NAS: Neonatal Abstinence Syndrome
The vast majority of people will live their lifetime without ever hearing the term. NAS or Neonatal Abstinence Syndrome is the term used to describe the symptoms of withdrawal neonates suffer following their birth. NAS is most commonly associated with the use of narcotics like heroin or methodaone however it does not exclusively refer to drug addicted mothers - there are also many cases of women who form drug dependency due to chronic illness or suffered truama which requires strong medication during pregnancy.
Nearly 4% of pregnant women in the United States use illicit drugs during pregnancy. Add that to the large number of women who are on maintenance programs like Methadone or Buprenorphine (Subutex/Subxone) and the numbers are staggering.
This hub is dedicated to all the carer's involved in delivering and treating of NAS babies and the wonderful work they do look. I hope that new mother's and their family's will find the informatation that they are looking for. It covers an overview of prenatal care to NCIU and taking your baby home. For an overview of Buprenorphine and Methadone in pregnancy click here. Please consult your Doctor for information about drugs in pregnancy and do not rely on word of mouth information only.
Prenatal care of the mother and child...
Due to the increasing demand of these services, clinics which specialize in the care of drug and alcohol addicted pregnancies are popping up all over the world . These clinics are based either in or near the hospital's and are staffed by a specialist team of Obstetrician's, Paediatrician's, midwive's and neonatal nurse's as well as mental health professionals and social workers, all of whom specialise in this area. They are generally very sympathic and non-judgemental. It is a one stop shop for drug dependant pregnancies.
They moniter the health of mother and child for the duration of the pregnancy, the birth and subsequent neonatal care. They are also shockingly busy.
The best option for expectant mothers is currently Subutex (Burenorphine). It is vital that women confide in the help of their Doctor as early as possible so that treatment on a maintainence programme can begin. You can find more information about the use of Methadone or Buprenorphine (Subutex or Suboxone) in pregnancy here.
The risks involved in drug use in pregnancy are serious and very real. Professional health care should be sought at the earliest possible time.
After the birth...
The majority of NAS babies are delivered via traditional means however Doctors may opt for a caesarian delivery for a number of reasons. Providing there is no immediate complications, NAS bnabies are encouraged to room-in with their mothers after delivery until withdrawal symptoms present.
Depending on the substance that was used in pregnancy, the baby may begin to present with symptoms of withdrawal within hours. More commonly, withdrawals present after 12-48hrs and peak around 72hrs. The severity of symptoms will depend on the drug that was used and the quantity. Symptoms will vary from one baby to the next - like adults, each baby has his/her own pain threshold and level of tolerance. For this reason, there is no way to judge how long the baby will require treatment or if they will require any treatment at all..
When required will begin within the first week after birth and may continue for weeks, sometimes months. Subutex, though vastly unstudied in pregnant women, has the best figures regarding NAS. Due to the young age of the drug there is currently no way of predicting the long term effects of Subutex in pregnancy though first studies indicate that it is the best choice.
The most common system used for measuring NAS and determining treatment is the Finnegan system. It is occasionally revised from time to time. Parents should familiarise themselves with the Finnegan to gain an accurate idea of what to expect and what to look out for.
You will find a printable version here.
The Finnegan System - Symptoms are measured on a scale of 1-5 depending on the severity or serious nature of the symptoms.
- Excessive sucking = 1,
- Sleeps less than 2hours = 2,
- Convulsions = 5.
- Snuffly nose - 1
- Tremors when disturbed = 2 etc
Assessments are made every four hours. Once the baby reaches an excessive score for three consequtive assessments, the Doctor will begin treatment. The favoured option these days in morphine. Seems excessive? Left unchecked, NAS babies suffer terribly. Convulsions can cause brain damage and death. It is the aim of carers to minimise the chances of these serious complications and more importantly, maximise the comfort of the baby.
Morphine is administered every four hours in minute quantities which are calculated using the weight at birth, the average starting dose will begin around 0.4mg morphine x4 daily.This dose may be increased if the baby continues to score highly otherwise will be maintained until the score is consistently low.
