Neonatal withdrawal syndromes include symptoms that some babies experience after exposure to certain drugs that their parent has taken during pregnancy. When a person is pregnant and takes one of these drugs, the fetus can become accustomed to the drug. Once born, the baby no longer has a supply of the drug their body had become used to, and they may experience some symptoms as a result. Newborns who are exposed to opioids for medical reasons while admitted to hospital may also be at risk for opioid withdrawal symptoms depending on the duration of exposure.
What causes neonatal withdrawal?
There are specific symptoms and withdrawal patterns that are seen with certain groups of medications and substances. For instance, neonatal opioid withdrawal syndrome (NOWS) is the term used to describe infant withdrawal after chronic prenatal exposure to opioids (including morphine, hydromorphone, codeine, oxycodone, fentanyl, buprenorphine, methadone, meperidine, heroin and tramadol). Poor neonatal adaptation syndrome (PNAS) is the term used to described infant withdrawal after prenatal exposure to certain antidepressants, such as selective serotonin reuptake inhibitors, or SSRIs (including fluoxetine, paroxetine, sertraline, escitalopram and citalopram), or serotonin and norepinephrine reuptake inhibitors, or SNRIs (including duloxetine and venlafaxine).
What symptoms are associated with neonatal opioid withdrawal syndrome (NOWS)?
Withdrawal symptoms usually arise in the first 24 to 72 hours of life. Sometimes, the symptoms may not appear until five to seven days after birth. The appearance and duration of symptoms depends on the type and formulation of opioid that was used in pregnancy.
Symptoms of NOWS include:
Central nervous system irritability
- High-pitched, continuous crying
- Decreased sleep or short sleep cycles
- Tremors
- Increased muscle tone
- Seizures
Gastrointestinal and feeding difficulties
- Poor feeding, trouble with suck/swallow coordination or excessive sucking
- Vomiting
- Loose or watery stools
- Poor weight gain
Other symptoms
- Sweating
- Fever
- Frequent yawning and sneezing
- Increased respiratory rate
- Nasal stuffiness and flaring
What symptoms are associated with poor neonatal adaptation syndrome (PNAS)?
Up to 30 per cent of babies exposed to antidepressants called SSRIs or SNRIs in the third trimester of pregnancy may develop PNAS. Symptoms are usually mild and may include:
- altered muscle tone
- tremors
- jitteriness
- irritability
- seizures
- feeding difficulties
- sleep disturbances
- low blood sugar
- difficulty breathing
Symptoms can develop within hours of birth up to 72 hours of life and usually disappear by about two weeks of life without any treatment. Decreasing antidepressant use in the third trimester of pregnancy may lower the baby’s risk of developing PNAS; however, this needs to be balanced against the harmful effects of depression during pregnancy.
How is neonatal withdrawal diagnosed?
There are several scoring systems to help evaluate and monitor newborn babies at risk for opioid withdrawal. These scoring systems assess various signs and symptoms, and the severity of each. They are useful tools to track a baby’s need for further treatment, as well as their improvement over time.
An analysis of the newborn baby’s urine may be used to help diagnose symptoms of withdrawal. This is a screening method to detect whether the birthing parent has taken specific medications or drugs in the days before birth.
How is neonatal withdrawal treated?
Many supportive measures can be used to reduce the severity of withdrawal symptoms in newborns. A quiet environment, swaddling, skin-to-skin care and frequent small feedings are common ways to manage neonatal withdrawal symptoms. Some babies may need medications to treat severe withdrawal symptoms. The most commonly used medication for severe NOWS is morphine, used in small doses. Other medications, such as clonidine, may be considered to help relieve the discomfort and symptoms of withdrawal if morphine and other supportive measures have not been enough to control the symptoms. Once the signs of withdrawal are under control, the baby will be gradually weaned off the treatment medication.
Babies are usually discharged from hospital once their withdrawal symptoms have disappeared and they have been weaned off any medications that have been used to treat them.
To avoid withdrawal in newborns who are treated with opioids for pain management in hospital for more than five days, the dose and frequency of opioid medications are slowly reduced rather than abruptly stopped.
References
Canadian Paediatric Society (2021). Selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors in pregnancy: Infant and childhood outcomes. Retrieved from https://cps.ca/en/documents/position/selective-serotonin
Hudak, M. L., Tan, R. C., Committee on Drugs, Committee on Fetus and Newborn, & American Academy of Pediatrics (2012). Neonatal drug withdrawal. Pediatrics, 129(2), e540–e560. https://doi.org/10.1542/peds.2011-3212
Moses-Kolko, E. L., Bogen, D., Perel, J., Bregar, A., Uhl, K., Levin, B., & Wisner, K. L. (2005). Neonatal signs after late in utero exposure to serotonin reuptake inhibitors: literature review and implications for clinical applications. JAMA, 293(19), 2372–2383. https://doi.org/10.1001/jama.293.19.2372
Provincial Council for Maternal and Child Health (2016). Neonatal abstinence syndrome (NAS) clinical practice guideline. Retrieved from: https://www.pcmch.on.ca/neonatal-abstinence-syndrome/
Patrick, S. W., Barfield, W. D., Poindexter, B. B., & Committee on Fetus and Newborn, Committee on Substance Use and Prevention (2020). Neonatal opioid withdrawal syndrome. Pediatrics, 146(5), e2020029074. https://doi.org/10.1542/peds.2020-029074