What is included in the initial assessment and management of neonatal abstinence syndrome (NAS)?

Updated: Dec 20, 2017
  • Author: Ashraf H Hamdan, MD, MBBCh, MSc, MRCP, FAAP; Chief Editor: Santina A Zanelli, MD  more...
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Answer

The large number of infants who suffer from neonatal abstinence syndrome (NAS) and the associated long-term morbidity mandate that affected infants be accurately identified and their treatment and support should be optimized. Note the following:

  • The assessment and management of NAS pose difficulties for staff and families and have been hampered by a lack of prospective studies and by few research studies that specifically assess the merits of one management approach over another.

  • Infants at risk for NAS should be carefully monitored in the hospital for the development of signs consistent with withdrawal. The appropriate duration of hospital observation is variable and depends on a careful assessment of the maternal drug history. An infant born to a mother on a low-dose prescription opiate with a short half-life (eg, hydrocodone) may be safely discharged if there are no signs of withdrawal by age 3 days, whereas an infant born to a mother on an opiate with a prolonged half-life (eg, methadone) should be observed for a minimum of 5-7 days. [40] After discharge, outpatient follow-up should occur early and include reinforcement of the education of the caregiver about the risk of late withdrawal signs.

  • Vomiting and diarrhea leading to dehydration and poor weight gain, in the absence of other diagnoses, are indications for treatment, even in the absence of a high drug-withdrawal score.

  • In the delivery room, naloxone use is contraindicated in infants whose mothers are known to be dependent on opioids because of the risk of neonatal seizures from abrupt drug withdrawal. However, in the absence of a specific history of opioid abuse in a mother who has recently received narcotics, naloxone treatment remains a reasonable option in the delivery room management of a depressed infant if the infant continues to demonstrate respiratory depression after positive pressure ventilation has restored normal heart rate and color.

  • The initial care of all infants who have been exposed to substances in utero and show signs and symptoms of withdrawal should be individualized, supportive, and nonpharmacologic (because pharmacologic therapy can prolong hospitalization and exposes the infant to additional agents that are often not necessary). The treatment for morphine administration has been reported to last 8-79 days. [65] This length of hospitalization interferes with maternal bonding, raises the potential for nosocomial infection, and is a major use of resources. [65]

  • Relatively recent studies suggest that infants who stay in the room with their mothers have a shorter length of stay, lower hospital costs, and reduced need of pharmacologic therapy, and they are more likely to be discharged home with their mothers. Rooming-in has also been associated with improved breast-feeding outcomes, and greater maternal involvement in the care of the newborn. [66, 67]

  • Although rooming-in is promising nonpharmacologic strategy, there are barriers to the implementation of this practice. Lack of funding, lack of personnel, and lack of appropriately designed hospital units may prevent many hospitals from providing rooming-in as a standard practice. [68]


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