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Expanding Treatment Options in the Neonatal Abstinence Syndrome Epidemic

Prenatal maternal drug use has long been known to cause drug withdrawal in newborns
(Committee on Drugs 1079). After birth, the infant no longer receives the drug and is thus
experiencing abstinence; this phenomenon is known as Neonatal Abstinence Syndrome (NAS).
NAS has generally been attributed to the use of illicit drugs, such as cocaine and heroin.
However, within the past decade, there has been an epidemic of NAS occurrence (Astho 2).
This is attributed to increased use of prescription opioids, antidepressants, chronic pain relievers,
and even caffeine by expecting mothers. While different drugs affect neonates in different ways,
many symptoms are consistent regardless of the drug used. Neonatal Abstinence Syndrome
produces deleterious effects in neonates and can also cause developmental problems; due to the
complex nature of NAS occurrence, successful treatment and prevention requires many people,
including healthcare professionals, nonmedical professionals such as social workers and
therapists, and community members.
NAS has a number of symptoms affecting the central nervous system, metabolic, motor,
and respiratory systems, and the digestive system. Symptoms regarding the central nervous
system include excessive crying, minimal sleeping, a hyperactive Moro reflex, tremors,
increased muscle tone, and convulsions. Because infants with NAS are not self-consolable, they
cry far more than most infants without NAS. The Moro reflex is an important reflex that reacts to
sudden noises or movements, and like most reflexes, is key to ensuring proper development.
Tremors can be the result of disturbance or can occur without a prompting stimulus; the latter is
more severe, but both are indicative of NAS. Increased muscle tone is also rather notable; infants
tend to be loose and relaxed, but NAS infants are often stiff enough to sit up.
Symptoms regarding the metabolic, motor, and respiratory systems include sweating,

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excessively high temperatures, and tachypnea. Tachypnea is generally defined as fast breathing
for an extended period of time, and is indicative of stress. Symptoms regarding the digestive
system include inconsistent feeding, vomiting, and loose stools. Some NAS infants feed poorly,
while other NAS infants find satisfaction in nothing other than food. In general, NAS infants are
prone to spitting up and vomiting, but they can also projectile vomit. The symptoms of drug
withdrawal in infants are quite similar to that seen in adults.
In order to quantify and better evaluate when an infant is suffering from NAS, a scoring
system is used. There is no one scoring system, but most are very similar, and each hospital tries
to most effectively suit their needs. For example, the most widespread abstinence scoring sheet is
the Finnegan scoring system. This system consists of a list of twenty common symptoms,
including the ones discussed above, and each is ranked on a scale of 1-5, 1 meaning the least
potential for adverse effects (Burgos 224). The scores for each category are then added up; a
total score above 8 indicates that pharmacological therapy may be needed. NAS can be first seen
anywhere between at birth to fourteen days; in general, when risk of NAS is high, the
observation period is five days.
From a purely clinical standpoint, helping with NAS seems simple: administer a drug to
balance out the effects of the withdrawal and slowly wean off of said drug. However, weaning
can bring up many complications, as can the infants parents. One of the goals of most Neonatal
Intensive Care Units (NICU) is to involve family in the care of their infant in order to promote
the infants psychological and social development in addition to its physical development. Given
the NICU setting of sick infants with new parents, this can be difficult at times, and even more so
in the case of NAS. However, it is particularly important to treat NAS from all sides in order to
best benefit the infant.

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The front line of any medical treatment is found with doctors, nurses, and nurse
practitioners, and the NICU is no different. As mentioned previously, the symptoms of
withdrawal are brought under control by using a drug to counteract withdrawal. Usually, this
drug is morphine or methadone. Both are opiates that effectively counteract NAS symptoms and
appear to leave fewer side effects than other drugs. After issuing the drug to be used and ensuring
that the infants NAS symptoms are under control, the drug dosage is decreased slowly until the
infant can be weaned off the supporting drug.
However, weaning an infant off an addictive drug is not always as simple as it sounds.
Unfortunately, outcomes can be very uncertain, and healthcare professionals must be extremely
sensitive to any changes in the infants behavior in order to ascertain what is due to withdrawal
symptoms and what is not. Knoxville Childrens Hospital in Tennessee provides an example of a
NICU that deals with this sort of problem on a regular basis (Chang). Similar to the case covered
in that source, healthcare professionals may try to rush the weaning process; this nearly always
leads to setbacks. The process of weaning a NAS infant off morphine is a very demanding task
for nurses and doctors, as this can take months, which is significantly longer than most NICU
stays. Additionally, setbacks are very discouraging and often places equipped to deal specifically
with NAS, like the unit mentioned in Tennessee, provide the most support to healthcare
professionals in this situation.
Nurses, in particular, are responsible for a lot of the comfort that NAS infants receive. As
NAS infants are often inconsolable due to the nature of their illness, they tend to cry far more
than other infants. Most nurses, when free, manage to spend time comforting and playing with
the crying infant. This is crucial, particularly when the infant grows older and does not sleep as
much as the general structure of the NICU accounts for. Nurses are invaluable to the

