Neonatal abstinence syndrome

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Contributors: Eric Ingerowski MD, FAAP

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Synopsis

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Neonatal abstinence syndrome 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). 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 neonatal abstinence syndrome is associated with the withdrawal of postnatal pain therapy medications that were administered to the infant.

Neonatal abstinence syndrome 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, dehydration, frantic sucking, yawning, flaring of nostrils, fever, sweating, sneezing, abnormal posture or movements, hyperreflexia, hypertonia, back arching, seizures, and abnormal eye movements. Withdrawal symptoms begin within 48 hours of birth in more than half of opioid-exposed neonates, and persist for weeks to months.

When a history of maternal drug addiction is suspected, a positive urine screening and findings consistent with maternal opioid withdrawal will aid in diagnosis. However, the findings of neonatal abstinence syndrome vary greatly and depend on multiple factors, including the drug or combination of drugs used, how recently the drugs were used, and the newborn's gestational age at birth. Compiling an accurate medical history is difficult as many mothers 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 involve using standardized neonatal abstinence scoring tools and treatment protocols. Therapy is usually inpatient, but can be outpatient, depending on the pros and cons of each case. It often involves substituting transition drugs such as methadone or buprenorphine while providing comfort and symptomatic relief to the infant. Treatment of the mother's withdrawal is best done simultaneously. Resources for opioid use disorder treatment can be found here.

Nonpharmacologic therapy involves creating a supportive environment without bright lights or loud noises, and providing adequate rest while promoting parent / baby bonding activities. Breastfeeding can 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 mother 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.

Codes

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

SNOMEDCT:
414819007 – Neonatal Abstinence Syndrome

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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