Neonatal Abstinence Syndrome
Neonatal Abstinence Syndrome (NAS)
Definition
Neonatal Abstinence Syndrome is a complex of withdrawal symptoms that occurs in newborns who were exposed to addictive substances in utero. Most commonly associated with opioids, but can occur with other substances.
Epidemiology
- Incidence: 3.4 to 5.4 per 1,000 hospital births
- Higher prevalence in rural areas
- 50-80% of opioid-exposed newborns develop NAS
- Mean hospital stay: 16-19 days
Pathophysiology
- Passive drug transfer across placenta during pregnancy
- Sudden discontinuation at birth leads to withdrawal
- Multiple neurotransmitter systems affected:
- Noradrenergic system hyperactivity
- Decreased dopamine production
- Increased acetylcholine release
- Serotonin imbalance
Clinical Presentation
Central Nervous System Signs
- Tremors
- Irritability
- High-pitched crying
- Hypertonicity
- Seizures (in severe cases)
- Sleep disturbances
- Hyperactive reflexes
Gastrointestinal Symptoms
- Poor feeding
- Uncoordinated/excessive sucking
- Vomiting
- Diarrhea
- Dehydration
- Poor weight gain
Autonomic Signs
- Fever
- Sweating
- Nasal stuffiness
- Mottling
- Temperature instability
- Yawning
Respiratory Signs
- Tachypnea
- Respiratory distress
- Nasal flaring
Assessment Tools
Modified Finnegan Scoring System
- Gold standard for NAS assessment
- Scoring intervals: Every 3-4 hours
- Key parameters assessed:
- Central nervous system disturbances
- Metabolic/vasomotor/respiratory disturbances
- Gastrointestinal dysfunction
- Scoring thresholds:
- ≥8: Consider treatment
- ≥12: Pharmacologic intervention typically needed
- Three consecutive scores ≥8: Indicates need for therapy
Eat, Sleep, Console (ESC) Method
- Newer, function-based assessment approach
- Evaluates:
- Ability to eat ≥1 oz per feed or breastfeed well
- Sleep undisturbed for >1 hour
- Ability to be consoled within 10 minutes
- Advantages:
- More family-centered
- May reduce pharmacologic treatment
- Shorter hospital stays
Management Approaches
Non-Pharmacologic Management
- First-line treatment for all cases
- Environmental measures:
- Minimal stimulation
- Dim lighting
- Quiet environment
- Swaddling
- Feeding support:
- Small, frequent feeds
- High-calorie formula if needed
- Breastfeeding support if appropriate
- Rooming-in programs
Pharmacologic Management
- Morphine:
- First-line medication
- Starting dose: 0.05-0.1 mg/kg/dose q3-4h
- Titrate based on symptoms
- Methadone:
- Alternative first-line option
- Longer half-life
- Initial dose: 0.05-0.1 mg/kg/dose q6-12h
- Adjunct therapy:
- Clonidine: 0.5-1 μg/kg/dose q3-6h
- Phenobarbital: For polydrug exposure
Complications & Prognosis
Short-term Complications
- Feeding difficulties
- Weight loss
- Dehydration
- Sleep disturbances
- Seizures
- Respiratory problems
Long-term Outcomes
- Neurodevelopmental:
- Attention deficits
- Behavioral problems
- Learning difficulties
- Motor delays
- Growth concerns
- Vision problems
- Speech delays
Monitoring Requirements
- Regular developmental assessments
- Growth monitoring
- Vision screening
- Hearing evaluation
- Early intervention services
Prevention Strategies
Prenatal Care
- Early identification of at-risk mothers
- Universal substance use screening
- Medication-assisted treatment programs
- Prenatal counseling
Healthcare System Approaches
- Standardized protocols
- Staff education
- Quality improvement initiatives
- Care coordination
