Neonatal Opioid Withdrawal Syndrome (NOWS)

Overview

NOWS describes symptoms caused when a newborn withdraws from opioids taken by the mother prior to delivery. Neonatal Abstinence Syndrome (NAS) is a term that has also been used to describe NOWS, and in some situations, these terms are used interchangeably. However, NAS is a broader term that can also include withdrawal from other substances or medications that babies were exposed to through the placenta before birth. This can include nicotine, stimulants, anti-depressants, and central nervous system depressants. It is important to distinguish NOWS because opioid withdrawal in neonates has specific treatment approaches that are essential to help promote healthy patterns of feeding and sleeping in newborns.
Withdrawal symptoms can include:
  • Tremors
  • Excessive or high-pitched crying
  • Sleep problems
  • Hypertonicity
  • Exaggerated reflexes
  • Yawning, stuffy nose, and sneezing
  • Poor feeding and sucking
  • Vomiting or diarrhea
  • Sweating
  • Fever or unstable temperature
  • Seizures
This web page summarizes key points for primary care clinicians and health care professionals, links to useful resources, and provides links to relevant service providers. Much of the content is derived from the 2021-22 Project SCOPE: National Training Initiative (USU).

Key Points

Terminology

Avoid use of stigma-laden terms; research suggests they induce bias:
  • Abuser, addict: use “person-first” language. Rather than call someone an addict, say they suffer from addiction or a substance use disorder.
  • Drug: Use specific terms such as “medication” or “a non-medically used psychoactive substance” to avoid ambiguity
  • Clean, dirty: Use proper medical terms for positive or negative test results from substance use.
  • Lapse, relapse, slip: use morally neutral terms like “resumed” or experienced a “recurrence” of symptoms.
For more guidance, see the Recovery Research Institute’s glossary of addiction-related terms, Addiction-ary (Recovery Research Institute).

Testing

Due to high false-positive and false-negative rates, a “Urine Tox” is not recommended as a stand-alone test. Urine Tox screening needs to be confirmed with more accurate testing. This should be done with consent.

Pregnancy Medication Guidance

Detoxification,” lowering doses, or tapering opioids prior to delivery does NOT decrease NAS in newborns. It does increase the risk of relapse for the mother. Eighty percent of women who were abstinent in the last month of pregnancy returned to using at least 1 substance within 1 year postpartum. So pregnant women should be treated appropriately for their symptoms.
  • Buprenorphine
    • Same efficacy and rates of adverse events as methadone
    • Lower risk of overdose and fewer drug interactions
    • Less frequent and milder withdrawal symptoms in neonates
    • Significantly decreased morphine dose and duration of treatment for the withdrawing neonate, resulting in shorter hospital stay for the neonate
  • Methadone
    • More structure – better for patients in unstable situations (i.e., therapist and wrap-around services)
    • Decreased risk of diversion
    • More long-term data on outcomes
  • Naltrexone
    • Limited but increasing data – fewer short-term neonatal effects

Postpartum and Infant Care

  • Postpartum year – significant support needed, high return to use potential
  • Rooming-in/paired-care – skin to skin, breastfeeding, low stimulation environment, etc., helps treat NOWS, often without medication.
  • NAS/NOWS is a qualifying diagnosis for Early Intervention. Primary developmental areas of concern:
    • Gross motor skills – movement patterns and balance
    • Expressive and Receptive Language – limited babbling, poor imitation verbally and non-verbally

Childhood

  • Early Intervention can be a useful support and NAS/NOWS is a qualifying diagnosis
  • If/then behavior reinforcements: if you do this first (like tooth-brushing), then you get this reward (5 minutes of playtime)
  • Social stories: having the child use a doll to explain the schedule to the doll and demonstrate how to get things done (when the child struggles with those things)
  • Ongoing support for the parent’s recovery and recognition of their successes as a parent

Prevalence

The national incidence of NOWS/NAS in 2017 was 7.3 cases per 1,000 hospital births, up from 6.7 in 2016 and 1.5 in 2004. [Agency: 2020] In 2016, hospital costs for NAS-related births totaled $572.7 million with a mean 15.9 days length of stay in the hospital. [Strahan: 2020]

