What Is Neonatal Abstinence Syndrome and How Can We Help Babies Affected?
Almost every woman on this earth wants what is best for their unborn child, but sometimes preexisting drug addictions cloud judgement — and without proper resources, drug use can continue during pregnancy. Neonatal abstinence syndrome (NAS) occurs when a baby is exposed to drugs in the womb before birth and goes through drug withdrawal after on the womb and after birth, according to the Mach of Dimes.
Opioids seem to be the most common cause for NAS, whether it's the misuse of prescription pills or pills obtained on the street. It should be noted, however, that NAS can also caused by antidepressants and sleeping pills.
To find out what the dangers are to an infant with a drug dependent mother and how to help both mother and child, we spoke to experts and did some research to gain more insight.
Opioid use on the rise
It's a commonly known that a fetus feels the effects of anything consumed by its mother — that's why many pregnant women swear off caffeine and sushi — and from the moment of conception, the developing baby is susceptible to harm from being exposed to the drugs and/or alcohol in a mother’s system. And just like adults, if a fetus or infant is exposed and consequently becomes dependent on a substance, they can also go through a painful withdrawal process.
Sadly, incidents of NAS are on the rise. In a 2012 study by Dr. Stephen Patrick, a neonatologist and assistant professor of pediatrics at Vanderbilt University, via MedPage Today, researchers found that the number of mothers using opiates at the time of delivery rose five-fold during the period between 2000 and 2009.
The scary thing? It's not mainly illicit drug use that's causing the surge, but painkillers being prescribed to pregnant mothers.
"I was surprised by the number of women prescribed opioid pain relievers in pregnancy," said lead author Dr. Patrick. "This serves as a reminder that this is really a public health emergency that requires attention from multiple levels from the federal government, from state government, and from researchers," he added.
Addiction in pregnancy
Fighting addiction is difficult, and not always successful. Most often intervention is necessary, under the supervision of a physician in either an outpatient or inpatient setting. Going cold turkey can be very dangerous for both mother and child, according to the March of Dimes, and can result in severe problems for the baby and even death.
For some women, their pregnancy is the kick they needed to get clean — and stay clean. Sadly, for others the lure of their addictions is too strong, and they continue to abuse drugs or alcohol during pregnancy and after delivery.
"Many women want to get clean once they find out that they are pregnant," shares Patricia Newell Bennett, a board certified therapist in private practice who specializes in substance abuse recovery. "It is one of the few things powerful enough to get a woman's attention if she is addicted. Again it depends on the extent of their addiction and the treatment that is available to them... Some women are too sick to be interested in getting well, for themselves or their babies."
When a pregnant woman suffers from addiction, it’s not enough to simply want to get clean — the mother needs to have access to support and treatment options.
We asked Lauren M. Jansson, M.D., an associate professor of pediatrics at Johns Hopkins University School of Medicine, about treatment for pregnant women fighting addiction.
"Ideally, women with drug dependencies can access drug abuse treatment, prenatal care and psychiatric treatment (when needed) before or during their pregnancies to be able to work on their recovery and parenting skills," says Dr. Jansson, who is opposed to the use of the terms "addicted" or "addicts" for infants and children. "Many opioid-dependent women need medication assisted treatment — which includes methadone or buprenorphine maintenance during their pregnancy — to help them to maintain their abstinence from illicit drug use and licit drug misuse. Sadly, these services are not always available, or when they are, not comprehensive in delivery or gender specific,” she adds.
Cali Estes is an addictions coach, and has been a therapist for over 20 years.
"Heavy users rarely quit; they will use before, during and after the pregnancy," she says. “In these cases usually the state steps in and places the baby in foster care. If the mother does not attend rehab and whatever requirements that are set forth for her to get the child back, the baby becomes a ward of the state. These cases are very sad and the women are the worst users."
If you or someone you know needs help, please visit the website for the National Council on Drug and Alcohol Dependence here and a look for a local treatment center with the treatment services locator here.
