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Understanding Neonatal Abstinence Syndrome

Written by Mariya Rizwan, PharmD

In recent years, the healthcare community has witnessed a concerning uptick in neonatal abstinence syndrome (NAS) incidences. This condition, characterized by withdrawal symptoms in newborns exposed to opioids or other substances in utero, has steadily climbed for the past several decades. This increase has often burdened healthcare systems, particularly nursing professionals, who often serve as the first line of care for these vulnerable patients. Various factors, such as the opioid crisis, increased prescription medication usage during pregnancy, and socio-economic conditions, have contributed to these increasingly worrisome occurrences.

From a definition standpoint, NAS occurs when a newborn undergoes various clinical manifestations and symptoms due to intrauterine drug withdrawal. The baby becomes dependent on the drugs the mother takes. Most commonly, it happens with maternal opioid use.

Within the last few decades, the incidences of NAS have dramatically increased. According to the Centers for Disease Control and Prevention (CDC), roughly every 24 minutes, a baby is diagnosed with the condition in the United States – which also amounts to an average of 60 newborns born with NAS in a 24-hour period. The increasing rate is alarmingly high and needs attention.

There are two major types of NAS commonly recognized. The first type happens due to prenatal or maternal substance use that causes withdrawal symptoms. The second type is postnatal NAS, which occurs due to the discontinuation of pain medications such as fentanyl or morphine that were given to the baby.

NAS Symptoms

The signs and symptoms of NAS can vary widely and are influenced by several factors. These include the specific type of drug used by the mother, the quantity consumed, the duration over which the drug was used, and how the mother's body metabolized the substance. Understanding these variables is essential for nursing professionals in diagnosing and managing NAS effectively, as the range and severity of symptoms can differ from one case to another based on these contributing factors.

Central nervous system symptoms:

  • High-pitched cry – the baby cries louder than usual
  • Jitteriness – in newborn babies, jitteriness is normal because their nervous system is poorly developed. But in infants with NAS, the child is irritable with jitteriness.
  • Tremors
  • Disturbed sleep
  • Abnormal electroencephalogram (EEG)
  • Generalized convulsions
  • Increased muscle tone
  • Exaggerated reflexes
  • Disturbed sleep
  • Hyperirritablity and hyperactivity
  • Cries continuously despite consoling measures
  • Excoriation of the chin, knees, elbow, toes, nose
  • Motor, respiratory tract, and metabolic symptoms:
  • Sneezing
  • Nasal flaring
  • Breath rates higher than 60 breaths per minute with or without retractions
  • Moaning
  • Nasal stuffiness
  • Frequent yawning – more than 3 to 4 times during the assessment interval
  • Sweating and fever – temperature greater than 37.2 C
  • Mottling – blotchy skin patches develop over the baby's body. It happens because the heart can not pump enough blood, leading to severe hypotension, a cold body, and blue patches on the body. Mottling also occurs with sepsis and can be misdiagnosed with it.

Gastrointestinal disturbances that occur:

  • Excessive sucking – this action occurs when the baby is rooting more than three times per assessment interval; it involves displaying swiping movements with a hand across the mouth in an attempt to suck on the fist, hands, and pacifier.
  • Hyperphagia – this happens when the baby is feeding more than usual. It usually starts within a week and takes three to four weeks to settle down, which can lead to weight gain in the infant.
  • Disorganized suck and swallow
  • Vomiting and diarrhea – can lead to dehydration, electrolyte imbalance, and buttock excoriation.
  • Poor feeding – the baby shows infrequent sucking during feeding or gulping milk and stops frequently in the interval to breathe.

NAS vs. Fetal Alcohol Syndrome

Accurate diagnosis is crucial for effective intervention and long-term management in neonatal care. Although NAS and fetal alcohol syndrome (FAS) manifest with some overlapping symptoms, such as irritability and feeding difficulties, they are distinct entities with different etiologies and treatment protocols. For healthcare professionals on the front lines of neonatal care, recognizing the unique features of each condition is essential for appropriate care management and family education.

NAS consists of withdrawal effects from maternal substance abuse during pregnancy, such as from meth or opioids. However, FAS occurs due to maternal alcohol consumption during pregnancy — it does not happen due to alcohol withdrawal.

The symptoms of FAS also include postnatal growth failure, microcephaly, intellectual disability, and a characteristic dysmorphic facial appearance. NAS does not cause these symptoms immediately.

NAS can often be managed effectively with early interventions, including medication and supportive therapies, leading to improved outcomes for the infant. In contrast, FAS is a lifelong condition that, although manageable to some extent, presents irreversible neurological and developmental challenges that require long-term care and support.

Prevalence of NAS in the United States

According to recent Healthcare Cost and Utilization Project (HCUP) data, out of every 1,000 hospital stays, six newborns are diagnosed with NAS in the United States. HCUP also indicated that the incidence of babies with the disorder varies greatly from state to state. While some areas, such as Hawaii, only saw 1 in 1,000 hospital stays from the condition, other states, such as West Virginia, saw as high as 43 in 1,000 newborns hospitalized with NAS.

Long-Term Effects

Children diagnosed with NAS face various neurodevelopmental challenges that can extend into early childhood. Compared to their unaffected peers, these children often demonstrate poorer neurodevelopmental outcomes, which is particularly noteworthy when considering cognitive abilities. Children exposed to opioids during pregnancy have been found to show a significant increase in mild developmental disability and various neurological deviations.

Moreover, research indicates that children between the ages of 10 and 14 exposed to opioids prenatally are at an elevated risk of being diagnosed with attention deficit hyperactivity disorder (ADHD). Additionally, these children may present with physical attributes, such as a smaller head circumference, compared to those not exposed to such substances during gestation.

From an early age, babies with NAS may experience difficulties with feeding. This condition often manifests as poor suck and swallow patterns, leading to malnutrition and low weight. Further complicating their health status are potential ophthalmic complications that could arise later in life. Conditions such as strabismus, nystagmus, reduced visual acuity, impaired smooth pursuit, and delayed visual development have all been associated with the direct neurotoxic effects of opioid exposure during pregnancy.

The Bottom Line

Analyzing a newborn's urine and meconium samples can identify prenatal substance exposure. Infants diagnosed with related conditions require ongoing medical assessments and close monitoring. As a healthcare provider, it's imperative to carefully track the baby's physical and cognitive development. Additionally, it is crucial to strongly encourage parents to adhere to a schedule of regular hospital check-ups for their child to ensure optimal care and early intervention if necessary.

About the Author:

Mariya Rizwan is an experienced pharmacist who has been working as a medical writer for four years. Her passion lies in crafting articles on topics ranging from Pharmacology, General Medicine, Pathology to Pharmacognosy.

Mariya is an independent contributor to CEUfast’s Nursing Blog Program.

Please note that the views, thoughts, and opinions expressed in this blog post are solely of the independent contributor and do not necessarily represent those of CEUfast. This blog post is not medical advice. Always consult with your personal healthcare provider for any health-related questions or concerns.

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