Neonatal Abstinence Syndrome (FL INITIAL Autonomous Practice - Differential Diagnosis)

Neonatal abstinence syndrome (NAS) is experienced by newborns exposed to opioids or other substances such as benzodiazepines and selective serotonin reuptake inhibitors. An infant exposed to such substances in utero is often at risk of developing withdrawal after birth. NAS is a generalized disorder characterized by signs and symptoms of autonomic nervous system dysfunction, respiratory distress, gastrointestinal symptoms, and neurobehavioral dysregulation. NAS describes infants at risk for withdrawal from polysubstance, including opioids. Neonatal opioid withdrawal syndrome (NOWS) describes neonates with opioid-only withdrawal symptoms. The term NAS will be used here to describe both polysubstance and opioid-only exposure and withdrawal.

NAS occurs in 50-95% of infants exposed to utero substances during pregnancy (Cooks et al., 2017). These infants often begin to demonstrate signs of withdrawal during the first two to seven days of life. Nurses caring for these infants must have the assessment skills to assist in the timely diagnosis and treatment of these infants. The care of these infants often requires environmental modifications, developmental modifications, feeding plans, and family partnership in care, and between 42-94 percent of these infants require pharmacotherapy treatment  (Patrick et al., 2015).

NAS is defined by signs of postnatal drug withdrawal and can occur from exposure to either licit (oxycodone, fentanyl) or illicit substances (heroin) in utero. It is also associated with antenatal exposure to medication used to treat opioid use disorder, such as methadone or buprenorphine. NAS causes major physiological changes in the infant, including respiratory distress, autonomic nervous system dysfunctions, nervous system irritability, and gastrointestinal disturbances.

The United States is experiencing an opioid use crisis, leading to an increased incidence of NAS. The number of infants covered by Medicaid diagnosed with NAS has increased fivefold from 2004 to 2014. In 2004, 2.8 per 1000 births resulted in NAS, compared to 2014, 14 (Tolia et al., 2015). Per 1000 births resulted in a NAS diagnosis (Winkleman et al., 2018). Similarly, in another cross-sectional study, NAS admissions to the neonatal intensive care unit increased from 7 to 27 per 1000 admissions, and the median length of stay increased from 13 to 19 days (Tolia et al., 2015).

In 2014, $563M was spent on costs for treatment of NAS; 82% of this was covered by state Medicaid programs, reflecting the greater tendency of mothers using opioids during pregnancy to be from lower-income communities (Honein et al., 2019).

The pathophysiology of NAS and the various factors that affect the severity is not completely understood today; however, it is directly related to the agonist effects of opioids. These agonist effects of opioids lead to supraspinal analgesia, sedation, euphoria, respiratory depression, and decreased gastrointestinal motility. Opioids at the cellular level inhibit the release of noradrenaline at synaptic terminals. Chronic exposure to opioids causes tolerance as noradrenaline release from the synapse rate increases towards normal. When the discontinuation of opioids occurs at birth, there is a supranormal release of noradrenaline, which then causes autonomic and behavioral symptoms of withdrawal. The mu receptors are more concentrated in the gastrointestinal tissue and the central nervous system; therefore, withdrawal likely includes the central nervous system, overactive autonomic system, and gastrointestinal disturbances (Ordean & Chisamore, 2014).

The onset of NAS symptoms and clinical signs of withdrawal vary depending on the history of the intrauterine exposure and the half-life of the substance used. For neonates exposed to maternal heroin and prescription opioids, withdrawal symptoms commonly present in the first 24 hours of life. Clinical signs and symptoms of withdrawal from methadone or buprenorphine generally start between 48 to 72 hours after birth because those substances are long-acting. However, for all opioids, withdrawal may be delayed for up to 5-7 days after birth.

The classic signs of NAS are related to the dysfunction of state of control and attention, motor and tone control, sensory integration, and autonomic functioning. Symptoms include:

• Metabolic, vasomotor, and respiratory system:
  • Temperate instability
  • Frequent yawning
  • Sweating
  • Sneezing
  • Nasal congestion
  • Tachypnea
  • Mottling
• Gastrointestinal system:
  • Projectile vomiting
  • Reflux
  • Loose / Watery stools
  • Poor weight gain
  • Poor feeding
  • Excessive sucking
• Central Nervous System:
  • Jitteriness
  • Short sleep cycles
  • Difficulty maintaining an alert state
  • High pitched cry
  • Irritability
  • Seizure
  • Hyperarousal
  • Excoriation

Healthcare providers caring for infants at risk for NAS based on maternal history or those newborns with suspected NAS are assessed and scored on a specific NAS scale to monitor the presence and severity of their withdrawal and help manage their care. Several screening tools have been developed over the past several decades; however, the Finnegan Neonatal Abstinence Scoring system is the most widely used. Loretta Finnegan developed this tool in 1975 to provide a standardized method for assessing full-term neonates exposed to narcotics. The tool assesses 21 of the most commonly found clinical symptoms and signs of newborn drug withdrawal symptoms, and the total score can range from 0-62. NAS assessment should begin at birth for all newborns with known opioids and other substance exposure, and the assessment should be performed every 2-4 hours for the length of the newborn's hospital stay.

