Neonatal withdrawal

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Neonatal Abstinence Syndrome
Classification and external resources
ICD-10 P96.1
ICD-9-CM 779.5
DiseasesDB 33462
MedlinePlus 007313
eMedicine ped/2760
MeSH D009357

Neonatal withdrawal or neonatal abstinence syndrome (NAS) is a withdrawal syndrome of infants, caused by the cessation of the administration of licit or illicit drugs. Tolerance, dependence, and withdrawal may occur as a result of repeated administration of drugs or even after short-term high-dose use—for example, during mechanical ventilation in intensive care units. There are two types of NAS: prenatal and postnatal. Prenatal NAS is caused by discontinuation of drugs taken by the pregnant mother, while postnatal NAS is caused by discontinuation of drugs directly to the infant.[1][2]


The drugs involved may be, for example, opioids, selective serotonin reuptake inhibitors (SSRIs), ethanol and benzodiazepines.[1][3] Neonatal abstinence syndrome does not happen in prenatal cocaine exposure (with babies exposed to cocaine in utero) in the sense that such symptoms are difficult to separate in the context of other factors such as prematurity or prenatal exposure to other drugs.[4]


Objectives of management are to minimize negative outcomes and promote normal development.[5] Supportive care is the first step in management, but this is typically not enough and is complemented with medication.


Non-medication based approaches to treat neonatal symptoms include swaddling the infant in a blanket, minimizing environmental stimuli, and monitoring sleeping and feeding patterns.[6] Breastfeeding promotes infant attachment and bonding and is associated with a decreased need for medication. These approaches may lessen the severity of NAS and lead to shorter hospital stays.[7]


Medication is used to relieve fever, seizures, and weight loss or dehydration.[5] When medication is use for opiate withdrawal in newborn babies is deemed necessary, opiates are the treatment of choice; they are slowly tapered down to wean the baby off opiates.[8] Phenobarbital is sometimes used as an alternative but is less effective in suppressing seizures; however, phenobarbital is superior to diazepam for neonatal opiate withdrawal symptoms. In the case of sedative-hypnotic neonatal withdrawal, phenobarbital is the treatment of choice.[9][10] Clonidine is an emerging add-on therapy.[11] Buprenorphine is under development as an alternative to morphine or methadone as initial therapy.[12]

Opioids such as neonatal morphine solution and methadone are commonly used to treat clinical symptoms of opiate withdrawal, but may prolong neonatal drug exposure and duration of hospitalization.[13] A study demonstrated a shorter wean duration in infants treated with methadone compared to those treated with diluted tincture of opium. When compared to morphine, methadone has a longer half-life in children, which allows for less frequent dosing intervals and steady serum concentrations to prevent neonatal withdrawal symptoms.[14]


A 2012 study from the University of Michigan and the University of Pittsburgh published in the Journal of the American Medical Association analyzed information on 7.4 million discharges from 4,121 hospitals in 44 states, to measure trends and costs associated with NAS over the past decade. The study indicated that between 2000 and 2009, the number of mothers using opiates increased from 1.19 to 5.63 per 1,000 hospital births per year. Newborns with NAS were 19% more likely than all other hospital births to have low birthweight and 30% more like to have respiratory complications. Between 2000 and 2009, total hospital charges for NAS cases, adjusted for inflation, are estimated to have increased from $190 million to $720 million.[15][16]


Neonatal Abstinence Syndrome is a growing health issue amongst the country. While Ontario claims the highest rate of narcotic use in the country and one of the highest rates of prescription narcotic use in the world (Dow et al., 2012),[17] Northern cities such as North bay are influential contributors. The number of neonates born with addiction or experiencing withdrawal symptoms are increasing at an undesirable rate in North Bay from 22 babies in 2012-2013 to 48 babies born with NAS in 2014-2015 (Leslie, 2015).[18] Furthermore, North Bay Regional Health Centre was home to 10 NAS babies in January 2016 alone (Sheikh, 2016).[19] The dramatic growth in numbers of neonates born with drug addiction will continue to grow if not confronted and managed in a way that is specific and appropriate for the city of North Bay. 


