Neonatal Opioid Withdrawal Syndrome (NOWS)

Overview

Neonatal opioid withdrawal syndrome (NOWS) describes signs and symptoms that may occur if an infant has prenatal exposure to opioids. Among infants with prenatal exposure to opioids near the time of delivery, about 30-50% will experience NOWS. Neonatal abstinence syndrome (NAS) is a term that has also been used to describe NOWS, and in some situations, these terms are used interchangeably. However, NAS is a broader term that describes an infant’s signs and symptoms of discontinuation of multiple types of substances or medications that the baby was exposed to through the placenta before birth, including opioids, nicotine, stimulants, and central nervous system depressants, etc. It is important to identify NOWS because opioid withdrawal has specific treatment approaches that main require longer observation and treatment in the hospital. [Morris: 2020] This care is essential to help promote healthy feeding and sleeping patterns in newborns and prevent morbidity. Interventions that decrease the likelihood of NOWS include nicotine cessation, polysubstance use reduction, breastfeeding encouragement, and rooming-in
Withdrawal symptoms can include:
  • Tremors
  • Excessive or high-pitched crying
  • Sleep problems
  • Hypertonicity
  • Exaggerated reflexes
  • Yawning, stuffy nose, and sneezing
  • Poor feeding and sucking
  • Hyperphagia and increased metabolic demands
  • Vomiting or diarrhea
  • Sweating
  • Fever or unstable temperature
  • Seizures
Project SCOPE: National Training Initiative (USU) has further key points for primary care clinicians and health care professionals and links to resources and provides. Much of the content is derived from the 2021-22 Pregnancy and Opioids: Resources for Women and Families (UDHHS).

Practice Guidelines

Patrick SW, Barfield WD, Poindexter BB.
Neonatal Opioid Withdrawal Syndrome.
Pediatrics. 2020;146(5). PubMed abstract

Reece-Stremtan S, Marinelli KA.
ABM clinical protocol #21: guidelines for breastfeeding and substance use or substance use disorder, revised 2015.
Breastfeed Med. 2015;10(3):135-41. PubMed abstract / Full Text

Pearls & Alerts

Language makes a difference
Let know that as their medical provider, you support their efforts toward recovery and aren’t there to judge them. Avoid the use of stigma-laden terms; research suggests they induce bias:
  • Terms to avoid:
    • Abuser, addict
      • Preferred: "A person suffering from addiction" or "a person with a substance use disorder"
      • Because person-first language is more respectful
    • Drug
      • Preferred: "Medication" or "a non-medically used psychoactive substance"
      • Because it reduces ambiguity
    • Clean, dirty
      • “A positive test result for ___” or “A negative urine drug screen”
      • Because it reduces ambiguity
    • Lapse, relapse, slip
      • “Resumed use of ___” or “Experienced a recurrence of [symptoms]”
      • Because it is morally neutral
For more guidance and a glossary of addiction-related terms, see Addiction-ary (Recovery Research Institute).

Screening & Testing

Universal screening using a validated screening tool (for example, 4P’s, NIDA Quick Screen, CRAFFT) for substance use should occur at the first prenatal visit in partnership with the pregnant person. Pregnant individuals who use opioids during pregnancy are diverse. It is important to recognize and distinguish among opioid use, opioid misuse, treated opioid use disorder, and untreated opioid use disorder. Early screening, brief intervention (engaging patient in a short conversation, providing feedback and advice) and referral for treatment of pregnant individuals with opioid use or opioid use disorder to improve maternal and infant outcomes. [American: 2021] In general, a coordinated multi-disciplinary approach without criminal sanctions has the best chance of helping infants and families.
Urine toxicology is not screening. It may be used to guide treatment for individuals with substance use disorders in partnership with the individual. Due to high false-positive and false-negative rates, a urine toxicology screen is not recommended as a stand-alone test, especially since it is a qualitative test (present or absent). Urine toxicology screening needs to be confirmed with more accurate testing, such as mass spectrometry. For infants, evaluating in-utero exposures often is performed through umbilical cord tox screen or meconium tox screen. Screening and testing for the pregnant individual should be done with maternal consent with a clear plan for the clinical utility of the results and how they will guide management. Testing of the infant should ideally occur with parental consent. [Kurtz: 2022]

