Why we are recommending this best practice
- Short-term effects can appear within 1-5 days and most commonly within 2-3 days. Symptoms can include but are not limited to high-pitched cries, tremors, difficulty sleeping, poor feeding, and diarrhea. Depending on the severity, the newborn’s hospital stay may be prolonged.
- Long-term effects can appear within months to years. These consequences may include problems with vision, motor skills, and behavior/cognition, sleeping disturbances, and ear infections. Early intervention programs can ameliorate these effects and provide surveillance for them.
Strategies for implementation
- Rooming-in when available. Encourage close and frequent maternal contact if unable to room-in.
- Initiating early skin-to-skin contact with the newborn which promotes bonding, soothes the newborn, and aids in breastfeeding.
- Promoting breastfeeding if the mother is on a stable medication assisted treatment (MAT) regimen and has no contraindications. Breastfeeding is encouraged for mothers taking methadone or buprenorphine regardless of dose, as transfer into milk is minimal. Breastfeeding is associated with decreased severity of symptoms, less need for pharmacotherapy, and shorter length of stay. Refer to Best Practice #9 for more information regarding breastfeeding.
- Decreasing stimulation by having limited visitors, reducing noise, and using low lighting.
- Using functional scoring to evaluate withdrawal (e.g., ability to eat, sleep, and be consoled). Refer to Best Practice #19 for more information regarding functional scoring.
- Preparing the family for potential escalation of care based on the clinical pathway used by the hospital. Discuss the environment (e.g., NICU or Level 2 nursery), level of family involvement, role of pharmacotherapy, weaning protocol, and discharge criteria.
- Explaining the potential for the newborn to be discharged without treatment if feeding and sleeping well with minimal or no signs of withdrawal after three days for opioids with a short half-life and 5-7 days for opioids with a long half-life. This period allows for adequate identification and monitoring of possible withdrawal symptoms, the onset of which may vary depending on the medication dose, the infant's metabolism, and the presence of polysubstance abuse. Refer to Table 1 in Reference #8 for detailed information regarding specific withdrawal patterns by substance. Refer to Best Practice #30 for information on inpatient monitoring of newborns managed with a non-pharmacologic bundle of care.
- Preparing the family for potential involvement of Child Protective Services (CPS). In California, there are no laws mandating that prenatal substance exposure be reported to CPS, unless the required assessment identifies other factors that indicate significant risk to a child. If CPS involvement is warranted, they will determine a safe home environment for the newborn. A safe and permanent home and family is the best place for children to grow up. CPS focuses on building family strengths and provides parents with the assistance needed to keep their children safe so that the family may stay together. CPS efforts are most likely to succeed when patients are involved and actively participate in the process. When concerns about risk factors don’t rise to the level of an investigation by CPS, a Plan of Safe Care is developed upon hospital discharge (or perhaps earlier in the pregnancy when opioid use disorder is identified) to support treatment and recovery for the mother and enhance protective factors for the dyad. Alternatively, if CPS makes an initial determination of child neglect or abuse, they may create an agreement between a parent or caretaker that is called a safety plan and which may restrict a parent from having any contact or unsupervised contact with a child. CPS must make reasonable efforts to develop safety plans to keep children with their families whenever possible, although CPS may refer for juvenile or family court intervention and placement when children cannot be kept safely within their own homes. When children are placed in out-of-home care because their safety cannot be assured, CPS will work to develop a permanency plan as soon as possible.
- Providing pregnant women and families with educational handouts, such as the NAS Parent Brochures developed by the Illinois Perinatal Quality Collaborative (ILPQC) (see Resources below) and others available on the MBSEI website.
- Enrolling the newborn in early intervention programs and developmental follow-up clinics prior to discharge.
Reference: Yogman, et al. The Prenatal Visit. Pediatrics 2018;142(1).
- Macmillan KDL, Rendon CP, Verma K, Riblet N, Washer DB, Holmes AV. Association of rooming-in with outcomes for neonatal abstinence syndrome. JAMA Pediatr. 2018;172(4):345. doi:10.1001/jamapediatrics.2017.5195.
- Crook K, Brandon D. Prenatal breastfeeding education. Adv Neonat Care. 2017;17(4):299-305. doi:10.1097/anc.0000000000000392.
- ACOG Committee Opinion No 711: Opioid Use and Opioid Use Disorder in Pregnancy. Obstet Gynecol. 2017;130: e81-94.
- Hudak ML, Tan RC. Neonatal drug withdrawal. Pediatrics. 2012;129(2):e540- 560.
- Kocherlakota P. Neonatal abstinence syndrome. Pediatrics. 2014;134(2):e547-561.
- US Department of Health and Human Services. Child Protective Services: A Guide for Caseworkers. https://www.childwelfare.gov/pubpdfs/cps.pdf. Accessed December 19, 2019.
- Putnam-Hornstein E, Prindle JJ, Leventhal JM. Prenatal substance exposure and reporting of child maltreatment by race and ethnicity. Pediatrics. 2016;138(3). doi:10.1542/peds.2016-1273.
- Maguire DJ, Taylor S, Armstrong K, et al. Long-term outcomes of infants with neonatal abstinence syndrome. Neonatal Netw. 2016;35(5):277-286.
- Yogman, et al. The prenatal visit. Pediatrics. 2018; 142 (1).