Opioids Neonatal Abstinence Syndrome - Minnesota Department of Health

Opioids
Neonatal Abstinence Syndrome

Women who use opioids or other drugs during their pregnancy are at risk for giving birth to an infant that experiences neonatal abstinence syndrome (NAS). NAS is a group of health issues that can impact newborns who are exposed before birth to certain substances including opioids, medications used in medication-assisted treatment (MAT), barbiturates, and benzodiazepines.

What is NAS?

During pregnancy, if a mother is using opioids or other drugs, the drugs can pass through the placenta to the baby. If this is happening, when an infant is born, they no longer receive these substances and experience withdrawal symptoms. Infants are not born addicted to substances, rather they have prenatal substance exposure and physiological dependence.

All infants born to a woman who has used substances during her pregnancy are at risk for NAS, but not all infants born to mothers that used substances during pregnancy will have NAS. It is estimated that between 55% and 94% of newborns whose mothers used opioids consistently while pregnant, either through illicit use or medication-assisted treatment (MAT), will develop NAS. 1

The symptoms of NAS range from mild to severe and can include:2

  • Body shakes (tremors)
  • Excessive crying and fussiness
  • Fever
  • Diarrhea
  • Seizures
  • Trouble sleeping
  • Poor feeding
  • Breathing problems

The initial symptoms of NAS usually begin shortly after birth (within 2-3 days) and can last for up to six months. Most babies just need therapeutic care from their parent(s) or nurse. Parents can soothe babies with NAS symptoms through: 2

  • Swaddling
  • Breastfeeding
  • Skin to skin contact
  • Rocking gently
  • Speaking in a soft voice
  • Staying in the same room as the baby (rooming in)

Some infants with NAS require medical treatment to manage their symptoms. Pain management with medication like morphine, intravenous (IV) fluids, and giving MAT medications in small doses that get gradually lower to wean the infant from these substances are all methods for helping to manage symptoms.

When infants require more intensive medical care, they are treated in neonatal intensive care units (NICUs). Not all hospitals in the state have NICUs so it is possible that if a baby is born with NAS and needs more care, they will be transferred to a different hospital. When a baby has to be transferred to a hospital with a NICU, this can be create challenges for the family to remain with baby and can be very expensive.4

Research is beginning to show that there might be long-term impacts of NAS including:2

  • Higher risk for ear infections
  • Speech problems
  • Learning difficulties
  • Memory issues
  • Hyperactivity

However, it has been difficult for researchers to determine if the health outcomes are because of NAS or other factors in an infant’s environment. Parental continued substance use, mental illness, domestic violence, and limited access to healthcare can have negative impacts on a baby’s health and development. Infant health outcomes improve when parents receive and maintain treatment for substance use disorder, live in a stable place, and have parenting support from friends, family, or professionals such as family home visitors.

How is NAS treated?

The most promising approach for treatment of NAS is the evidence-based Eat, Sleep, Console (ESC) model of family-centered care.3 The ESC model emphasizes the mother’s ability to provide care for their infant to reduce NAS symptoms through breastfeeding, swaddling, and skin to skin contact. Hospitals can adapt policies and protocols to support the ESC model by promoting rooming in, allowing mothers to provide the majority of infant care, and encouraging mothers to spend as much time with their infant as possible.

Mothers of infants with NAS can benefit from additional supports to provide care for their infant and reduce stress associated with caring for a newborn with NAS symptoms. These additional supports can include receiving prenatal/postpartum counseling on how to care for an infant with NAS, receiving substance use disorder and mental health treatment, and joining a support group for mothers with substance use disorder.

How can NAS be prevented?

Preventing NAS is best accomplished by intervening with a mother’s potential use during pregnancy. Preventing NAS requires an understanding that substance use is not simply an individual problem, but is also shaped by factors such as community and family support, access to health care, and healthy relationships.

The best method of prevention and treatment of maternal opioid use and NAS is a whole-patient approach that includes a combination of medical, behavioral health, and community supports.  Women using opiates during pregnancy benefit from accessing comprehensive obstetric care that provides medication-assisted treatment (MAT) in addition to health monitoring and referral to recovery services. MAT has been shown to improve a patient’s adherence to treatment, reduce illicit opiate use, and support long-term recovery.5  

Other prevention strategies include preventing maternal opioid misuse through changes in prescribing practices, using evidence-based screening tools to identify substance use and misuse during pregnancy, and increasing access to wraparound recovery support services.

NAS in Minnesota

Data on NAS in Minnesota is available in the Neonatal Abstinence Syndrome (NAS) Data Brief: Statewide and Country Trends, 2012-2019. From 2012 to 2019, there were 3,354 NAS diagnoses in Minnesota (Figure 1). This corresponds to a rate of 63.0 per 10,000 live births. The median rate (i.e. the rate in the middle of the overall range of rates for Minnesota counties) among counties in Minnesota was 46.2 per 10,000 live births (Figure 1). Information on NAS by region of the state and by sex of infant is available in the NAS data brief.