Assessment & Guidance

Prenatal

Prior to delivery, it is important to identify neonates at risk for NAS and NOWS by reviewing medications and substances with the pregnant individuals. In order to determine infectious disease risk and need for rescreening of the pregnant individual and the infant (i.e., HIV, Hepatitis C, Hepatitis B, syphilis), it is important to know the timing of prenatal labs in relation to timing of last use. Below are questions that may be useful in assessing risks:
  • What medications did you take during your pregnancy that were prescribed to you?
  • Which medications or substances did you take during your pregnancy that were not prescribed to you?
  • When was the last time you took your medication/substance?
  • How did you take that those medication/substance delivery (i.e., oral, intravenous, intranasal)?

Pregnancy Medication Guidance

Detoxification, lowering doses, or tapering opioids prior to delivery does NOT decrease NOWS risk or symptom severity in newborns. It does, however, increase the risk of return to use for the pregnant individual. Therefore, pregnant individuals should be treated appropriately for their medical condition. Polysubstance exposure may not increase the need for treatment or length of hospitalization for the newborn. [Morris: 2020]
For individuals with opioid use disorder, medications for opioid use disorder are life-saving and significantly decrease the risk of overdose and death during pregnancy and the year postpartum. [Schiff: 2018]
  • Buprenorphine
    • Same efficacy and rates of adverse events as methadone
    • Lower risk of overdose and fewer drug interactions
    • Less frequent and milder withdrawal symptoms in neonates
    • Shorter hospital stay and lower morphine doses for infants with NOWS
  • Methadone
    • Administered in outpatient treatment programs which may be better for individuals with higher treatment needs (therapist and wrap-around services)
    • Decreased risk of diversion
    • More long-term data on outcomes
  • Naltrexone
    • Limited but increasing data – fewer short-term neonatal effects

Postpartum/Nursery Care

  • Every nursery should have a standardized care plan for evaluating and treating infants with NOWS.
  • Infants should be observed for signs of withdrawal for 72 hours if exposed to short-acting opioids and at least 96 hours if exposed to long-acting opioids. Polysubstance exposure could worsen signs and symptoms attributed to opioid exposure alone so they must be taken into consideration for length of observation
  • Rooming-in/paired-care – skin-to-skin, breastfeeding, low stimulation environment, etc., helps treat NOWS, often without or reducing need for medication.
    • Breastfeeding is discouraged if there was active substance use in the 30 days prior to delivery and encouraged if no use in >90 days. [Reece-Stremtan: 2015]

Infant & Child Outpatient Care

Prevalence

The national incidence of NOWS/NAS in 2017 was 7.3 cases per 1,000 hospital births, up from 6.7 in 2016 and 1.5 in 2004. [Agency: 2020] In 2016, hospital costs for NAS-related births totaled $572.7 million with a mean 15.9 days length of stay in the hospital. [Strahan: 2020]

Prevention

Stop the Cycle of Addiction, Focus on Prevention
  • Encourage parents to share their decision-making skills and stress management skills with their kids, in addition to their recovery stories.
  • Protective factors that help improve multiple youth outcomes by preventing substance abuse, dependency, risky sexual behavior, school drop-out, violence, depression, and anxiety include:
    • Cognitive competence, emotional competence, and social/behavioral competence
    • Self-efficacy, belief in the future, self-determination
    • Prosocial norms, spirituality, opportunities for positive social involvement, recognition for positive behavior, and bonding to prosocial others. The Center for Communities That Care.
  • Advocate for the following strategies in families, schools, communities, and peer groups to promote protective, healthy behaviors for all children and youth:
    • Develop healthy beliefs and set clear standards
    • Build connections through bonding, attachment, and commitment
    • Provide opportunities, skills, and recognition, and
    • Nurture individual characteristics

Resources

Information & Support

For Professionals

Dealing with the Epidemic of Neonatal Opioid Withdrawal Syndrome (Webinar)
Camille Fung, MD, is an Associate Professor in the Division of Neonatology at University of Utah Health. In this 35-minute narrated PowerPoint lecture, Dr. Fung discusses the common symptoms of Neonatal Opioid Withdrawal Syndrome (NOWS), along with resources for patients and family members.