It should be noted that most of the assessment tools to assess NAS are based on a full-term infant and are not appropriate for use in preterm newborns. Preterm infants less than 35 weeks gestation have lower rates of NAS when compared to full-term newborns. NAS symptoms are noted to be less severe as gestational age decreases. This syndrome is related to the developmental immaturity of the central nervous system and decreased mu receptor development, and a lower amount of fat deposition of substances. Premature infants also have a limited ability to express signs of motor dysfunction and experience a reduced total substance exposure during their shortened intrauterine period.

Identification of NAS in neonates is through the reported maternal history of drug use, physical examination, and laboratory tests. The clinical diagnosis of perinatal drug exposure is based on the reported or suspected history of maternal opioid use, positive maternal drug screening, positive newborn drug screen results, or neonates presenting with findings consistent with NAS. Identifying newborns at risk for NAS begins during prenatal care of the mother. If the healthcare team is aware of the maternal use of opioid substances before the newborn's birth, the team will be able to provide accurate clinical assessments and early interventions and mitigate signs of NAS. However, women are often less likely to self-report illegal drug use with their healthcare providers because of social and legal consequences. Screening for maternal substance use through toxicology requires consent, and currently, there is not a consensus on universal screening. In the United States, screening newborns' biological specimens for substance exposure may not require maternal consent based on state laws. Neonatal testing most commonly is performed on urine, although this screening has a low sensitivity. Hair, meconium, and umbilical cord tissue are other specific toxicology tests used to assess newborn intrauterine drug exposure. Although a positive maternal or neonatal toxicology specimen is useful in confirming the diagnosis of NAS, it should always be considered an adjunct to the healthcare providers' clinical assessment.

NAS may also have similar features to other conditions affecting newborns; therefore, clinical signs should not be purely attributed to drug withdrawal without assessment and diagnostic tests to differentiate from other causes. Seizure-like activity may be related to hypocalcemia, hypoglycemia, and hypoxic-ischemic encephalopathy. Newborns presenting with fever, irritability, and poor feeding may be linked to sepsis, hyperthyroidism, and polycythemia.

The care of the newborn at risk for or diagnosed with NAS must be delivered by a nonjudgmental multidisciplinary team trained in the management of maternal substance use disorder and NAS. Social services and healthcare providers must work together to care for newborn mother dyad during their hospital stay and outpatient care. The goal of the care is to promote maternal-infant bonding, normal growth and development, and minimize signs of NAS expression. This goal should be accomplished in a safe, compassionate environment designed to be inclusive and the mother and her newborn. The mother's ability to assist in the care of her infant has positive effects for both mother and newborn and leads to enhanced bonding and parenting. If the mother cannot provide care to her newborn, the family should be incorporated into the place of care.

Since the signs of withdrawal can begin almost immediately after birth, all healthcare workers must know how to assess these newborns. Like the Finnegan Neonatal Abstinence Scoring System, a standard assessment tool should be initiated within the first two hours are life and then performed every 4 hours until discharged from the hospital. Nurses caring for the mothers and their newborns after birth must be highly trained on these tools. The tool assesses the severity of the withdrawal and the effects of individualized adaptations to care. When postpartum nurses have an increased understanding and knowledge of their institution's chosen assessment tool, nurses are better able to determine which symptoms can lead to an earlier diagnosis and treatment plan.

Nursing care for this vulnerable population includes both nonpharmacologic and pharmacologic therapies. The dyad nurse uniquely designed the nursing care based on the infant's behavioral symptoms to minimize withdrawal symptoms. Environmental modifications include dim lighting, quiet, limited handling, stimulation, cotton linen, soft music or white noise, swaddling, and aromatherapy. These modifications address the hypersensitivity NAS infants experience to external stimuli. They assist in reducing hyperactivity and help the infant organize their behaviors. Non-nutritive sucking, frequent smaller feeds, diaper cream, and frequent diaper changes can assist in minimizing the gastrointestinal side effects associated with NAS. Breastfeeding should be encouraged for mothers taking prescribed opioids, methadone, or buprenorphine. Breastfeeding may reduce the severity of the NAS symptoms and the need for pharmacologic treatment. Breastfeeding provides more easily digestible milk in small and more frequent on-demand feeds.

