Neonatal Abstinence Syndrome

Neonatal abstinence syndrome is a condition that a baby experiences when withdrawing from certain drugs that his mother has taken during pregnancy. When a woman is pregnant and takes one of these drugs, her unborn baby can become addicted. Once born, the baby is still dependent on the drug; since the drug is no longer available, the baby experiences withdrawal symptoms. 

Which drugs are associated with neonatal abstinence syndrome?

Neonatal abstinence syndrome was originally used to describe withdrawal from narcotics, or opioid drugs. However, this definition has been expanded to include withdrawal from other illicit drugs, alcohol, and certain medications, including drugs for depression called selective serotonin reuptake inhibitors (SSRIs). Many health care providers are beginning to refer to the neonatal abstinence syndrome condition as a drug dependency syndrome.

The following drugs are frequently associated with neonatal problems:

• Codeine
• Fentanyl
• Heroin and methadone
• Meperidine (Demerol)
• Morphine
• Pentazocine
• Propoxyphene
• Barbiturates
• Caffeine
• Chlordiazepoxide
• Cocaine
• Amphetamines
• Diazepam and lorazepam
• Diphenhydramine
• Ethanol
• Marijuana
• Nicotine
• Phencyclidine
• SSRIs (fluoxetine, paroxetine, sertraline, citalopram)

What are the effects of these drugs?

Babies born with neonatal abstinence syndrome may appear normal at birth. Withdrawal symptoms usually arise in the first 24 to 48 hours of life, although sometimes the symptoms may not appear until five to 10 days after birth.

Symptoms of withdrawal may include the following:

• Excessive, high pitched crying
• Tremor
• Sleep problems
• Tight muscle tone
• Seizures
• Increased startle reflex
• Fever
• Sweating
• Increase in respiratory rate
• Poor feeding, uncoordinated or excessive sucking
• Vomiting
• Loose or watery stools

Other problems that may arise due to drug exposure, but which are not directly related to withdrawal, include:

• Birth defects
• Decreased birth weight
• Increased weight loss in the first few days of life

Some drugs cause specific problems, for example:

• Opioid drugs produce dramatic withdrawal symptoms, fetal growth restriction, premature birth, and low birth weight. Heroin is an opioid, and withdrawal from this drug occurs within 48 to 72 hours of birth in most babies born to addicted mothers. Methadone, which is used to treat heroin addiction, has similar effects to heroin. Methadone use during pregnancy is also associated with fetal growth restriction, increased risk of fetal distress, and increased risk of sudden infant distress syndrome (SIDS).
• Cocaine stimulates the central nervous system. Prenatal cocaine use may cause increased startling, jitteriness, excessive sucking, and may be associated with an increased risk of SIDS.
• Amphetamines, also called “speed,” stimulate the central nervous system. Prenatal use of these drugs is associated with premature birth, low birth weight, or bleeding within the baby’s head, which is called intracranial bleeding.
• Prenatal exposure to nicotine may lead to low birth weight, premature birth, and stillbirth. Babies exposed to nicotine during pregnancy may also be born with an increased startle reflex, tremor, and other problems.
• Exposure to marijuana during pregnancy may result in low birth weight, intracranial bleeding, jitteriness, low blood sugar, low levels of calcium in the blood, an infection of the blood called sepsis, and other problems such as poor feeding, irritability, and rapid breathing.
• SSRIs are used to treat depression and other behavioural disorders. Babies exposed to SSRIs in the third trimester of pregnancy may have various symptoms such as irritability, agitation, tremor, increased respiratory rate, nasal congestion, or diarrhea. These problems usually disappear by about two weeks of life. A decrease in SSRI use in the third trimester of pregnancy may lower the baby’s risk of developing SSRI-related problems; however, this needs to be balanced against the harmful effects of depression during pregnancy.

How is neonatal abstinence syndrome diagnosed?

A neonatal abstinence syndrome scoring system has been developed to help diagnose and determine the severity of the condition in newborn babies. This scoring system assesses various signs and symptoms, and the severity of each.

An analysis of the newborn baby’s urine is a useful screening method to detect whether the mother has used drugs in the days before birth. Tests on meconium and hair samples can be done to reflect exposure over a longer timeframe, but these are not as widely available.

How is neonatal abstinence syndrome treated?

Swaddling and frequent small feedings of a high calorie formula are common ways to manage this condition. Some babies may need medications to treat severe withdrawal symptoms, such as the following:

• The anti-epileptic drug, phenobarbital, can help to control the central nervous system symptoms and reduce irritability. However, it has little effect on gastrointestinal symptoms, it impairs the baby’s ability to suck, and it has no effect on seizures caused by withdrawal.
• The opioid drug, morphine, is a mild sedative that can help improve the baby’s ability to suck and increase the intake of nutrients. Morphine can also control seizures caused by withdrawal. However, this drug itself is addictive and has a long withdrawal period.

Other drugs may be considered to help relieve the discomfort and problems of withdrawal. The drug used for treatment is usually from the same class as the drug the baby is withdrawing from. Once the signs of withdrawal are under control, the baby will be gradually weaned off the treatment drug.

Important notes about breastfeeding

If the mother is receiving methadone as treatment for her drug use, and she is not abusing any other drugs, she may be able to continue breastfeeding. Only small amounts of methadone are detected in breast milk. Breastfeeding provides immune system antibodies to the baby, and is important to the bonding process between mother and baby.

If the mother is still using illicit drugs, she should not breastfeed. Babies who are exposed to marijuana or alcohol through breastfeeding have decreased motor development at one year of age. Also, if the mother has developed an infectious disease such as HIV or hepatitis, she should not breastfeed.