Maternal-Infant Health and Opioid Use (AAP)
Provides resources and information about maternal opioid use and NOWS, including overcoming negative social attitudes and stigma towards pregnant and parenting women with opioid use disorder; American Academy of Pediatrics.

Addiction-ary (Recovery Research Institute)
Dictionary of terms to help de-stigmatize addiction and unify language use.

Project SCOPE: National Training Initiative
Project SCOPE: Supporting Children of the Opioid Epidemic is a national training initiative intended to build nationwide provider capacity and confidence in applying evidence-based practices in screening, monitoring, and interdisciplinary support for children and families diagnosed with Neonatal Abstinence Syndrome (NAS), Neonatal Opioid Withdrawal Syndrome (NOWS), or who are suspected of being impacted by opioid use, trauma, or related exposure.

Make Swaddle Bathing Easy in the NICU and Well-Baby Unit (Webinar)
This 20-minute video webinar, sponsored by TurtleTub, discusses how nurses and clinicians can coach parents to bond with a baby through bathing and touch. This technique can be used to alleviate withdrawal symptoms like hypertonicity. The Medical Home Portal does not endorse the use of any particular bath manufacturer.

Developmental Monitoring and Screening for Health Professionals (CDC)
Information on incorporating developmental screening into the Medical Home and resources for practice as well as patient education; Centers for Disease Control & Prevention.

Health Equity: What You Can Do (NICHQ)
Information about recognizing implicit bias and improving health equity. Links to an Implicit Association Test (IAT) from Project Implicit. National Institute for Children's Health Quality

For Parents and Patients

Support

The Center for Communities That Care
Our mission is to promote the healthy development of young people through high-quality implementation of CTC PLUS, Guiding Good Choices, and other preventive interventions. The Center for Communities That Care is part of the Social Development Research Group, School of Social Work, University of Washington.

Center for Parent Information and Resources (DOE)
Parent Centers in every state provide training to parents of children with disabilities and provide information about special education, transition to adulthood, health care, support groups, local conferences, and other federal, state, and local services. See the "Find Your Parent Center Link" to find the parent center in your state; Department of Education, Office of Special Education.

General

Neonatal Opioid Withdrawal Syndrome: What Families Need to Know (healthychildren.org)
Information about NOWS signs, symptoms, breastfeeding, going home, and follow-up care; from the American Academy of Pediatrics.

What is NOWS? (YouTube) (MIHP)
Four-minute video describing neonatal opioid withdrawal syndrome and how babies at risk for NOWS are monitored and treated after birth; Maternal & Infant Health Program.

How Is NOWS Treated? (YouTube) (MIHP)
Three-minute video explaining how parents can support infants experiencing neonatal opioid withdrawal symptoms; Maternal & Infant Health Program.

What Do I Need to Know Before I Take My Baby Home? (YouTube) (MIHP)
Three-minute video offering brief medical advice on caring for a newborn once you leave the hospital, including caring for newborns with neonatal opioid withdrawal syndrome; Maternal & Infant Health Program.

Caring for a Baby Exposed to Drugs During Pregnancy (NMDOH) (PDF Document 258 KB)
Brochure for parents and other caregivers of infants exposed to drugs during pregnancy. Provides an overview of neonatal abstinence syndrome (NAS, also referred to as NOWS or neonatal opioid withdrawal syndrome), what causes it, and tips on how to console your baby; New Mexico Department of Health.