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development of infants diagnosed with NAS, and provide most personal contact to NAS infants.
They also make many of the observations that control dosage amount and administer the dosage.
While healthcare professionals have very demanding and stressful careers, seeing patients
recover far outweighs all other costs to the profession.
In addition to medical treatment, support from social workers, therapists, and counselors
is necessary for successful NAS treatment in the NICU. First, a lactation specialist is required to
ensure that the mother does not pass on any drugs to her child through her breastmilk, assuming
she chooses to breastfeed. The mother should also be made familiar with the course of treatment;
if this cannot be done by the healthcare professionals, then an interpreter is also necessary. The
information given to the mother should include the possibilities such as respiratory depression,
convulsions, or months with NAS. People such as speech and respiratory therapists should also
be provided for the benefit of the infant in the eventuality that he needs speech or respiratory
therapy.
A social worker can ensure the safety of the child and the capacity of the parents to care
for the child while the child is in the hospital. If they are found lacking, they could promptly be
connected to counselors regarding parenting, drugs of abuse, or any other topic that they may
need support in. While this system is not yet in place, it would greatly benefit the life of the NAS
infant, which is the ultimate goal. A major obstacle for an NAS infant is that its mother has
struggled or still struggles with the use of some potent drug, and until that is addressed in a
healthy and caring way, the child has a smaller chance at having a happy and safe childhood and
life. Many studies need to be done to clarify the long-term effects of NAS on children,
adolescents, and adults; however, until that time, every effort must be made to support and care
for the primary supporters of the infant its parents.

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The final group of people that must be involved in the care of the NAS infant is the
infants family and friends. A close bond with family, beginning close to birth, is key to the
infants proper social and psychological development, as shown by the promotion of kangaroo
care (March of Dimes). Physical nearness and touch are both extremely beneficial to all infants,
with or without NAS. However, NAS makes the infant more vulnerable to difficulties in social
and/or psychological development. As a result, the infants family must be strong and caring, and
a large support system in the community can only benefit that.
By learning about NAS and non-pharmacologic treatments, the family can tangibly
support the infant. The goal of non-pharmacologic treatment is to help the infant sleep, eat, gain
weight, and interact with caregivers, (Astho 16). Becoming involved with the infants care
while in the hospital sets a good precedent and strengthens the parent-child bond. Additionally, a
correlation has been shown between rooming-in, when the mother and infant room together, and
a shorter hospital stay (Astho 16).
This focus on the family unit is also necessary because mothers of NAS infants often feel
guilty or anxious, and can sometimes be blamed by parents or relatives. This increases the
mothers distress and can decrease her attentiveness toward her infant. As a result, modeling
positive relationships and providing support is key in taking care of NAS infants. In addition to
the infants well-being, the mothers well-being is also very important. While the decision to stop
taking drugs is an individual one, the mother requires a firm support system of people she can
turn to in any situation in order to successfully raise her child. A good support system is vital to
overcoming difficulties and would significantly benefit nearly every person, but especially an
NAS infant.
NAS occurrence has been drastically increasing over the course of the past decade.

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Preventative care is the only full solution, but in the meantime, the combined efforts of NICU
staff, social workers, and communities will greatly benefit everyone exposed to Neonatal
Abstinence Syndrome. These efforts are a necessity. According to a 2005 case study of a visually
impaired infant and his mother, a language barrier between the mother and NICU staff stunted
the bond between mother and child and limited the childs development until infant massage
therapy was introduced (Lappin). The fact that this was not an infant affected by NAS simply
makes the message more potent: the consistent support of many people, particularly medical
professionals, nonmedical professionals like translators, and the infants community, is required
for the infants continued growth and development both during and after his hospital stay.
Similar to many severe illnesses, recovery from NAS is a long and often discouraging process.
Commitment to the mother and child from many is crucial to successfully overcoming drug
addiction in the long run.

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Works Cited
Astho. Neonatal Abstinence Syndrome: How States Can Help Advance the Knowledge Base for
Primary Prevention and Best Practices of Care. Arlington: Association of State and
Territorial Health Officials, 2014. Print.
Burgos, Anthony E., and Bryan L. Burke, Jr. "Neonatal Abstinence Syndrome." NeoReviews 10
(2009): e222-e229. Print.
Chang, Juju, and Erin Brady. Hidden America: Nearly Half of Newborns at Tennessee Hospital
Are Drug-Dependent. N.p.: ABC News, 11 July 2012.
Committee on Drugs. "Neonatal Drug Withdrawal." Pediatrics 101.6 (1998): 1079-88. Print.
Lappin, Grace. "Using Infant Massage Following a Mother's Unfavorable Neonatal Intensive
Care Unit Experiences: A Case Study." Re:view 37.2 (2005): 87-94. Print.
"Medical Resources." March of Dimes. March of Dimes Foundation, n.d. Web. 24 Oct. 2015.