CDC Grand Rounds

Public Health Strategies to Prevent Neonatal Abstinence Syndrome

Jean Y. Ko, PhD; Sara Wolicki, MPH; Wanda D. Barfield, MD; Stephen W. Patrick, MD; Cheryl S. Broussard, PhD; Kimberly A. Yonkers, MD; Rebecca Naimon; John Iskander, MD


Morbidity and Mortality Weekly Report. 2017;66(9):242-245. 

In This Article

Public Health Burden of Neonatal Abstinence Syndrome

Neonatal abstinence syndrome (NAS) is a drug withdrawal syndrome that most commonly occurs in infants after in utero exposure to opioids, although other substances have also been associated with the syndrome.[1] NAS usually appears within 48–72 hours of birth with a constellation of clinical signs, including central nervous system irritability (e.g., tremors), gastrointestinal dysfunction (e.g., feeding difficulties), and temperature instability[1] (Box 1). Opioid exposure during pregnancy might result from clinician-approved use of prescription opioids for pain relief; misuse or abuse of prescription opioids; illicit use (e.g., heroin); or medication-assisted treatment (MAT) of opioid use disorder[2] (Box 2).

Opioid pain reliever sales quadrupled in the United States from 1999 to 2010. From 2000 to 2014, opioid-related overdoses among U.S. adults increased 200%.[3] Opioid use during pregnancy has also increased nationally in recent years. The percentage of Medicaid-enrolled women who filled at least one opioid prescription during pregnancy increased 23% during 2000–2010, from 18.5% to 22.8%.[4] The prevalence of opioid abuse or dependence among pregnant women has increased from 1.7 per 1,000 delivery admissions in 1998 to 3.9 in 2011.[5] Reflective of increasing maternal opioid exposure, the incidence of NAS has increased approximately 400% nationally, from 1.2 per 1,000 hospital births in 2000 to 5.8 in 2012, with some states reporting rates in excess of 30 per 1,000 hospital births.[6,7] By 2012, on average, one NAS-affected infant was born every 25 minutes in the United States.[6]

Respiratory and feeding difficulties, low birth weight, and seizures are more prevalent among infants with NAS.[1] Care for infants with NAS has placed a substantial burden on hospitals, particularly on neonatal intensive care units. In 2012, a term infant without complications had a mean length of stay of 2.1 days and charge of $3,500; whereas, an infant with NAS had a mean hospital stay of 16.9 days and a mean hospital charge of $66,700.[6] Aggregate hospital charges for all infants with NAS in 2012 were estimated to be $1.5 billion; approximately 80% was financed by Medicaid programs.[6] Public health measures to prevent and treat opioid dependence before and during pregnancy are essential to reducing the incidence of NAS and its related health care burden. Strategies include promoting responsible opioid prescribing, decreasing unplanned pregnancies among women who abuse opioids, screening and treatment during pregnancy, and standardizing postnatal treatment for infants with NAS (Figure).


Specific strategies to reduce the health care burden of neonatal abstinence syndrome (NAS), by population impact