eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Neonatology

Neonatal Abstinence Syndrome: Follow-up

Author: Ashraf H Hamdan, MB, BCh, MSc, MD, MRCP, Clinical Assistant Professor of Pediatrics, Vanderbilt University Medical Center; Neonatologist, Mid Tennessee Neonatology Associates.
Contributor Information and Disclosures

Updated: Jun 18, 2009

Follow-up

Further Inpatient Care

  • The length of hospitalization in patients with neonatal abstinence syndrome (NAS) varies, depending on the drug, withdrawal symptoms, and social factors.
  • Other issues that need to be addressed include breastfeeding and infectious disease prevention. If the mother abuses intravenous drugs, screen for HIV, hepatitis B and hepatitis C, Chlamydia, syphilis, and gonorrhea.
  • Breastfeeding confers immunologic benefits to the neonate, and bonding benefits the mother. Advise breastfeeding for the mother who is receiving maintenance doses of methadone if she receives no more than 20 mg of methadone per 24 hours and is not abusing other drugs. Only small amounts of methadone are detected in breast milk.
  • Breastfeeding is contraindicated if the mother is still using illicit drugs or has infections such as HIV or hepatitis. Enrollment in a drug rehabilitation program may be a prerequisite for breast feeding. Both marijuana and alcohol exposure through breast milk result in decreased motor development at age 1 year.

Further Outpatient Care

  • Provide follow-up care in the first few weeks to months of life to assess infant growth, behavioral characteristics, and motor ability.
  • Discharging otherwise healthy infants home once they are stable on treatment for neonatal abstinence syndrome can reduce hospital stay and associated costs. However, a safe discharge of the infant requires that support structures within the home and community are in place. In one study, compliance with the necessary clinic attendance was facilitated by establishment of a weekly follow-up clinic. This continuity of care was provided by staff with whom the families were familiar and which met all the families’ needs for the infants, including vaccinations, subspecialist appointments, and prescriptions.

Deterrence/Prevention

  • Identification of substance abuse is the first step in attempting to break the cycle of reproductive morbidity or mortality. Ideally, substance use should be terminated by women and their male sexual partner before conception. Pregnant drug-using women should be counseled at the earliest opportunity to abstain completely from all injurious substances and to seek prenatal care. Adequate dietary intake and supplemental prenatal vitamins should be stressed.
  • Health education specifically targeting consequences of drug abuse during and after pregnancy is beneficial to prevent this growing social problem.

Complications

  • Narcotics may have a direct effect on the development of the respiratory center in the brain stem, but an adverse effect of opiates on long-term postnatal growth is not evident. In longitudinal studies, developmental sequelae have not been proven. Problems with habituation, visual and auditory responsiveness, and interactive patterns have been observed in the first months of life.

Prognosis

  • Infants born to mothers who are chemically dependent face not only the experience of sudden withdrawal from poly intoxicants but also other medical and social challenges. Prognosis widely varies and depends on the family, socioeconomic variables, and whether either or both parents continue to use illicit drugs. A home environment with an addicted mother is a compromising variable.
  • Long-term problems of children exposed to illicit drugs in utero include adverse neurodevelopmental outcomes. Lower intelligence quotient scores have been reported in children with in utero exposure to cocaine or methadone. Speech, perceptual, and cognitive disturbances have been reported in toddlers who were exposed to opiates. Difficulties with expressive language articulation have been reported in children of mothers who abused cocaine. Behavioral problems are also reported in children of mothers who have taken illicit substances in pregnancy. These include lower levels of learning and adapting to new situations; higher sensitivity to their environment resulting in irritability, agitation, aggression, poor social skills; and a lack of imitative play and late emergence of symbolic play.
  • The severity of withdrawal signs, including seizures, has not been proven to be associated with differences in long-term outcome after intrauterine drug exposure. Furthermore, treatment of drug withdrawal may not alter the long-term outcome.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to screen for neonatal abstinence syndrome (NAS)
    • The medicolegal implications of screening the infant who has been exposed to drugs for the purpose of providing clinical care are complex. Screening creates a conflict between maternal, fetal, and neonatal interests. Although the state courts have granted unborn children some rights in other contexts, any attempt to grant unborn children greater protection against actions taken by their mothers during pregnancy is subject to strict scrutiny.
    • Screening neonates for illicit drugs without maternal consent is not recommended. In addition, performing these tests without maternal approval may be illegal in certain areas.
  • Failure to protect an infant at risk
    • Evidence of maternal substance abuse should alert the infant's medical caretaker that the mother may have medical, psychological, or behavioral problems that could have an impact on the infant's long-term health and welfare.
    • Testing the mother, infant, or both, with informed consent, is useful in some clinical situations, even when drug use is not suspected.
    • Some infants may be ill served if the physician relies solely on urine toxicology testing for screening. These test findings may be negative if drugs were used early in pregnancy or during the immediate 48 hours prior to delivery. Results also depend on laboratory variability.