Nurses who assess infants with jitteriness, myoclonic jerks, excessive moro reflexes, and neurologic hypersensitivity can use treatments that may help the newborn relax. These treatments can include Reiki, infant massage, and swaddling. Swaddling also helps skin excoriation due to excessive rubbing, thereby reducing trauma to the skin. Topical barrier creams help treat diaper dermatitis and should be used at the earliest signs of skin irritation. Kangaroo care should be performed when the mother can, and this will assist the newborn in regulating their temperature, oxygenation, heart rate, and respiratory rate. Evidence supports the nurse caring for the mother's newborn dyad and encouraging rooming-in. Rooming-in is associated with improved breastfeeding outcomes, increased maternal satisfaction, and greater involvement in the maternal care of the newborn.

In many cases, even with continued thorough nursing assessments and individualized non-pharmacologic care of the NAS newborn, a pharmacologic intervention has to be initiated. Pharmacologic therapy is designed to be a short-term agent used to improve the clinical symptomology of NAS. The goal of the therapy is to mitigate the signs of withdrawal, seizures, fever, weight loss, and dehydration. Although the Academy of Pediatric guidelines suggest the preferred treatment method is opioid therapy, there is no universal standard of care, and variations in practice exist. Morphine and methadone are the preferred opioid formulations, morphine being a short-acting opioid and methadone a long-acting opioid.

Each medication has an advantage and disadvantages, and recent research suggests that a standardized protocol for pharmacological treatment of NAS is more important than which drug is used to treat it. Improved standardization of nursing assessment, standards of nursing care, pharmacological treatment plans, and weaning protocols led to shorter durations of medication use and reduced length of hospitalization. Discharge planning of the NAS infant must involve a multidisciplinary team. The mother's health and her maternal functioning, mental health, substance abuse treatment, assessment of the home environment, and support systems must all be assessed. Healthcare providers should educate the mother on SIDS, sleeping positions, ongoing substance use disorder treatment, infant signs of infection, and the traditional newborn education received during the postpartum period.

The long-term effects of intrauterine opioid exposure on the child's development are difficult to determine because of the small sample sizes of published studies and other variables. Prenatal variables include: polysubstance exposure, low birth weight, intrauterine growth restriction, etc., and postnatal variables range from continued maternal drug abuse, socioeconomic status, maternal educational levels, and other multiple factors. Several observational studies have found associations between NAS and a negative effect on neurodevelopment and psychological outcomes, including lower intelligence scores, educational disabilities, maltreatment, and trauma during childhood. These adverse outcomes suggest a need for early intervention for both the newborn and the mother. After discharge, pediatric and social service follow-up is recommended for child safety and the promotion of healthy development and continued maternal substance use treatment. For mothers and newborns with NAS, the complexity of their care both while hospitalized and after discharge requires collaboration between early intervention programs, child protective services, and healthcare team members. This collaboration may lead to a more positive outcome for the dyad and their families.

Newborns with intrauterine exposure to opioids are at risk for developing NAS after birth. Recently, researchers noted that male infants are more likely to be diagnosed with NAS when compared to females. Male newborns are also 24 percent more likely than females to require pharmacologic treatment for their NAS (Charles et al., 2017). Researchers have also found that maternal polysubstance use puts infants at greater risk for NAS. Higher doses of maternal buprenorphine were also correlated with more severe NAS symptoms and treatment needs  (Jansson et al., 2017).

Additionally, there is a greater risk for a newborn to develop NAS when they were exposed for greater than 30 days in utero compared to a shorter duration of exposure, and there was a greater risk when the opioid exposure was during the third-trimester verse first or second-trimester intrauterine exposure  (Desai et al., 2015).

The primary prevention of NAS includes awareness about the risk associated with the use of opioids and other substances to prevent addiction in all women, especially during the reproductive age. Before pregnancy, healthcare providers need to be taking opportunities to assess and treat any unhealthy drug use prior to conception. Clinicians should counsel women of reproductive age about the risk associated with opioid therapy, misuse, addiction potential, and the risks to a pregnancy. Routine screening for unhealthy substance use at all healthcare visits will help increase primary prevention opportunities. Women should be routinely asked about alcohol and drug use during pregnancy, including opioids and prescriptive medications. Referrals should readily be made when appropriate to substance abuse treatment services for managing opioid dependency during pregnancy. Opioid abuse prevention for women is the gold standard for primary prevention of NAS in newborns.

Identifying infants at risk for NAS and standardized treatment of newborns with NAS are strategies to reduce NAS effects. Nonpharmacological treatment plans should be initiated first, including rooming in, breastfeeding, minimizing stimuli, swaddling, and others discussed in the above sections. If needed, pharmacologic therapies should be coupled with customized nonpharmacologic strategies as recommended by the Academy of Pediatrics. For mothers and newborns with NAS, the complexity of their care both while hospitalized and after discharge requires collaboration between early intervention programs, child protective services, and healthcare team members. This collaboration may lead to a more positive outcome for the dyad and their families.