Caring for a Baby Exposed to Drugs During Pregnancy (NMDOH) (Spanish) (PDF Document 257 KB)
Brochure in Spanish for parents and other caregivers of infants exposed to drugs during pregnancy. Provides an overview of neonatal abstinence syndrome (NAS, also referred to as NOWS or neonatal opioid withdrawal syndrome), what causes it, and tips on how to console your baby; New Mexico Department of Health.

How to Swaddle Bathe at Home (English version)
Swaddle bathing is a technique used by parents to calm a newborn with gentle bathing and touch. This can be very soothing for a baby experiencing withdrawal symptoms. This short video provides guidance on how to do this with your baby.

How to Swaddle Bathe at Home (cómo hacer el baño envolvente a casa)
El baño envolvente es una técnica utilizada por los padres para calmar a un recién nacido con un suave baño y tacto. Esto puede ser muy relajante para un bebé que experimenta síntomas de abstinencia. Este breve video brinda orientación sobre cómo hacer esto con su bebé.

Zero to Three
A national nonprofit organization that aims to promote the health and development of infants and toddlers, with information and resources for parents and professionals. Information about parenting, development, learning, behavior, and well-being of infants and toddlers. Includes video real-life examples, articles, and FAQs.

Parents as Teachers (PAT)
Home visiting program to help with child development and literacy.

PCIT International - Information for Parents
Parent-Child Interaction Therapy (PCIT) is a therapy to promote healthy family functioning. This website provides answers to frequently asked questions and other information for parents about PCIT.

ParentGuidance.org
This online resource offer education and therapeutic support to empower and give you hope as you support your child’s mental health. Free weekly coaching is available in some school districts.

Child Development Institute
Information, products, and services related to child development, psychology, health, parenting, media, entertainment, and family activities. Helps families to connect with other parents, professionals, and organizations.

Emotional Problems (healthychildren.org)
Helpful information about emotional difficulties, including anxiety and associated problems; American Academy of Pediatrics.

Baby Your Baby: Taking Medications During Pregnancy Podcast (KUTV 2News)
Moms may feel like they shouldn’t take medications during pregnancy to protect the baby, but their illness or condition may be more harmful to the baby than the medication that treats it. Toughing out an illness usually isn’t better for a baby. Anchor Holly Menino sits down with Al Romeo, a registered nurse with the Utah Department of Health’s MotherToBaby/Pregnancy Risk Line program to discuss the risks and benefits of taking certain medications and vitamins.

Know Your Script
When it comes to overdose and addiction, we all have a part to play in keeping ourselves, our loved ones, and our communities safe. “Know Your Script” is an initiative to empower each of us to make smart decisions and ask the right questions regarding prescribed medications. Champion your role against prescription drug misuse and always know your script.

Center for Parent Information and Resources (DOE)
Parent Centers in every state provide training to parents of children with disabilities and provide information about special education, transition to adulthood, health care, support groups, local conferences, and other federal, state, and local services. See the "Find Your Parent Center Link" to find the parent center in your state; Department of Education, Office of Special Education.

Tools

Drug Abuse Screening Test (DAST-10) (PDF Document 161 KB)
A 10-item screen that assesses drug use, not including alcohol or tobacco use, in the past 12 months. A clinician-administered version and a self-report version are provided. The screen and scoring instructions can be downloaded or printed for free; developed and validated by Dr. Harvey A. Skinner at the Addiction Research Foundation.

Watch Me! Celebrating Milestones and Sharing Concerns - Training (CDC)
Target audience: early care and education providers. This free, 1-hour, 4-module course provides tools and best practices for monitoring the development of children in your care and talking about it with their parents. CE available. Centers for Disease Control and Prevention.

Breaking through Bias in Maternity Care Training (March of Dimes)
An implicit bias training course that provides health care professionals with important insights to recognize and remedy implicit bias in maternity care settings. Delivered in-person or through a self-paced, e-learning platform to provide authentic and compelling content for health care providers caring for women before, during, and after pregnancy. CME and CNE available.

