Article Recommended by Dr. Don Stader: Advances in the Care of Infants With Prenatal Opioid Exposure and Neonatal Opioid Withdrawal Syndrome

As the opioid epidemic’s impact broadened and crept into all corners of medicine and public health, prenatal opioid exposure (POE) and neonatal opioid withdrawal syndrome (NOWS) necessarily became areas of focus in obstetrics and pediatrics. Data has indicated that national rates of POE and NOWS have decreased since 2017, but it is still an all-too-regular and high stakes occurrence. It also appears to affect our most vulnerable populations in low-income and rural areas. In an effort to shape high quality care in the future, the American Journal of Pediatrics published a review of the literature over the past 5 years to summarize lessons learned and best practices. Here are some of the key takeaways:

• Identification and Diagnosis: 

NOWS is a clinical diagnosis made when 1) there has been exposure to opioids during pregnancy (self-reported or toxicology testing) and 2)  at least two of the common symptoms of NOWS are exhibited: excessive crying, fragmented sleep, tremors, hypertonia, GI dysfunction. Clinicians should be aware of legal consequences of toxicology testing including racial and class disparities in perinatal tox testing. It is encouraged hospitals outline clear guidelines for clinicians that prioritizes patient consent, education and transparency. 

• Preparing for Delivery and Hospitalization:

Actions should be taken to reduce anxiety and shame of families, namely education and person-first, non-stigmatizing language. Walking expecting parents through likely symptoms and expected management of NOWS alleviates confusion. Refer to the newborn as “substance-exposed newborn” and “infant with NOWS” rather than “born addicted” and  “addicted infant”.

• Assessment and Management of Newborns With POE:

Allowing the newborn to room-in with parents/primary caregivers is associated with more positive outcomes, including breast-feeding initiation, decreased rates and lengths of pharmacologic treatment. Some newborns will need cardiopulmonary monitoring on pharmacologic treatment, though multiple studies found no significant difference in cardiopulmonary adverse events between newborns with NOWS on pharmacologic therapy and newborns with NOWS who did not receive pharmacotherapy. Infants with POE should be monitored for development of NOWS, with special attention paid to wake times. The 2 most common assessments are the Finnegan Neonatal Abstinence Scoring Tool (FNAST) (Link) and the Eat, Sleep, and Console (ESC) assessment (Link) approach.

• Non-Pharmacologic Interventions

First-line treatment of NOWS is optimizing the infant’s environment and feeding. Such interventions include reducing noise and bright lights in the infant’s room, swaddling and skin-to-skin time to reduce hyperarousal, and clustering of care times to limit disruptions to infant sleep. Some other interventions that have shown potential benefit are vibrating mattresses, prone positioning, waterbeds, and a low stimulation nursery settings. Breastfeeding has been associated with decreased severity and length of NOWS symptoms. No consensus exists on which type of formula is best if needed. If weight and feeding goals are not met, there should be a low threshold for NG tube placement. 

• Pharmacologic Interventions:

If the infant’s NOWS symptoms persist after maximizing non-pharmacological interventions, then first-line pharmacological treatment with an opioid is indicated. Morphine is most typical at this time, though research shows improved short-term NOWS outcomes including length of stay attributable to NOWS and length of treatment of methadone-treated infants and potentially even better results with buprenorphine (refer to table 4 in the article for specific doses). Phenobarbital and Clonidine are used for secondary medications with specific weaning protocols. 

• Contributors to Severity of NOWS Presentation:

NOWS severity was associated with co-exposures to other substances and medications (specifically cocaine and cannabis, psychiatric medications), maternal and neonatal characteristics, genetic factors (specific locus on chromosome 7 (Link), epigenetic factors), and perinatal behavioral and environmental factors (engagement in prenatal care associated with more positive outcomes). Of note, one study (Link) showed pregnant people with OUD who were treated with buprenorphine had lower rates of neonates that received NOWS diagnosis. 

• Discharge Planning:

Considerations for readiness to discharge: resolution of withdrawal symptoms, a period of 24 to 48 hours of observation after stopping pharmacological treatment, adequate feeding and weight gain, safety assessment of the caregivers, completing a plan of safe care, and placing referrals for outpatient follow-up.

• Outpatient Management:

Literature in this area is limited, though studies in these patients in their first year after birth have shown increased risk of morbidity and mortality thought to be due to factors such as decreased attendance at doctor’s appointments, higher ED visits and hospital admissions. Special considerations exist for developmental milestone assessments, vision and hearing screenings as well as screening for HCV. Data tracking long term outcomes is more scarce. This is where education and counseling of primary caregivers in the perinatal period and prior to discharge becomes crucial. 

https://publications.aap.org/pediatrics/article-abstract/153/2/e2023062871/196385/Advances-in-the-Care-of-Infants-With-Prenatal