After consistently low scores have been achieved, Doctors will then begin to wean the baby. In the case of a full term baby of an average weight, the dose will be reduced about 0.05mg at a time. Close monitoring will ensue. If the baby has three consecutively high scores, the Doctor will consider returning them to the previous dose.
Buprenorphine in Pregnancy - Statistically Speaking...
- 55-94% of babies born to opioid dependent mothers will exhibit symptoms of NAS.
- There have only been 21 published reports of the use of Buprenorphine in pegnancy.
- These reports involved the study of 309 infants who had been exposed to Buprenorphine (Subutex and Suboxone) in utero.
- Of these 309 babies, 62% exhiited NAS
- Of these 309 babies, 48% exhibited NAS and required treatment (though nearly half of this group was also exposed to illicit drugs too).
- Buprenorphine babies begin to present with symptoms of NAS within 12-48hrs of birth
- Withdrawals peak at approx 72-96 hrs.
In short, 96% of babies born to opioid dependent mothers experience NAS and only 62% of Buprenorphine babies experience NAS. This is one of the benefits of Subutex over Methadone during pregnancy. This is the reason that doctors favour Subutex over Methadone - the withdrawals are milder, shorter and require less medical intervention.
Additional care of NAS babies...
There are many additional cares that NAS babies require that are specific to your individual case - such as the care of premature babies or poor feeders etc. Your Doctor will discuss these problems with you. The nurses who care for your baby will also be an invaluable source of information...don't be afraid to ask the same question to every nurse you come across until it's answered to your satisfaction.
In some instances, babies can continue their weaning regime at home under close medical supervision. Your hospital will have social workers who can assist you throughout your pregnancy (and beyond) and may be able to help you discuss the possibility of home based weaning with your Doctor - this varies from one region to the next and is assessed on a case by case basis. Home based weaning always begin with at least one week in a special care nursery until the babies score has stabilized..
Breastfeeding whilst using illicit drugs increases the occurrence of SIDS and health complications. These babies also tend to be more irritable and cry more than others. Breastfeeding whilst using Subutex (Buprenorphine) is still uncharted territory. Most experts agree that since the drug is broken down (rather than being absorbed) in the digestive system, the very little amount that is found in breast milk is acceptable. Subutex is preferred over Suboxone during pregnancy and breastfeeding. All decisions should be made with your Doctor.
There are some additional traits and problems that occur in nearly every NAS baby that every parent or carer should know before bringing their baby home. Be sure to inform family. friends and babysitters of these needs too.
Excessive suckers - It's ironic that NAS babies are often such poor feeders and yet they are excessive suckers. Whilst pacifiers/dummies are discouraged amongst the experts, for NAS babies they make an exception. Dummies are especially beneficial to premature NAS babies as it allows them to practice their feeding reflexes and strengthen their jaw.
Low/No Stimuli - You don't like bright lights and loud noises when you're sick either. NAS babies are very sensitive to stimuli and respond well to minimal handling. They will require prompt care when they are distressed but this is best given with minimal fuss.
Fragile: Avoid direct sunlight! NAS babies do not appreciate bright lights. Where ever possible, it's a good idea to keep them in a temperate low lit room as NAS babies become irritable and difficult when they are exposed to bright sunlight.
Excessive Crying - As a drug dependent adult you would know that there's a lot to cry about. Any new mother will attest to a crying baby being the source of much anxiety, frustration, helplessness and confusion. Dependant mothers can also add guilt to the list. It's good to remember that not every cry that issues from his/her mouth is a cry of pain. Once you have ruled out the usual suspects - hunger, wind, clean bottom, tiredness - you all you can do is swaddle them and hold them close. Reassess the usual suspects accordingly.
Excessive Cuddles? - No such thing!! NAS babies need a lot of extra cuddles but be sure not to allow your baby to be overstimulated.
What every new NAS parent should remember...
