Neonatal Abstinence Syndrome

What is neonatal abstinence syndrome?

Neonatal abstinence syndrome is what happens when babies are exposed to drugs in the womb before birth. Babies can then go through drug withdrawal after birth. The syndrome most often applies to opioid medicines.

What causes neonatal abstinence syndrome?

Almost every drug and medicine passes from the mother’s bloodstream through the placenta to her unborn baby. If the mother uses substances that affect her nervous system, they will also affect the baby's. At birth, the baby has become used to getting the drug. But because the drug is no longer available, the baby may have symptoms of withdrawal.

Some drugs and medicines are more likely to cause the syndrome than others. But nearly all have some effect on the baby. When more than one drug has been used, the symptoms are often worse. These include:

• Opioids like heroin and prescribed medicines such as codeine and oxycodone
• Stimulants such as amphetamines or cocaine. For these drugs, the effects on a baby are more likely from the drug itself instead of withdrawal.
• Antidepressant medicines such as selective serotonin reuptake inhibitors (SSRIs)
• Depressants such as barbiturates, or alcohol, or marijuana
• Nicotine from cigarette smoking

Alcohol use can also cause another group of problems called fetal alcohol spectrum disorders.

Who is at risk for neonatal abstinence syndrome?

Pregnant women who use drugs, smoke, or drink alcohol put their unborn babies at risk for neonatal abstinence syndrome and other problems. Women who use drugs also may be less likely to get prenatal care. This can also increase the risks for both mother and baby.

What are the symptoms of neonatal abstinence syndrome?

Symptoms of the syndrome may vary depending on:

• The type of drug used
• The last time it was used
• Whether the baby is full-term or premature

Symptoms of withdrawal may start as soon as 24 to 48 hours after birth. Or they may start as late as 5 to 10 days after birth.

The following are the most common symptoms of the syndrome. Symptoms may be slightly different for each baby. Symptoms of withdrawal in full-term babies may include:

• Trembling
• Too much crying or high-pitched crying
• Sleep problems
• Tight muscle tone
• Overactive reflexes
• Seizures
• Yawning, stuffy nose, and sneezing
• Poor feeding and sucking
• Vomiting or diarrhea
• Sweating
• Fever or unstable temperature

Premature babies may have a lower risk for withdrawal symptoms or have less severe symptoms. They may also get better faster because they were exposed to less of the drug than full-term babies.

The symptoms of this problem may look like other health conditions. Make sure your child sees his or her healthcare provider for a diagnosis.

How is neonatal abstinence syndrome diagnosed?

The diagnosis is made based on a history of medicine or substance abuse in the mother. An accurate report of the mother’s drug use is important. This includes the time the last drug was taken. The healthcare provider may use a scoring system to help diagnose and pinpoint how serious the baby’s withdrawal is. Points are assigned for certain signs and symptoms and the seriousness of each. This scoring may also help in planning treatment.

The healthcare provider may check meconium, urine, umbilical cord blood, or all three if the provider suspects that the mother was using drugs. It can also be done if the baby shows symptoms of the syndrome. Some birth centers routinely screen all babies.

How is neonatal abstinence syndrome treated?

Treatment will depend on your child’s symptoms, age, and general health. It will also depend on how severe the condition is.

Babies suffering from withdrawal are irritable. They often have a difficult time being comforted. Wrapping the baby snugly in a blanket may help give comfort. Babies also may need extra calories added to their feedings because of their increased activity. They may also need IV fluids if they are dehydrated or have severe vomiting or diarrhea.

Some babies may need medicines to treat severe withdrawal symptoms such as seizures. Medicines may also help relieve the discomfort and problems of withdrawal. If medicine is needed, babies will usually be given a medicine that is in the same family of drugs as the drug the baby was exposed to before birth. Once the signs of withdrawal are controlled, the amount of the medicine is slowly decreased. This helps wean the baby off the drug. Talk with your baby's healthcare provider to learn which treatments might work for your baby.

What are the complications of neonatal abstinence syndrome?

In addition to the problems of withdrawal after birth, complications in the baby may include:

• Poor growth in the uterus
• Being born too soon
• Seizures
• Yellowing of the skin or eyes (jaundice)
• Birth defects

Even without neonatal abstinence syndrome, prenatal drug exposure can be related to later developmental delay. This may be the result of the environment in which the baby grows up as well. 

Specific drugs have been linked to specific problems in the baby. These problems may include:

• Heroin and other opioids, including methadone, can cause serious withdrawal in the baby. Some symptoms can last as long as 4 to 6 months. Seizures may also occur in babies born to opioid users.
• Amphetamines can lead to low birth weight and premature birth.
• Cocaine use can cause poor growth. It also makes complications such as placental abruption more likely.
• Marijuana use may cause lower birth weight, as well as later learning and behavior problems.
• Alcohol use can have major effects on babies before and after birth. Growth during pregnancy and after birth is slowed. It can also cause certain problems of the head and face, heart defects, learning problems, and mental problems.
• Cigarette smoking may cause low birth weight. It may also put babies at higher risk for premature birth and stillbirth.

Can neonatal abstinence syndrome be prevented?

This syndrome is a potentially preventable problem. But it can only be prevented if the mother stops using drugs before pregnancy or as soon as she learns she is pregnant. In some cases, this is not possible to do safely. In all cases it needs close medical supervision.

Key points about neonatal abstinence syndrome

• Neonatal abstinence syndrome happens when babies are exposed to drugs in the womb before birth. Babies can then be affected or go through drug withdrawal after birth.
• Symptoms of withdrawal may begin as soon as 24 to 48 hours after birth. Or they may start as late as 5 to 10 days after birth.
• Some babies may need medicines to treat severe withdrawal symptoms. The medicines help relieve the discomfort and problems of withdrawal.
• Neonatal abstinence syndrome is a potentially preventable problem. But it can only be prevented if the mother stops using drugs before pregnancy or as soon as she learns she is pregnant. In some cases, this is not possible to do safely. In all cases it needs close medical supervision.

Next steps

Tips to help you get the most from a visit to your child’s healthcare provider:

• Know the reason for the visit and what you want to happen.
• Before your visit, write down questions you want answered.
• At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you for your child.
• Know why a new medicine or treatment is prescribed and how it will help your child. Also know what the side effects are.
• Ask if your child’s condition can be treated in other ways.
• Know why a test or procedure is recommended and what the results could mean.
• Know what to expect if your child does not take the medicine or have the test or procedure.
• If your child has a follow-up appointment, write down the date, time, and purpose for that visit.
• Know how you can contact your child’s provider after office hours. This is important if your child becomes ill and you have questions or need advice.