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).

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

Prenatal

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

• Make a referral to Early Intervention for Children with Disabilities/Delays (see NM providers [34]); NAS/NOWS is a qualifying diagnosis. Primary developmental areas of concern:
  • Gross motor skills – movement patterns and balance
  • Expressive and receptive language – limited babbling, poor imitation verbally and non-verbally
• During the first postpartum year, anticipate the need for significant support and possible return to use, depending on individual’s circumstances. Eighty percent of women who were abstinent in the last month of pregnancy returned to using at least 1 substance within 1 year postpartum. [Forray: 2015] The infant’s clinician may recommend that the family work with a Family Peer Support Specialist to promote recovery and resiliency. Peer support can be critical to successfully managing recovery. Find support near you at
  • Utah Support Advocates (USARA)
  • National Federation of Families Affiliates and Partners,
  • your health department, or
  • Family Voices (FVAO) or Health Information(F2F) Center to identify local options.
• Home visitation models with nurses or trained parent peers can be beneficial (see Prenatal/postnatal Home Visitation (see NM providers [29])).
• Head Start/Early Head Start (see NM providers [10]) are also excellent options to support learning and emotional self-regulation.
• Offer the parents behavioral tips and resources such as:
  • If/then behavior reinforcements: if you do this first (like tooth-brushing), then you get this reward (5 minutes of playtime).
  • Social stories: having the child use a doll to explain the schedule to the doll and demonstrate how to get things done (when the child struggles with those things).
  • Zero to Three, ParentGuidance.org, and the Child Development Institute give lots of great online parenting tips and resources. Emotional Problems (healthychildren.org) offers focused support for parents caring for children with emotional issues.
  • Provide ongoing support for the parent’s recovery and recognition of their successes as a parent.

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]

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

• Adoption/Foster Care > … (see NM providers [8])
• Preschools (see NM providers [6])
• Early Intervention for Children with Disabilities/Delays (see NM providers [34])
• Family Support Services (see NM providers [23])
• Financial Assistance > … (see NM providers [175])
• Head Start/Early Head Start (see NM providers [10])
• Home-based Mental Health Care (see NM providers [1])
• National Support Services, Addiction (see NM providers [6])
• Pregnancy Care & Counseling (see NM providers [7])
• Prenatal/postnatal Home Visitation (see NM providers [29])
• Substance Use Disorder Care > … (see NM providers [16])