Neonatal Abstinence Syndrome Treatment

Pregnancy is typically a time of happiness and excitement, but it can also present health problems for the mother and baby if the mother isn’t aware that her own health will affect that of her baby. Thanks to modern medicine and procedures, giving birth has become easier and often results in a healthy birth, but there are still potential risks for both the mother and infant. A healthy diet, light exercise, and the omittance of caffeine, fish, and alcohol are suggested for mothers-to-be. However, one of the greatest dangers to the health of an infant can come from the mother’s use of opioids.

With a national increase in opioid misuse, there has also been an increase in Neonatal Abstinence Syndrome (NAS) in recent years. NAS is a substance withdrawal syndrome occurring in infants after utero exposure to opioids or other substances. The NAS symptoms in an infant typically occur 48–72 hours after birth. Some of these symptoms include respiratory issues, feeding difficulties, low birth weight and seizures.

Once an infant is born and the symptoms of withdrawal appear, medical professionals typically use pharmacological intervention with methadone or morphine to treat the baby. When the NAS symptoms begin to diminish, the treatment medication being used is tapered as part of a modified protocol that can last for three or more weeks. Pharmacological intervention is often required for 50–70 percent of infants that are born with NAS.

The severity of withdrawal for the infants is approximated using a number of scoring systems, the most common of which is the Finnegan Neonatal Abstinence Severity Score. This scoring system lists 21 symptoms that are most frequently observed in opioid-exposed infants. Each symptom and its accompanying level of severity is assigned a score and the subsequent total is recorded.

Neonatal Abstinence Syndrome Withdrawal

Just like withdrawal symptoms can vary from adult to adult, NAS symptoms vary from baby to baby — but the difference is these infants can’t talk and explain how they’re feeling, so it’s critical that if any symptoms are observed, the infant is closely watched for any additional signs of withdrawal. Symptoms are often dependent on which substances were misused by their mother.

Neonatal Abstinence Syndrome Withdrawal Symptoms

Most withdrawal symptoms begin three days after birth, but some may occur right after birth or sometimes weeks after birth. These symptoms can last from one week to six months after the infant is born.

Some common signs and symptoms of a withdrawal for infants with NAS include:

• Tremors
• Convulsions
• Twitching
• Tight muscles
• Excessive crying
• High-pitched crying
• Poor feeding or slow weight gain
• Breathing problems
• Fever
• Sweating
• Blotchy skin
• Trouble sleeping
• Diarrhea
• Stuffy nose
• Sneezing

Neonatal Abstinence Syndrome Treatment Options

Treatment for the infant with NAS is imperative, most babies with NAS who receive treatment often get better within the first five to thirty days. Once a baby is diagnosed with NAS, treatment for the syndrome begins with non pharmacological techniques, like decreasing environmental stimuli by, for example, placing the infant in a dark, quiet space, and swaddling. If an infant has a severe case of NAS they will often require tapered doses of morphine or methadone as recommended by the American Academy of Pediatrics. This strategy is to ease the discomfort of the infant’s withdrawal.

Additional treatment for infants with NAS may include:

• Receiving fluids through an intravenous (IV) to prevent the infant from becoming dehydrated because infants with NAS vomit or have diarrhea more often than healthy infants, due to withdrawal.
• Drinking higher-calorie baby-formula. Some infants with NAS need extra calories to help them grow and develop because they have difficulty feeding.
• Skin-to-skin care (also known as kangaroo care) is when the mother places the infant on her bare chest.
• Breastfeeding if, of course, the mother is able to.

Prior to the birth of the infant, treatment can begin for the mothers who are misusing opioids. Care providers typically begin with medically supervised tapering of opioids in pregnant women. The Substance Abuse and Mental Health Services Administration (SAMHSA)  and the American College of Obstetricians and Gynecologists (ACOG) recommend that pregnant women misusing opioids receive medically assisted treatment with methadone or buprenorphine. ACOG recommends prevention methods like all women who are pregnant being routinely asked about substance misuse.

Other preventative measures that pregnant women can employ to help prevent NAS in their baby include:

• Telling their provider immediately about their misuse of opioids so they receive treatment. Stopping use suddenly can cause severe problems for the mother and their baby, sometimes including death. The mother should seek treatment for their opioid misuse disorder as soon as possible, since it’s safer for them and their baby compared to receiving no treatment at all.
• Asking their provider about medically assisted treatment (MAT). NAS in infants may be easier to treat for babies whose mothers received MAT during their pregnancy.
• Making sure health care providers know that they are pregnant. Pregnant women may have to stop taking certain medicines or change to a safer option. Prescription opioids and other medications can still cause NAS in an infant.
• If a woman is thinking about getting pregnant, she should stop misusing prescription or illicit opioids. The woman can either change prescriptions to a non-opioid or seek treatment for her continued misuse of opioids.
• If a woman is using or misusing prescription opioids or illicit opioids, she should use birth control until she is ready to get pregnant. If a woman who is taking opioid prescriptions or misusing opioids and she gets pregnant, her baby could be at risk for developing NAS.

Neonatal Abstinence Syndrome Length of Stay

Similar to a substance withdrawal in adults, the withdrawal and treatment duration for infants with NAS varies from baby to baby. Recent studies have discovered that hospitals can also utilize additional strategies to decrease the amount of time infants with NAS must remain in the hospital to receive treatment. These strategies include rooming-in (instead of the infant being placed in neonatal intensive care units), increased family involvement and standard opioid weaning guidelines. When hospitals implement standardized procedures for treating infants with NAS, it can shorten their hospitalization and treatment.

Neonatal Abstinence Syndrome Treatment Costs

The rise of opioid misuse has led to an increase in babies born with NAS. A majority of the costs for treatment of NAS in infants is paid for by state Medicaid programs. The average cost for a healthy newborn is $3,500 compared to the cost of a newborn with NAS, which is $66,700. Medical treatments for NAS can cost roughly $150,000 per child and the average cost in 2015 for a newborn diagnosed with NAS was determined to be between $159,000 and $238,000.

While treatment for an infant with NAS is critical for the baby’s health, prevention is the most effective strategy in making sure a pregnant woman delivers a healthy baby. The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain suggests that medical professionals acknowledge the unique sensitivities of prescribing opioid medications to pregnant women or even women who aren’t pregnant but are of reproductive age. The guidelines also recommend that clinicians discuss how long-term opioid use could affect current and future pregnancies and how women of reproductive age can avoid an unintended pregnancy if they are taking opioids long-term. Finally, the guide recommends women of reproductive age consider non-pharmacological treatments for chronic pain management or getting prescribed one of the lowest doses if they are prescribed an opioid medication.