Figure 1: Following a relatively stable number of diagnoses from 2015 to 2018, NAS diagnoses increased substantially in 2019

Year

Number of Cases

Rate per 10,000 live births

2012

236

35.9

2013

326

49.2

2014

396

59.1

2015

479

71.4

2016

402

60.0

2017

488

72.5

2018

360

54.2

2019

667

102.5

Total

3,354

63.0

SOURCE: Hospital Discharge Data, Injury and Violence Prevention Section, Minnesota Department of Health, 2012-2019

Research from the University of Minnesota found that diagnoses of maternal opioid use disorder and NAS are increasing fastest among rural residents.6 Unfortunately, rural areas in the state have the fewest NICUs and have seen the most closures of hospitals with obstetric services, meaning hospitals where babies can be delivered.

Opioid use does not affect all women equally. More than one in ten American Indian women has a diagnosis of opioid dependency or abuse during pregnancy. In Minnesota, there is an 8-fold higher rate of NAS among infants born to American Indians.7

The Minnesota Perinatal Quality Collaborative (MNPQC), a partnership between the Minnesota Department of Health and the Minnesota Perinatal Organization, leads initiatives focused on improving maternal and infant health. The MNPQC is currently leading a maternal opioid use disorder initiative. The aims of this initiative are to decrease misuse of opioids, inform providers of alternatives to prescribing opioids, and increase identification and treatment of opioid misuse with an overall goal of reducing NAS.

To learn more about NAS in Minnesota, please refer to the Neonatal Abstinence Syndrome data story created during the Title V Maternal and Child Health Needs Assessment

Get Support

If you think that you are pregnant or might become pregnant and are currently using opioids, it is important to discuss this with your doctor. Your doctor and other healthcare providers can provide you with information on how to safely reduce or stop opioid use, provide referrals to substance use treatment, and support you in having a healthy pregnancy.

Fast Tracker is a tool developed by the Minnesota Department of Human Services to connect people with substance use and mental health treatment in their communities.

Family Home Visiting can provide support during pregnancy and after birth. Home visitors can help connect people to substance use treatment and recovery resources, provide parenting education, and help monitor a mother and her baby’s health. To find family home visiting in your area, search for family home visiting on minnesotahelp.info.

Learn more about NAS:

Children’s Hospital of Minnesota has created fact sheets on Neonatal Abstinence Syndrome and Opiate Use During Pregnancy.

March of Dimes Neonatal Abstinence Syndrome webpage has information on what NAS is, the symptoms of NAS, and methods of treatment.

The National Center on Substance Abuse and Child Welfare (NCSACW) has collected policy and practice resources, videos, and webinars on their Neonatal Abstinence Syndrome topic page.

The Substance Abuse and Mental Health Services Administration has developed Clinical Guidance for Treating Pregnant and Parenting Women with Opioid Use Disorder and Their Infants. This clinical guidance is designed for healthcare providers and details promising best practices for the prevention and treatment of maternal opioid use disorder and NAS.

The Neonatal Abstinence Syndrome review article from the New England Journal of Medicine provides a review of how NAS has increased in recent years and public health strategies to prevent NAS.

Sources:

  1. McQueen, K. and Murphy-Oikonen, J. (2016). Neonatal abstinence syndrome. New England Journal of Medicine, 375, 2468-2479. 
  2. March of Dimes. (2019). Neonatal abstinence syndrome. https://www.marchofdimes.org/complications/neonatal-abstinence-syndrome-(nas).aspx
  3. Grossman, M.R., Lipshaw, M.J., Osborn, R.R., & Berkwitt, A.K. (2018). A novel approach to assessing infants with neonatal abstinence syndrome. Hospital Pediatrics, 8,(1), 1-6.
  4. Minnesota Department of Health Child and Family Health Division. (2019). Neonatal Abstinence Syndrome. https://www.health.state.mn.us/docs/communities/titlev/neonatal.pdf
  5. Pew Charitable Trusts. (2016). Medication-assisted treatment improves outcomes for patients with opioid use disorder. https://www.pewtrusts.org/-/media/assets/2016/11/medicationassistedtreatment_v3.pdf
  6. Kozhimannil, K.B., Chantarat, T., Ecklund, A.M., Henning-Smith, C., & Jones, C. (2018). Maternal opioid use disorder and neonatal abstinence syndrome among rural US residents, 2007-2014. The Journal of Rural Health 35,(1), 122-132.
  7. Moldenhauer, Rick. (2017). Tribal Opioid Summit “The Song Remains the Same” [PowerPoint presentation]. Tribal Opioid Summit 2017, Minnesota. https://www.mnchippewatribe.org/opioidsummit.html

For more information on NAS, questions about NAS data, and Minnesota Department of Health efforts to reduce NAS, please contact liz.corey@state.mn.us.

Please visit the Opioid Dashboard for more information on opioid overdose death, nonfatal overdose, use, misuse, substance use disorder, prescribing practices, supply, diversion, harm reduction, co-occurring conditions, and social determinants of health.
Updated Monday, 09-Nov-2020 10:38:04 CST