Special Concerns

  • Infants exposed in-utero to drugs have a higher than expected risk of subsequent abuse compared with children in the general population.22
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Jaques Belik, MD, and Judy Hawes, RN, MN, to the writing and development of this article.



More on Neonatal Abstinence Syndrome

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Differential Diagnoses & Workup: Neonatal Abstinence Syndrome
Treatment & Medication: Neonatal Abstinence Syndrome
Follow-up: Neonatal Abstinence Syndrome
Multimedia: Neonatal Abstinence Syndrome
References
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Further Reading

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Keywords

neonatal abstinence syndrome, neonatal withdrawal syndrome, NAS, prenatal NAS, postnatal NAS, maternal substance abuse, low birth weight, prematurity, intrauterine growth retardation, IUGR, hypoglycemia, hypocalcemia, sepsis, hypoxic encephalopathy, intracranial hemorrhage, jitteriness, neonatal adaptation syndrome, maternal drug use, pregnant drug use, placental abruption, fetal alcohol syndrome, maternal substance abuse, drug use in pregnancy, sudden infant death syndrome, SIDS, depression, fetal alcohol syndrome, treatment, diagnosis

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Contributor Information and Disclosures

Author

Ashraf H Hamdan, MB, BCh, MSc, MD, MRCP, Clinical Assistant Professor of Pediatrics, Vanderbilt University Medical Center; Neonatologist, Mid Tennessee Neonatology Associates.
Ashraf H Hamdan, MB, BCh, MSc, MD, MRCP is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Medical Editor

Scott MacGilvray, MD, Clinical Associate Professor of Pediatrics, East Carolina University School of Medicine
Scott MacGilvray, MD is a member of the following medical societies: American Academy of Pediatrics and American Medical Association
Disclosure: MedImmune Speakers Bureau Honoraria Speaking and teaching

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Brian S Carter, MD, FAAP, Professor of Pediatrics (Neonatology), Vanderbilt University School of Medicine; Co-director, Pediatric Advance Comfort Team, Monroe Carell Jr Children's Hospital at Vanderbilt
Brian S Carter, MD, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Society for Bioethics and Humanities, American Society of Law Medicine and Ethics, National Hospice and Palliative Care Organization, and Southern Society for Pediatric Research
Disclosure: Nothing to disclose.

CME Editor

Carol L Wagner, MD, Professor of Pediatrics, Medical University of South Carolina
Carol L Wagner, MD is a member of the following medical societies: American Academy of Pediatrics, American Chemical Society, American Medical Women's Association, American Public Health Association, American Society for Bone and Mineral Research, American Society for Clinical Nutrition, Massachusetts Medical Society, National Perinatal Association, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Chief Editor

Ted Rosenkrantz, MD, Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine
Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Pediatric Society, Connecticut State Medical Society, Eastern Society for Pediatric Research, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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