The U.S. has experienced a surge in the use of prescription opioids, and the use of
illicit heroin and fentanyl that affects nearly every segment of the population, including
pregnant women and those of reproductive age (Paulozzi LJ, et al. MMWR Morb Mortal Wkly Rep. 2011;60:1487-1481). This has led to a significant increase in the incidence of neonatal
opioid withdrawal syndrome (NOWS), resulting in prolonged hospitalizations and elevated
health care costs (Strahan AE, et al. JAMA Pediatr. 2020;174:200-202).
Although public health measures to prevent and treat opioid use disorder before and
during pregnancy are critical, there is an opportunity to improve and standardize
postnatal treatment for infants to reduce morbidity, hospital length of stay and associated
costs. In addition, postnatal treatment varies substantially across the country due
to variation in facility protocols and state policies.
A new AAP clinical report gives pediatric providers the information and tools to improve
care of infants born with NOWS and serves as a companion to a 2012 report on neonatal
drug withdrawal (https://bit.ly/36kcrR9).
The prevalence of opioid misuse among pregnant women hospitalized for delivery has
increased 333%, from 1.5 cases per 1,000 delivery hospitalizations in 1999 to 6.5
per 1,000 in 2014, according to the Centers for Disease Control and Prevention (Haight
SC, et al. MMWR Morb Mortal Wkly Rep. 2018;67:845-849).
In parallel, the U.S. experienced a substantial rise in diagnoses of neonatal abstinence
syndrome, primarily from opioids, from 1.2 per 1,000 U.S. hospital births in 2000
to 8.8 per 1,000 in 2016 (Leech AA, et al. Health Aff (Millwood). 2020;39:764-767).
Clinical presentation, assessment, treatment
The report describes the clinical presentation of NOWS, noting timing and onset, and
how opioid exposure can originate from prescription pain medications, illicit substances
or medications for opioid use disorder.
The clinical presentation of NOWS should be considered with additional maternal exposures
(e.g., hepatitis C virus exposure) and differentiated from other neonatal conditions
(e.g., sepsis, hypoglycemia). Assessment of NOWS is discussed with consideration of
maternal and neonatal screening and testing, and old and new neonatal scoring systems,
including the challenges of objectivity and inter-rater reliability.
Providing a broader approach to treatment based on new evidence, the report recommends
initiating or transitioning care outside the neonatal intensive care unit and supporting
the mother-infant dyad through rooming-in (Holmes AV, et al. Pediatrics. 2016;137:e20152929). Research shows rooming-in is associated with lower rates of
pharmacotherapy for withdrawal and shorter lengths of hospital stays for infants (MacMillan
KDL, et al. JAMA Pediatr. 2018;172:345-351).
Other nonpharmacologic treatment options include swaddling, rocking, feeding and skin-to-skin
care; when indicated, breastfeeding is encouraged in accordance with Academy of Breastfeeding
Medicine recommendations (Jansson LM. Breastfeed Med. 2009;4:225-228).
For neonates with severe NOWS, pharmacological care may be required, even after nonpharmacologic
measures are applied. The report reviews evidence for medications to treat withdrawal,
including longer-acting opioids (e.g., buprenorphine) and morphine, the most common
first-line therapy for NOWS. Also addressed is the evidence to support the use of
secondary medication for NOWS, either when initiating pharmacotherapy or more commonly
as a rescue medication when clinical signs continue to escalate despite pharmacotherapy
with an opioid.
Because the transition home can come with risks, it is critical to formalize the discharge
process. The report emphasizes discharge education, medical follow-up and utilization
of social services, public health and community resources such as home nurse visitation
The report also reviews changes to the child welfare system. For example, the 2016
Comprehensive Addiction and Recovery Act requires that Plans of Safe Care are created
for “substance-affected” infants, including those with NOWS. The needs of the affected
family or caregiver also should be addressed.
In addition, infants with NOWS may be at increased risk for developmental delay, so
they should be referred to early intervention services.
Public health considerations
The report addresses public health and policy implications. It discusses state efforts
to improve reporting through standard definitions and improve quality of care through perinatal quality collaboratives and state learning collaboratives. These efforts aim to improve surveillance, support pregnant and postpartum mothers,
and reduce newborn length of hospital stay.
NOWS reflects the implications of a complex public health crisis of opioid use and
misuse. The clinical report can help pediatric providers manage the impact of the
opioid crisis on newborns by providing information on consistent diagnoses and quality
treatment to reduce the amount and length of pharmacologic exposure to newborns postnatally.
Pediatricians also have an important role in supporting the mother-infant dyad, improving
our understanding of the long-term sequelae of NOWs, improving diagnostic approaches
and treatment, and supporting caregivers and families affected by opioids.
Drs. Barfield and Patrick are lead authors of the clinical report. Dr. Barfield is
a liaison from the Centers for Disease Control and Prevention to the Committee on
Fetus and Newborn. Dr. Patrick is a member of the Committee on Substance Use and Prevention.
The findings and conclusions in this report are those of the authors and do not necessarily
represent the views of the U.S. Centers for Disease Control and Prevention.