Neonatal Abstinence Syndrome Differential Diagnoses

Updated: May 17, 2023
  • Author: Ashraf H Hamdan, MD, MBBCh, MSc, MRCP, FAAP; Chief Editor: Santina A Zanelli, MD  more...
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Diagnostic Considerations

Important considerations

Many state laws and policies have been established in an attempt to prevent and/or address prenatal substance use. Existent laws address the testing, reporting, prosecution, and receipt of welfare benefits for pregnant women who use drugs.

Historically, substance abuse testing and reporting laws differ among states, as in the following examples:

  • The Guttmacher Institute reported that four states (Iowa, Kentucky, Minnesota, and North Dakota) require health care professionals to test for prenatal drug exposure when prenatal drug abuse is suspected, and 14 states (Alaska, Arizona, Illinois, Iowa, Louisiana, Massachusetts, Michigan, Minnesota, Montana, North Dakota, Oklahoma, Rhode Island, Utah, and Virginia) require reporting women to child protective services (CPS) for prenatal substance use. However, federal Public Law 108-36 (Keeping Children and Families Safe Act of 2003) attempted to create a uniform state response to prenatal substance abuse.

  • The 2003 reauthorization of the federal Child Abuse Prevention and Treatment Act (CAPTA) requires states receiving CAPTA grants to develop a plan for medical workers to notify CPS of infants identified at birth as affected by prenatal drug exposure. The law states that this referral, in and of itself, is not grounds for a child abuse and/or neglect determination and cannot be used for criminal prosecution. Rather, it is intended to provide a safety screening and to link the mother to voluntary community services. The law also requires that CPS develop a safe plan for infants in this situation. [48]

Each physician should be familiar with his state law regarding screening and reporting of prenatal substance abuse and neonatal exposure to substances in utero.

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.

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. [49]

Women who abuse substances face multiple stressors, including poverty, mental illness, and past and present physical, emotional, and sexual abuse. In turn, their children must cope with the consequences of living in a home environment where their developmental needs may not be met, and where they are at risk of out-of-home placement.

Prenatal maternal alcohol and drug use predicted child maltreatment and postnatal exposure to substances, as well as increased risk for maternal involvement with a substance-abusing partner. [50]

Other problems to be considered

Hyperviscosity and intracranial hemorrhage should also be considered. Drug withdrawal should be considered as a diagnosis in infants in whom compatible signs develop. Physicians should be aware of other potential diagnoses that should be evaluated and treated, if confirmed.

Infants with signs and symptoms of neonatal abstinence syndrome (NAS) may have other conditions that result in abnormal behavior. The nonspecific nature of the clinical features of neonatal abstinence syndrome mean that some drug-exposed infants may have exaggerated scores when they are hungry or may have other conditions such as neonatal sepsis, hypoglycemia, hypocalcemia, hyperthyroidism, or subarachnoid hemorrhage. However, congenital hypothyroidism has been reported to mask the symptoms of neonatal abstinence syndrome. [51] For that reason, assess the infant and consider whether symptoms are solely due to neonatal abstinence syndrome and whether other investigations are warranted.

Differential Diagnoses