Services for Patients & Families in New Mexico (NM)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Authors & Reviewers

Initial publication: December 2020; last update/revision: August 2022
Current Authors and Reviewers:
Authors: Jennifer Goldman, MD, MRP, FAAP
Kimberly Stowers, MD
Senior Author: Bhanu Muniyappa, MD
Reviewers: Marcela C Smid, MD, MS, MA
Camille Fung, MD
Authoring history
2022: update: Jennifer Goldman, MD, MRP, FAAPA; Kimberly Stowers, MDA; Bhanu Muniyappa, MDSA
2021: update: Jennifer Goldman, MD, MRP, FAAPA; Kimberly Stowers, MDA; Bhanu Muniyappa, MDSA
2021: update: Kimberly Stowers, MDA
2020: first version: Jennifer Goldman, MD, MRP, FAAPA
AAuthor; CAContributing Author; SASenior Author; RReviewer

Page Bibliography

Agency for Healthcare Research and Quality, Rockville, MD.
HCUP Fast Stats. Healthcare Cost and Utilization Project (HCUP). August 2020.
(2020) http://www.hcup-us.ahrq.gov/faststats/nas/nasmap.jsp. Accessed on 9/7/21.

American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice in collaboration with committee members Maria A. Mascola, MD, MPH; Ann E. Borders, MD, MSc, MPH; and the American Society of Addiction Medicine member Mishka Terplan, MD, MPH.
Opioid Use and Opioid Use Disorder in Pregnancy.
Committee Opinion. 2021; (711). https://www.acog.org/clinical/clinical-guidance/committee-opinion/arti...
Replaces Committee Opinion Number 524, May 2012. Reaffirmed 2021.

Kurtz T, Smid MC.
Challenges in Perinatal Drug Testing.
Obstet Gynecol. 2022;140(2):163-166. PubMed abstract

Morris E, Bardsley T, Schulte K, Seidel J, Shakib JH, Buchi KF, Fung CM.
Hospital Outcomes of Infants with Neonatal Opioid Withdrawal Syndrome at a Tertiary Care Hospital with High Rates of Concurrent Nonopioid (Polysubstance) Exposure.
Am J Perinatol. 2020. PubMed abstract / Full Text
This study was to determine hospital outcomes of infants exposed to opioids alone or co-exposed with nonopioid substances (polysubstance) in a single urban academic center.

Patrick SW, Barfield WD, Poindexter BB.
Neonatal Opioid Withdrawal Syndrome.
Pediatrics. 2020;146(5). PubMed abstract
This policy statement by the American Academy of Pediatrics (AAP)'s Committee on Fetus and Newborn and Committee on Substance Use and Prevention provides an overview of the effect of the opioid crisis on the mother-infant dyad and provide recommendations for management of the infant with opioid exposure, including clinical presentation, assessment, treatment, and discharge.

Reece-Stremtan S, Marinelli KA.
ABM clinical protocol #21: guidelines for breastfeeding and substance use or substance use disorder, revised 2015.
Breastfeed Med. 2015;10(3):135-41. PubMed abstract / Full Text
A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Schiff DM, Nielsen T, Terplan M, Hood M, Bernson D, Diop H, Bharel M, Wilens TE, LaRochelle M, Walley AY, Land T.
Fatal and Nonfatal Overdose Among Pregnant and Postpartum Women in Massachusetts.
Obstet Gynecol. 2018;132(2):466-474. PubMed abstract / Full Text

Strahan AE, Guy GP Jr, Bohm M, Frey M, Ko JY.
Neonatal Abstinence Syndrome Incidence and Health Care Costs in the United States, 2016.
JAMA Pediatr. 2020;174(2):200-202. PubMed abstract / Full Text
This cross-sectional study examines the national incidence rate of neonatal abstinence syndrome using data from the 2016 Healthcare Cost and Utilization Project Kids’ Inpatient Database.