What about the babies?
We asked Dr. Jansson about some of the physical symptoms and characteristics she sees in her work in the newborn nursery with babies of addicted mothers.
"Women who are drug dependent face many obstacles," she says. "Those who are opioid and poly drug dependent often have infants that struggle with neonatal abstinence syndrome (NAS). NAS is a constellation of signs and symptoms of infant neurobehavioral dysregulation that occurs in the immediate neonatal period... The syndrome is variable in both expression and intensity between infants."
Here are some of the signs and symptoms of NAS in newborn babies, according to Dr. Jansson:
- Difficulties with tone and movement. Infants with these problems can have tight muscles and tremors and/or jitteriness. These problems can lead to difficulties in feeding, which can mean weight loss or failure to thrive.
- Difficulties with state regulation. These infants have difficulty maintaining a quiet alert state, which is needed to interact with their caretakers, and to be able to feed and grow. They can have problems going smoothly from sleep to awake states, and often become irritable and cry.
- Difficulties with reactivity to stimuli. Infants can have atypical responses to touch, sound, movement or visual stimulation and can become either over-stimulated and poorly reactive, or “pull down” to avoid the stimulation.
- Problems with autonomic nervous system control. Infants can have gagging, vomiting/diarrhea, color changes, fever, fast breathing or hiccupping, indicating their inability to smoothly regulate their functioning.
- Fussiness, excessive crying or having a high-pitched cry
- Fever, sweating or blotchy skin
- Trouble sleeping and lots of yawning
- Stuffy nose or sneezing
Treatment for babies
Babies with NAS can be treated with or without medication to help with their withdrawal symptoms. Supporting these infants through the difficult time of withdrawal takes close attention and support of hospital staff. If medication interventions are necessary, physicians have historically used morphine — though methadone and other medications can also be used.
"The goal of pharmacologic therapy for NAS is to provide just enough medication so that the infant can eat, sleep and interact,” adds Dr. Jansson. "The medication is gradually weaned off prior to hospital discharge."
A 2017 study published in the New England Journal of Medicine found that sublingual buprenorphine may provide benefits in the treatment of NAS babies.
"Among infants with the neonatal abstinence syndrome, treatment with sublingual buprenorphine resulted in a shorter duration of treatment and shorter length of hospital stay than treatment with oral morphine, with similar rates of adverse events," the authors wrote.
The March of Dimes also suggest the following if you are caring for a baby with NAS:
- Swaddle the baby in a blanket.
- Give the baby skin-to-skin care. It’s when you put the baby, dressed only in a diaper, on your bare chest.
- Keep the baby in a quiet, dimly lit room.
- Breastfeed, if possible.
Once these babies have worked through their withdrawal period, what is their long-term prognosis?
The effects of drugs and alcohol on the developing infant can go way beyond just the physical symptoms. Researching the long-term outcomes of substance exposed infants is difficult to do due to other co-existing factors such as continued maternal drug use, exposure to violence, poor nutrition or adequate well-baby care.
"We do understand that substance-exposed children are at higher risk for medical, developmental, emotional and behavioral concerns as they grow," shares Dr. Jansson.
"Anecdotally, the children that I have been following for over 20 years at the Johns Hopkins Center for Addiction and Pregnancy pediatric clinic have more than their share of these kinds of disabilities. But many can and do function well when their mothers are able to maintain their sobriety and parent," she says. "And that takes ongoing and multi-disciplinary support from the medical community to provide medical care for parents and children, contraceptive services for women that request them, ongoing drug abuse treatment and psychiatric care for parents, and early intervention services for children when they are needed."
When these children and their parents can receive the assistance that they need, they have the opportunity to lead happy, productive lives. And in Dr. Jansson's opinion, treating the whole family is key.
“Comprehensive, ongoing, non-judgmental and mindful care can provide these families with what they need to be healthy and productive members of their communities, and to break the cycle of addiction within families,” adds Dr. Jansson.
Originally published May 2013. Updated May 2017.