Baby boy Jack was born at 37 weeks gestation to a mother who received fragmented prenatal care. At 24 hours of age, the postpartum nurse notes that his respiratory rate is 65, he has nasal congestion, increased moro reflex, mild tremors, and high pitched cry. The mother has been exclusively breastfeeding and reports that he cluster-fed most of the night.

Think about:

• Differential diagnoses:
  • Hypoglycemia – glucose 96
  • Hypocalcemia – calcium is 9
  • Hypomagnesemia– magnesium is 1.6
  • Hyponatremia – Na is 140
  • Birth injury – Apgars 8 & 9
• What additional history is important to gather?
  • The Obstetric team could not do a toxicology screen on the mother before delivery because she was in active labor on admission and delivered within 10 minutes of arrival.
  • The postpartum nurse reviews the mother's chart from her limited OB care and finds a positive urine drug screen for opiates and marijuana from her 20-week Maternal-Fetal Medicine appointment.
• What studies confirm the diagnosis?
  • An infant urine drug screen and meconium drug screen were positive for opioids and marijuana. NAS diagnosis is confirmed.
• What are the next steps?

After talking with the women's health social worker, Jack's mom revealed she had a history of heroin use, and one year ago, she overdosed and started a methadone program. She could not commit to the program and began buying methadone off the street. She also admitted to intermittently smoking marijuana for many years.

Think about:

• What are some of the risk factors in this case?
• What type of continuous assessment needs to be performed on this baby?
• What type of nonpharmacologic interventions can the nurse start, and
• what pharmacologic therapies should the nurse anticipate?

Finnegan Neonatal Abstinence Scoring System was initiated, and the newborn was scored every 4 hours. The social worker, provider, and nurse worked together to establish a plan with the mother to best care for her infant experiencing withdrawal. The mother was exclusively breastfed in a dimly lit room, external stimuli were kept to a minimum, and soft white noise was played. When the infant was not breastfeeding or skin to skin, that infant was swaddled tightly and had frequent diaper changes and diaper cream applied with each change. The mother agreed to an outpatient treatment program that included parenting classes and regular visits with support services. Five days after delivery, the newborn and mother were discharged home with a safe newborn and mother plan of care in place and extensive community resources.

• Charles, M.K., Cooper, W.O., Jansson, L.M., Dudley, J., Slaughter, J.C., & Patrick, S.W. (2017). Male sex is associated with an increased risk of neonatal abstinence syndrome. Hospital Pediatrics, 7:328.
• Cooks, C.L., Dahms, S.K., & Meiers, S.J. (2017). Enhancing care for infants with neonatal abstinence syndrome: An evidence-based practice approach in a rural Midwestern region. Worldviews on Evidence Based Nursing, 14:422.
• Desai, R.J., Huybrechts, K.F., Hernandez-Diaz, S., Mogun, H., Patorno, E., Kaltenbach, K., Kerzner, L.S., & Bateman, B.T. 2015. Exposure to prescription opioid analgesics in utero and risk of neonatal abstinence syndrome: population based cohort study. British Medical Journal, 14:350.
• Honein, M.A., Boyle, C., & Redfield, R.R. (2019). Public health surveillance of prenatal opioid exposure in mothers and infants. Pediatrics, 143:3.
• Jansson, L.M., Velez, M.L., McConnell, K., Spencer, N., Tuten, M., Jones, H., Rios, R., King, V.L., Gandotra, N., Millio, L., & DiPietro, JA (2017). Maternal buprenorphine treatment and infant outcomes. Drug and Alcohol Dependence, 180:56.
• Patrick, S.W., Dudley, J., Martin, P.R., Harrell, F.E., Warren, M.D., Hartmann, K.E., Ely, E.W., Grijalba, C.G., & Cooper, W.O. (2015). Prescription opioid epidemic and infant outcomes. Pediatrics, 135:842.
• Ordean, A. & Chisamore, B. (2014). Clinical presentation and management of neonatal abstinence syndrome: an update. Research and Reports in Neonatology, 4:75.
• Tolia, V.N., Patrick, S.W., Bennett, M.M., Murthy, K., Sousa, J., Smith, P.B., Clark, R.H., & Spitzer, A.R. (2015). Increasing incidence of the neonatal abstinence syndrome in US Neonatal ICU's. New England Journal of Medicine, 372:2118.
• Winkleman, T.N.A., Villapiano, N., Kozhimannil, K.B., Davis, M.M., & Patrick, S.W. (2018). Incidence and costs of neonatal abstinence syndrome among infants with Medicaid: 2004-2014. Pediatrics, 141:4.

Additional Resouces:

• Jansson, L.M. Neonatal Abstinence Syndrome. UpToDate. Updated: December 4, 2019. Accessed: February 5-6, 2020. Visit Source.