Neonatal Abstinence Syndrome

Neonatal Abstinence Syndrome in United States

United States

Neonatal abstinence syndrome (NAS) is a drug withdrawal syndrome occurring in newborns. NAS is most commonly caused by fetal exposure to maternal opioid use, and is also associated with benzodiazepines, barbiturates or alcohol. Data linking NAS with other maternal drug use is inconclusive, but use of any chemically addictive substances during pregnancy, including SSRI antidepressants, can cause postnatal symptoms characteristic of withdrawal. Between 55% and 94% of infants exposed to opioids during pregnancy will experience withdrawal symptoms. The use of opioids during pregnancy has increased in the United States in the last 20 years, resulting in corresponding increases in NAS.

Symptoms of NAS can include central nervous system irritability (tremors, increased muscle tone, high-pitched crying and seizures), feeding difficulties, low birthweight and temperature instability. Some children can develop long-term symptoms of NAS, such as developmental delays, growth problems and hearing/vision problems.

According to the Healthcare Cost and Utilization Project (HCUP)’s most recent data, the average cost of hospitalization for a newborn with NAS is $9,200, compared with $1,200 per other newborn hospitalizations. 82.0% of NAS-related births were covered by Medicaid in 2014, accounting for $462 million in total hospital costs.

The prevalence of neonatal abstinence syndrome is higher among:

• American Indian/Alaska Native and white infants compared with Hispanic and Asian/Pacific Islander infants.
• Infants in rural areas compared with infants in metropolitan areas. 
• Infants in lower-income zip codes compared with infants in higher-income zip codes.
• Male newborns compared with female newborns.

Preventing and treating maternal opioid dependence before and during pregnancy is crucial to reducing cases of NAS. Strategies include:

• Screening pregnant women for substance use and, if positive, offering information and more detailed examination in order to provide and prescribe appropriate treatment for both mother and baby.
• Responsible opioid prescription practices and prescription drug monitoring. Providers can refer to the CDC Guideline for Prescribing Opioids for Chronic Pain, which has a section on pregnant patients. Posters, checklists, fact sheets and trainings on the guideline can be found on the Centers for Disease Control and Prevention (CDC) website.
• Treating for Two, a CDC initiative dedicated to research and development on pregnancy-safe treatments for both parents and infants.

Mandated reporting of NAS cases in hospitals helps guide programs and services with consistent and reliable data on NAS incidence, trends and associated factors. It may also help identify more cases of maternal opioid use disorder, improving data critical to developing effective interventions. 

The American College of Obstetricians and Gynecologists has several recommendations with regard to opioid use during pregnancy, including: 

• Early, universal screening, preferably at the first prenatal visit.
• Minimizing the use of opioids for chronic pain and highlighting alternative therapies.
• Increasing access to contraceptive services among women of reproductive age.

The CDC’s Division of Reproductive Health has assembled a directory of collaborative research and work with outside and state-level partners on improving outcomes for pregnant and postpartum women with opioid use disorder.

Healthy People 2030 has multiple goals relating to neonatal abstinence syndrome, including increasing abstinence from illicit drugs among pregnant women and reducing the proportion of women who use illicit opioids during pregnancy.

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Jilani, Shahla M., Meghan T. Frey, Dawn Pepin, Tracey Jewell, Melissa Jordan, Angela M. Miller, Meagan Robinson, et al. “Evaluation of State-Mandated Reporting of Neonatal Abstinence Syndrome — Six States, 2013–2017.” MMWR. Morbidity and Mortality Weekly Report 68, no. 1 (January 11, 2019): 6–10. https://doi.org/10.15585/mmwr.mm6801a2.

Ko, Jean Y., Stephen W. Patrick, Van T. Tong, Roshni Patel, Jennifer N. Lind, and Wanda D. Barfield. “Incidence of Neonatal Abstinence Syndrome — 28 States, 1999–2013.” MMWR. Morbidity and Mortality Weekly Report 65, no. 31 (August 12, 2016): 799–802. https://doi.org/10.15585/mmwr.mm6531a2.

Ko, Jean Y., Sara Wolicki, Wanda D. Barfield, Stephen W. Patrick, Cheryl S. Broussard, Kimberly A. Yonkers, Rebecca Naimon, and John Iskander. “CDC Grand Rounds: Public Health Strategies to Prevent Neonatal Abstinence Syndrome.” MMWR. Morbidity and Mortality Weekly Report 66, no. 9 (March 10, 2017): 242–45. https://doi.org/10.15585/mmwr.mm6609a2.

Mascola, Maria A., Ann E. Borders, and Mishka Terplan. “ACOG Committee Opinion No. 711: Opioid Use and Opioid Use Disorder in Pregnancy.” Obstetrics & Gynecology 2017, no. 130 (August 2017): e81-94. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/opioid-use-and-opioid-use-disorder-in-pregnancy.

Rainey, Jacob C., Lacee Satcher, and Sarah J. Nechuta. “A Population-Based Descriptive Study of Neonatal Abstinence Syndrome Using Hospital Discharge and Birth Certificate Data.” Journal of Substance Use, July 14, 2022, 1–8. https://doi.org/10.1080/14659891.2022.2098841.

Winkelman, Tyler N. A., Nicole Villapiano, Katy B. Kozhimannil, Matthew M. Davis, and Stephen W. Patrick. “Incidence and Costs of Neonatal Abstinence Syndrome Among Infants With Medicaid: 2004–2014.” Pediatrics 141, no. 4 (April 1, 2018): e20173520. https://doi.org/10.1542/peds.2017-3520.