Neonatal Abstinence Syndrome

Neonatal abstinence syndrome (NAS) occurs when neonates who were exposed to drugs in utero experience withdrawal after birth. While most of the data around NAS focuses on opioids, other common drugs that can lead to NAS are SSRIs, barbiturates and benzodiazepines. These substances pass through the placenta into neonatal circulation, causing dependency and ultimately withdrawal symptoms in the newborn.

According to the Centers for Disease Control and Prevention, an infant is diagnosed with NAS every 15 minutes in the United States. Non-hispanic white infants are at highest risk for NAS, with males tending to have increased severity of symptoms. All infants born to mothers who use opioids or other culprit substances are at risk, though not all opioid-exposed newborns will have symptoms.

Complications of NAS

Neonatal abstinence syndrome is more than the unpleasant symptoms the neonate experiences and the complications can be significant. The most serious complication is sudden infant death syndrome (SIDS) which is the primary cause of mortality, especially in cocaine, opioids and polysubstance abuse. Other complications and comorbidities include:

• Low birth weight and preterm birth
• Poor feeding and weight loss 
• Transient tachypnea of the newborn (TTN) and other respiratory complications
• Meconium aspiration syndrome
• Jaundice
• Seizures and visual disturbances (strabismus, nystagmus, lower visual acuity)
• Dysregulation of behavioral systems
• Developmental delays, learning difficulties and behavioral issues
• Longer hospital stays

Now that you have an understanding of NAS, it’s time to learn how to care for these patients using the Straight A Nursing LATTE method.

L: How does the patient LOOK?

An infant experiencing NAS can display a wide variety of symptoms depending on the type of opioid used, timing of the last dose, polysubstance use, maternal metabolism and the infant’s metabolism. 

CNS disturbances – High pitched cry, tremors, poor sleep, irritability, increased muscle tone, myoclonic jerks, convulsions, and a hyperactive moro reflex. The moro reflex is in response to sudden stimulation or a sudden lack of support and involves the infant extending the arms and neck, and then pulling the arms in.

GI disturbances – Poor feeding and suck, regurgitation and vomiting, loose/watery stools.

Respiratory disturbances – Tachypnea, nasal stuffiness, nasal flaring.

Other – Sweating, fever, yawning, weight loss, mottling of skin, excoriation (often on the chin, nose and cheeks due to the infant clawing at his face).

A: How do you ASSESS the infant with NAS?

A key component of your assessment is NAS scoring, most often done with the Finnegan Neonatal Abstinence Scale (FNASS). This scoring tool assigns points to the 21 most common symptoms (most of which are listed above), with a score of 7 or less indicating no medication is needed. Scoring is conducted routinely, often every three to four hours during the infant’s hospital stay and anytime there’s a change in behavior or treatment. When using The Finnegan Scale, do so with the knowledge that it is a subjective assessment which could lead to over or under medicating patients. It’s a good idea to periodically have another nurse perform the assessments to help ensure more reliable scoring.

Another assessment framework is part of the Eat, Sleep, Console method (discussed in treatments). 

• Assess if the infant is able to eat an appropriate amount
• Assess the infant’s sleep habits; the infant should sleep for a minimum of 1 hour after feeding
• Assess the infant’s ability to be consoled within 10 minutes

Other key assessments include:

• Intake and output
• Weigh the infant to assess for weight loss
• Assess for dehydration secondary to poor intake, vomiting, and watery stools
• Monitor for complications such as respiratory distress and seizures

T: What TESTS are utilized in NAS?

There is no specific diagnostic test for NAS and it is diagnosed based on the maternal history and through ruling out other possible causes for the infant’s symptoms. If NAS is suspected, maternal and infant toxicology tests may be conducted. Note that a negative test does not rule out NAS as the opioid may have cleared the system.

T: What TREATMENTS are provided for NAS? 

Treatment for NAS is guided by scoring and continuous assessment of the infant’s symptom severity. One such treatment modality is Eat, Sleep, Console (ESC). This family-centered approach starts with non-pharmacologic treatments of feeding the infant on demand, consoling the child when they are irritable, and letting them sleep between feedings as much as possible. If these interventions are ineffective, then pharmacological interventions are utilized. Benefits of ESC over other modalities are shorter NICU stays, less use of pharmacologic agents, lower treatment costs, and more family involvement in care of the infant.

And then of course, the Finnegan scale is also used to determine if pharmacologic treatment is warranted. Medications utilized for NAS include morphine, methadone, buprenorphine, clonidine, and phenobarbital. Note that in most cases, infants will be weaned off these medications prior to discharge. 

Other non-pharmacologic symptom management interventions:

• Maintain a neuro friendly environment that includes dim lights and low noise
• Swaddling and gentle handling of the infant to avoid overstimulation
• Wake infant gently to avoid overstimulation
• Support infant’s sleep after feeding (may require holding the infant)
• Provide a pacifier for non-nutritive sucking
• Rocking the infant
• Skin-to-skin contact (kangaroo care)

Other interventions may include IV hydration and nutritional supplementation with high-calorie formula if breastfeeding is not utilized or does not provide adequate calories.

E: How do you EDUCATE the family?

It is important to maintain a nonjudgmental demeanor when caring for families of NAS infants and to provide education in an open and honest manner. Key elements of your teaching plan should include:

• Provide opioid use disorder (OUD) resources to prevent instances of NAS with future pregnancies
• Breastfeeding is safe with maternal use of methadone and buprenorphine
• Avoid breastfeeding if continuing to use substances that cause opioid dependency in the newborn; ensure caregivers know how to provide nutrition to the infant
• NAS symptoms can persist or occur later; ensure caregivers know the potential signs and symptoms to watch for
• Encourage mother to seek prenatal care with future pregnancies and discuss drug use with their physician
• Follow-up care is important to monitor for developmental delays and assess the ongoing health of the child

Learn about NAS on the go in episode 263 of the Straight A Nursing podcast. Listen from any podcast platform, or straight from the website here.

Looking for more topics covering maternal newborn? Explore them here!

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