Neonatal Abstinence Syndrome Treatment & Management
- Author: Ashraf H Hamdan, MD, MBBCh, MSc, MRCP; Chief Editor: Ted Rosenkrantz, MD more...
The large number of infants who suffer from neonatal abstinence syndrome (NAS) and the associated long-term morbidity mandate that affected infants be accurately identified and their treatment and support should be optimized. Note the following:
The assessment and management of neonatal abstinence syndrome pose difficulties for staff and families and have been hampered by a lack of prospective studies and by few research studies that specifically assess the merits of one management approach over another.
Infants at risk for NAS should be carefully monitored in the hospital for the development of signs consistent with withdrawal. The appropriate duration of hospital observation is variable and depends on a careful assessment of the maternal drug history. An infant born to a mother on a low-dose prescription opiate with a short half-life (eg, hydrocodone) may be safely discharged if there are no signs of withdrawal by age 3 days, whereas an infant born to a mother on an opiate with a prolonged half-life (eg, methadone) should be observed for a minimum of 5-7 days.  After discharge, outpatient follow-up should occur early and include reinforcement of the education of the caregiver about the risk of late withdrawal signs.
Vomiting and diarrhea leading to dehydration and poor weight gain, in the absence of other diagnoses, are indications for treatment, even in the absence of a high drug-withdrawal score.
In the delivery room, naloxone use is contraindicated in infants whose mothers are known to be dependent on opioids because of the risk of neonatal seizures from abrupt drug withdrawal. However, in the absence of a specific history of opioid abuse in a mother who has recently received narcotics, naloxone treatment remains a reasonable option in the delivery room management of a depressed infant if the infant continues to demonstrate respiratory depression after positive pressure ventilation has restored normal heart rate and color.
Primary treatment of neonatal symptoms related to prenatal substance exposure should be supportive because pharmacologic therapy can prolong hospitalization and exposes the infant to additional agents that are often not necessary. The treatment for morphine administration has been reported to last 8-79 days.  This length of hospitalization interferes with maternal bonding, has potential for nosocomial infection, and is a major use of resources. 
Pharmacotherapy for infants with more severe expression of neonatal abstinence syndrome is necessary to allow them to feed, sleep, gain weight, and interact with caregivers. Approximately 30-91% of infants who exhibit signs of neonatal abstinence syndrome receive pharmacological treatment. The limited available evidence from controlled trials of neonatal opioid withdrawal supports the use of oral morphine solution and methadone when pharmacologic treatment is indicated. Growing evidence suggests that oral clonidine is also effective either as a primary or adjunctive therapy, but further prospective trials are warranted. 
There is evidence that, compared with oral methodone treatment, oral morphine sulfate therapy for NAS reduces the length of stay in the hospital and neonatal intensive care unit (NICU), treatment duration, maximum opioid requirements, and total cost.  Similarly, treatment with sublingual buprenorphine for NAS appears to be associated with a shorter duration of opioid therapy and hospitalization compared with oral methadone therapy. 
Nonpharmacologic approaches include the following:
Assess daily for signs of withdrawal, sleeping habits, feeding patterns, and weight gain.
Minimize environmental stimuli by reducing light exposure, minimize excessive noise, avoid unnecessary handling, provide swaddling, and non-nutritive sucking with a pacifier.
Provide frequent small feeds of hypercaloric formula.
In a study of 547 late preterm and term neonates with narcotic abstinence syndrome who received inpatient pharmacologic treatment, including 417 who were managed with an established weaning protocol and 130 who were managed without an established weaning protocol, researchers found that use of a stringent weaning protocol reduced the duration of opioid exposure and the length of hospital stay.[46, 47]
After adjustment for treatment site, infants who underwent protocol-based weans had a significantly shorter duration of opioid treatment (17.7 vs 32.1 days; P < .0001) and a significantly shorter hospital stay (22.7 vs 32.1 days; P = .004).[46, 47] There was no difference among infants who received protocol-based weaning in duration of opioid treatment or length of hospital stay between those treated with morphine and those treated with methadone. The duration of administration of phenobarbital was significantly longer among patients treated with morphine compared with those treated with methadone (P ≤ .002).[46, 47]
Newborns with NAS are frequently cared for in NICUs. Studies suggest that care for NAS delivered in hospital settings outside of the NICU and outpatient management reduces length of stay and cost.[48, 49]
Interdisciplinary intervention for the mother and her offspring (and the father, when possible) should be available at all points of access to care. Professionals involved in this care should include obstetricians, neonatologists, pediatricians, nurses, nutritionists, mental health professionals, social workers, substance abuse counselors, and child development specialists, at a minimum.
The American Academy of Pediatrics (AAP), The American College of Obstetricians and Gynecologists (ACOG), and the Academy of Breastfeeding Medicine (ABM) support breastfeeding among opioid-dependent women if the women are enrolled in substance abuse treatment and no contraindications to breastfeeding are observed, such as ongoing drug use or HIV infection.[31, 50, 51]
Frequent small feedings are preferable and should provide 150-250 kcal/kg per 24 hours for proper growth of the infant undergoing significant withdrawal.
Neonates undergoing treatment of NAS have increased caloric requirements and may develop hyperphagia. Therefore, careful monitoring of fluid intake and weight gain are essential.
Swaddling, pacifiers, low lighting, oscillating cribs, and avoidance of abrupt changes in the infant’s environment can be helpful.
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