Neonatal Abstinence Syndrome

Question 1

What is neonatal abstinence syndrome?

Answer 1

Neonatal abstinence syndrome (NAS) refers to the withdrawal symptoms that happens in neonates of mothers that used substances in pregnancy. The symptoms and management is slightly different for each substance used in pregnancy. Mothers should be encouraged and supported with cutting back, and if possible stopping, substances that can affect the pregnancy.

Question 2

Substances that cause NAS?

Answer 2

Opiates
Methadone
Benzodiazepines
Cocaine
Amphetamines
Nicotine or cannabis
Alcohol
SSRI antidepressants

Question 3

Signs and symptoms of NAS?

Answer 3

Withdrawal from most opiates, diazepam, SSRIs and alcohol occurs between 3 – 72 hours after birth. Withdrawal from methadone and other benzodiazepines occurs between 24 hours and 21 days.

CNS:

Irritability
Increased tone
High pitched cry
Not settling
Tremors
Seizures

Vasomotor and respiratory:

Yawning
Sweating
Unstable temperature and pyrexia
Tachypnoea (fast breathing)

Metabolic and gastrointestinal:

Poor feeding
Regurgitation or vomiting
Hypoglycaemia
Loose stools with a sore nappy area

Question 4

Management of NAS?

Answer 4

Mothers that are known to use substances should have an alert on their notes so that when they give birth the neonate can have extra monitoring and management of NAS.

Babies are kept in hospital with monitoring on a NAS chart for at least 3 days (48 hours for SSRI antidepressants) to monitor for withdrawal symptoms. A urine sample can be collected from the neonate to test for substances. The neonate should be supported in a quiet and dim environment with gentle handling and comforting.

Medical treatment options for moderate to severe symptoms are:

Oral morphine sulphate for opiate withdrawal
Oral phenobarbitone for non-opiate withdrawal
Neonates should be gradually weaned off oral treatment. SSRI withdrawal does not typically require or benefit from medical treatment.

Additional considerations:

Testing for hepatitis B and C and HIV
Safeguarding and social service involvement
Safety-net advice for readmission if withdrawal signs and symptoms occur
Follow up from paediatrics, social services, health visitors and the GP
Support for the mother to stop using substances
Check the suitability for breastfeeding in mothers with substance use