symptoms, how much drug exposure the baby has had, how many drugs the baby has been exposed to and how bad the withdrawal is, says Welch-Carre. “There are neonatal abstinence scoring tools,” she says. “Based on those scores, you can make a decision about whether or not an infant needs to be treated with medication.” Having that standard protocol really helps decrease the length of the baby’s hospital stay as well, she says.

Nonpharmologic strategies, or comfort care, have nothing to do with medication, says Wallace. “Those are the strategies that I think have so much potential – not to take the place of medications, but to reduce the symptoms and to engage parents in the process and to reduce the trauma of babies’ experience in the hospital,” she says. “Some of these strategies are breastfeeding, family-centered care, swaddling, skin-to-skin care and modifying the environment to reduce noise and light stimulation.”

Medication, such as morphine, methadone or phenobarbital, is sometimes prescribed for babies born with NAS. Treatment may also include intravenous (IV) fluids for dehydration that can be caused by diarrhea and/or vomiting and feeding the baby a higher calorie baby formula to help ensure growth.11

A recent study found that having parents at the bedside helps decrease the severity of symptoms of NAS in infants and also leads to shorter hospital stays.12 “You really don’t want families to have to be separated, if at all possible,” Welch-Carre says. “If treatment can be offered in which the baby and the mother can be together, you have a higher success rate with that.”

Most babies who receive treatment for NAS show improvement within five to thirty days.13

Who Is Most at Risk?

While studies show that some states have a much higher incidence of babies born with NAS, “when we do testing on babies, there are a lot of babies who have been exposed, who are of any class, any race,” Welch-Carre says. “It’s a non-discriminating disorder. I think what we’re discovering is that it’s becoming a more universal issue and it’s not just limited to any given population.”

Recent research indicates that rural areas of the United States do seem to be more at risk than urban areas. A December 2016 study published by JAMA Pediatrics showed that there has been an enormous increase in NAS in rural areas between 2004 and 2013. In that period, the number of newborns with NAS climbed from 1.2 per every 1,000 hospital births to 7.5 per 1,000 births.14 In comparison, urban babies born with NAS went from 1.4 to 4.8 per 1,000 hospital births in that same time frame.15

Strategies to Prevent NAS

* Responsible opioid prescribing.One way to ensure responsible opioid use is for healthcare providers to use prescription drug monitoring programs, which are databases every state but Missouri uses to track prescription drugs. These databases can give providers a good overview of a patient’s prescription history and flag potential opioid overuse or dependence. In order for these programs to work, however, providers have to consistently use them.16

* Access to preconception care and family planning for women who use opioids.When healthcare providers encourage family planning services and preconception care, particularly for women who use opioids, receiving these services can increase understanding of NAS and help reduce its occurrence, as well as create access to all available contraceptive methods to prevent pregnancy in the first place.17 “One of the factors that we know that places babies at higher risk for all kinds of problems at birth and with the pregnancy is lack of prenatal care or inadequate prenatal care,” Wallace says. “In women who are struggling with addiction, that’s a big, big issue.”

* Screening women of childbearing age and pregnant women for substance use disorders. Screening tools could include questionnaires and urine, hair and blood tests. “If the substance use disorder can be addressed prior to becoming pregnant, it’s easier,” Welch-Carre says. Though it’s unclear which method is best, the CDC is doing research in this area because screening would result in more detection of opioid use during pregnancy.18

What to Do If You Believe Your Unborn Baby Is at Risk

If you plan to become pregnant and are using an opioid or any other drug, talk to your healthcare provider about the best course of action to take before you get pregnant. Be sure to disclose all substances you take so your provider can make informed decisions to help you. If you have a substance use disorder, your doctor can help you get into treatment, if needed.

If you are pregnant and are taking any of the drugs listed above that can cause NAS, tell your healthcare provider as soon as you can, but DO NOT stop taking the drug(s) without talking to your doctor. Suddenly discontinuing drugs of any sort can cause serious problems for your baby and can even lead to your baby’s death, Welch-Carre notes. Your provider will assist you in deciding the best path to take to limit the exposure your baby has. Be sure to continue care with your provider and closely follow the instructions given to you because this will lead to the best outcome for both you and your baby.

If you have an opioid addiction and are pregnant, maintenance therapy with methadone or buprenorphine may be a good option for you. It won’t prevent NAS, but studies have shown that maintenance therapy creates fewer withdrawal symptoms in infants, thereby decreasing the need for treatment and lessening hospital stays.19

If you have a substance use disorder and aren’t pregnant, but plan to be someday, get treatment now so you can be drug-free when you do get pregnant. This is the best way to prevent your baby from developing NAS.

In all cases, find a sympathetic, non-judgmental healthcare provider who has had experience with women and addiction or opioid use, advises Wallace. “We believe that addiction is a disease, just like diabetes or high blood pressure,” she says. “(Women who are addicted) deserve and need consistent and good medical care, just like if they had diabetes or high blood pressure and they were pregnant. There’s so much shame and guilt involved in being an addict anyway.” If your healthcare provider seems judgmental or unsupportive, it’s time to find a new one.

1. https://www.cdc.gov/cdcgrandrounds/pdf/archives/2016/august2016.pdf, page 4
2. http://www.marchofdimes.org/complications/neonatal-abstinence-syndrome-(nas).aspx
3. https://www.drugabuse.gov/related-topics/trends-statistics/infographics/dramatic-increases-in-maternal-opioid-use-neonatal-abstinence-syndrome
4. https://www.cdc.gov/cdcgrandrounds/pdf/archives/2016/august2016.pdf, page 9
5. https://www.cdc.gov/cdcgrandrounds/pdf/archives/2016/august2016.pdf, page 7
6. https://www.cdc.gov/mmwr/volumes/65/wr/mm6531a2.htm
7. http://www.drugfree.org/news-service/high-prescribing-rates-likely-factor-neonatal-abstinence-syndrome-increase-expert/
8. http://jamanetwork.com/journals/jamapediatrics/article-abstract/2556200
9. https://www.cdc.gov/cdcgrandrounds/pdf/archives/2016/august2016.pdf, page 17
10. https://www.cdc.gov/cdcgrandrounds/pdf/archives/2016/august2016.pdf, page 13
11. http://www.marchofdimes.org/complications/neonatal-abstinence-syndrome-(nas).aspx
12. https://www.sciencedaily.com/releases/2016/04/160430100230.htm
13. http://www.marchofdimes.org/complications/neonatal-abstinence-syndrome-(nas).aspx
14. http://www.csmonitor.com/USA/USA-Update/2016/1213/Why-are-rural-areas-seeing-a-rise-in-drug-dependent-newborns
15. https://www.nytimes.com/2016/12/12/health/rise-in-infant-drug-dependence-in-us-is-felt-most-in-rural-areas.html
16. https://www.cdc.gov/mmwr/volumes/66/wr/mm6609a2.htm
17. https://www.cdc.gov/mmwr/volumes/66/wr/mm6609a2.htm
18. https://www.cdc.gov/cdcgrandrounds/pdf/archives/2016/august2016.pdf, page 44
19. https://www.cdc.gov/cdcgrandrounds/pdf/archives/2016/august2016.pdf, page 43

Other Sources
1. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0024264/
2. http://www.marchofdimes.org/advocacy/neonatal-abstinence-syndrome.aspx
3. https://www.childrens-specialized.org/programs-and-services/inpatient-programs/neonatal-abstinence-syndrome
4. https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=90&ContentID=P02387

Written by Sarah E. Ludwig

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