Be patient and know that hospital's never keep a patient for a second longer than absolutely necessary - it's just not good business sense. The staff who specialize in this area are dedicated and professional and they have your child's best interests at heart. Be honest about your dependency from the start (they know...whether you tell them or not, they know). They are full of wisdom that they are happy to share. Don't rush your baby. Like every adult will experience withdrawal differently, so will every baby.
In the long term...
For all the trauma that NAS babies and their parents endure in the months ensuing birth, many babies go on to have perfectly normal lives.
The long term health of Buprenorphine (Subutex/Suboxone) babies are of considerable interest to professionals.
Methadone on the other hand hes been used to treat drug dependent mother to be for over 40 years and has been found "safe" however there is a much high occurrence of NAS (up to 94%). You will find more statistics in the companion article called NAS: Subutex, Subone & Methadone in Pregnancy.
Every effort should be made to treat depression or social issues as early as possible for they have a significant effect on the longterm development of the child. (For example there is a higher occurance of depression found in adult's whose mother's had prenatal depression). There are many health care professionials on hand to assist mothers with drug dependency and it's important that the first steps are those made in the right direction.
For additional information you should consult your Doctor. For additional reading:
- Maternity Care in SA > Perinatal Practice Guidelines > Section 5 > Chapter 82 - Infants of
The South Australian Perinatal Practice Guidelines (SAPPG) are medical guidelines. They are based on systematic research and identification of the best available evidence. They have been developed in cooperation with the major metropolitan public hos
- Neonatal Abstinence Syndrome - Brochure
This printable brochure has been put together by one of Australia's leading maternal health hospitals specifically for the families of babies suffering from NAS
- Printable copy of the Finnegan scoring sheet
Know what to expect from a baby with NAS
The results of a recent study into Methadone vs Buprenorphine in pregnancy. Be warned, this research has been written for Doctors and you may need to familiarize yourself with the terminology.
- Methadone and Pregnancy
Subutex and Breast Feeding
Due to the very young age of Burenorphine (Subutex and Suboxone) there have not been enough studies to determine either way whether it is safe to use during lactation. There is much information to be found but most of this is dated - there are new studies being conducted regularly.
In adults, the Buprenorphine tablets are designed to be taken sub-lingually (under the tongue). When the drug is swallowed it is broken down by stomach acids before the body can absorb it. The amount that does find it's way into the bloodstream is tiny.
Against - There are many who strongly object to the use of Buprenorphine (Subutex) during breast feeding because it has been found in breast milk and therefore the baby is exposed.
For - The baby has been exposed in utero and the quantity which is found in breast milk is very small. In theory when Buprenorphine is swallowed by the baby it should be broken down in gut.
For this reason, many Doctors are now unofficially approving the use of Buprenorphine (namely Subutex) during lactation.
Their have been several animal tests so far and discovered (besides that fact that goats don't like Subutex) is that Buprenorphine may limit the milk production. This can be remedied with drugs such as Motillium which is safely used by many mothers who need to increase their milk supply. They have also observed irritable behaviour.in animals.
At the end of the day, mother's must consult their Doctor's and make an informed decision based on the limited knowledge available. You must do what you feel is right for your family.
Subutex Babies Forum
As a temporary solution to my flooded inbox from mothers using (or thinking about using ) buprenorphine during pregnancy and breastfeeding, I have created a forum dedicated to addressing the issue.
If you're in need of support or have any questions, I'd like to invite you to come along and contribute to the...
Looking for support??
You are welcome to contact the author at eliz.nesbitt@gmail
This address has been created for mothers and families to contact me privately with any queries about Subutex/Suboxone in pregnancy and the subsequent care of your baby.
I am dreaming big - I hoping to eventually create a support network for mothers by mothers - there is far to much mis-information available on line for families in search of unbiased information and as I researched the latest studies I realized that most of the information I found through Google was years out of date. After a quick keyword search, I also realsized that there are thousands of searches each month, confused parents looking for this information.
So...if you are willing to get in touch with me, as a mother with an experience to share or as a Paediatrician or a Neonatal Nurse I will be thoroughly grateful for your contribution - however small - to this network.