  1. ^ a b Neonatal Abstinence Syndrome on eMedicine
  2. ^ Hall, RW.; Boyle, E.; Young, T. (Oct 2007). "Do ventilated neonates require pain management?". Semin Perinatol. 31 (5): 289–97. PMID 17905183. doi:10.1053/j.semperi.2007.07.002. 
  3. ^ Iqbal MM, Sobhan T, Ryals T (January 2002). "Effects of commonly used benzodiazepines on the fetus, the neonate, and the nursing infant". Psychiatric Services. 53 (1): 39–49. PMID 11773648. doi:10.1176/ 
  4. ^ Mercer, J (2009). "Claim 9: "Crack babies" can't be cured and will always have serious problems". Child Development: Myths and Misunderstandings. Thousand Oaks, Calif: Sage Publications, Inc. pp. 62–64. ISBN 1-4129-5646-3. 
  5. ^ a b Longo, Dan L.; McQueen, Karen; Murphy-Oikonen, Jodie (22 December 2016). "Neonatal Abstinence Syndrome". New England Journal of Medicine. 375 (25): 2468–2479. doi:10.1056/NEJMra1600879. 
  6. ^ Lee, Kimberly G. "Neonatal abstinence Syndrome". MedlinePlus. A.D.A.M., Inc. Retrieved 2 November 2014. 
  7. ^ Pritham, Ursula A.; Paul, Jonathan A.; Hayes, Marie J. (March 2012). "Opioid Dependency in Pregnancy and Length of Stay for Neonatal Abstinence Syndrome". Journal of Obstetric, Gynecologic, & Neonatal Nursing. 41 (2): 180–190. PMC 3407283Freely accessible. PMID 22375882. doi:10.1111/j.1552-6909.2011.01330.x. 
  8. ^ Hudak, ML; Tan, R. C. (30 January 2012). "Neonatal Drug Withdrawal". Pediatrics. 129 (2): e540–e560. PMID 22291123. doi:10.1542/peds.2011-3212. 
  9. ^ Osborn, DA; Jeffery, HE; Cole, M (2010). Osborn, David A, ed. "Opiate treatment for opiate withdrawal in newborn infants". Cochrane Database Syst Rev (3): CD002059. PMID 20927730. doi:10.1002/14651858.CD002059.pub3. 
  10. ^ Osborn, DA; Jeffery, HE; Cole, MJ (2010). Osborn, David A, ed. "Sedatives for opiate withdrawal in newborn infants". Cochrane Database Syst Rev (3): CD002053. PMID 20927729. doi:10.1002/14651858.CD002053.pub3. 
  11. ^ Kraft, WK; van den Anker, JN (Oct 2012). "Pharmacologic management of the opioid neonatal abstinence syndrome". Pediatric clinics of North America. 59 (5): 1147–65. PMC 4709246Freely accessible. PMID 23036249. doi:10.1016/j.pcl.2012.07.006. 
  12. ^ Kraft, WK; Dysart, K; Greenspan, JS; Gibson, E; Kaltenbach, K; Ehrlich, ME (Mar 2011). "Revised dose schema of sublingual buprenorphine in the treatment of the neonatal opioid abstinence syndrome". Addiction (Abingdon, England). 106 (3): 574–80. PMC 3022999Freely accessible. PMID 20925688. doi:10.1111/j.1360-0443.2010.03170.x. 
  13. ^ Logan, Beth A.; Brown, Mark S.; Hayes, Marie J. (March 2013). "Neonatal Abstinence Syndrome: Treatment and Pediatric Outcomes". Clinical Obstetrics and Gynecology. 56 (1): 186–192. PMC 3589586Freely accessible. PMID 23314720. doi:10.1097/GRF.0b013e31827feea4. 
  14. ^ Johnson, Melissa R.; Nash, David R.; Martinez, Michael A. (July 2014). "Development and Implementation of a Pharmacist-Managed, Neonatal and Pediatric, Opioid-Weaning Protocol". The Journal of Pediatric Pharmacology and Therapeutics. 19 (3): 165–173. PMC 4187529Freely accessible. PMID 25309146. doi:10.5863/1551-6776-19.3.165. 
  15. ^ "Neonatal Abstinence Syndrome and Associated Health Care Expenditures: United States, 2000-2009"., retrieved May 15, 2012
  16. ^ Patrick, SW; Schumacher, RE; Benneyworth, BD; Krans, EE; McAllister, JM; Davis, MM (May 9, 2012). "Neonatal abstinence syndrome and associated health care expenditures: United States, 2000-2009". JAMA: The Journal of the American Medical Association. 307 (18): 1934–40. PMID 22546608. doi:10.1001/jama.2012.3951. 
  17. ^ Dow, Ordean (2012). "Neonatal Abstinence syndrome clinical practice guidelines for Ontatio" (PDF). Journal of Population Therapeutics and Clinical Pharmacology. 19: 488–506. 
  18. ^ Leslie, K (2015). "Officials can't explain increase in North Bay babies born to addicted moms". CTV News. 
  19. ^ Sheikh, I. "North Bay's struggle with opioid-dependent babies.". TVO.