Prevention

Stop the Cycle of Addiction, Focus on Prevention.
  • Parents can share their decision-making skills, stress management skills with their kids, not just their recovery stories.
  • Protective factors that help improve multiple youth outcomes, including substance abuse, dependency, risky sexual behavior, school drop-out, violence, depression, and anxiety include:
    • Cognitive competence, emotional competence, social/behavioral competence, self-efficacy, belief in the future, self-determination, pro-social norms, spirituality, opportunities for positive social involvement, recognition for positive behavior, and bonding to prosocial others. The Center for Communities That Care.
  • Implement the following strategies in families, schools, communities, and peer groups to promote protective, healthy behaviors for all children and youth:
    • Develop healthy beliefs and set clear standards
    • Build connections through bonding, attachment, and commitment
    • Provide opportunities, skills, and recognition, and
    • Nurture individual characteristics.

Resources

Information & Support

For Professionals

What You Need to Know: Care of Pregnant Women with Substance Use Disorders (PDF Document 10.1 MB)
Powerpoint of high-level, important information for clinicians caring for the pregnant women with SUDS; by Dr. Marcela Smid, Maternal Fetal Medicine / Addiction Medicine. Presented in Project SCOPE/Pediatrics ECHO, 8/10/2021.

Addiction-ary (Recovery Research Institute)
Dictionary of terms to help de-stigmatize addiction and unify language use.

Project SCOPE: National Training Initiative
Project SCOPE: Supporting Children of the OPioid Epidemic is a national training initiative intended to build nationwide provider capacity and confidence in applying evidence-based practices in screening, monitoring, and interdisciplinary support for children and families diagnosed with Neonatal Abstinence Syndrome (NAS), Neonatal Opioid Withdrawal Syndrome (NOWS), or who are suspected of being impacted by opioid use, trauma, or related exposure.

Developmental Monitoring and Screening for Health Professionals (CDC)
Information on incorporating developmental screening into the Medical Home and resources for practice as well as patient education; Centers for Disease Control & Prevention.

Health Equity: What You Can Do (NICHQ)
Information about recognizing implicit bias and improving health equity. Links to an Implicit Association Test (IAT) from Project Implicit. National Institute for Children's Health Quality

For Parents and Patients

Baby Your Baby: Taking Medications During Pregnancy Podcast (KUTV 2News)
Moms may feel like they shouldn’t take medications during pregnancy to protect the baby, but their illness or condition may be more harmful to the baby than the medication that treats it. Toughing out an illness usually isn’t better for a baby. Anchor Holly Menino sits down with Al Romeo, a registered nurse with the Utah Department of Health’s MotherToBaby/Pregnancy Risk Line program to discuss the risks and benefits of taking certain medications and vitamins.

What is NOWS? (YouTube) (MIHP)
Four-minute video describing neonatal opioid withdrawal syndrome and how babies at risk for NOWS are monitored and treated after birth; Maternal & Infant Health Program.

How Is NOWS Treated? (YouTube) (MIHP)
Three-minute video explaining how parents can support infants experiencing neonatal opioid withdrawal symptoms; Maternal & Infant Health Program.

What Do I Need to Know Before I Take My Baby Home? (YouTube) (MIHP)
Three-minute video offering brief medical advice on caring for a newborn once you leave the hospital, including caring for newborns with neonatal opioid withdrawal syndrome; Maternal & Infant Health Program.

Caring for a Baby Exposed to Drugs During Pregnancy (NMDOH) (PDF Document 258 KB)
Brochure for parents and other caregivers of infants exposed to drugs during pregnancy. Provides an overview of neonatal abstinence syndrome (NAS, also referred to as NOWS or neonatal opioid withdrawal syndrome), what causes it, and tips on how to console your baby; New Mexico Department of Health.

Caring for a Baby Exposed to Drugs During Pregnancy (NMDOH) (Spanish) (PDF Document 257 KB)
Brochure in Spanish for parents and other caregivers of infants exposed to drugs during pregnancy. Provides an overview of neonatal abstinence syndrome (NAS, also referred to as NOWS or neonatal opioid withdrawal syndrome), what causes it, and tips on how to console your baby; New Mexico Department of Health.

PCIT International - Information for Parents
Parent-Child Interaction Therapy (PCIT) is a therapy to promote healthy family functioning. This website provides answers to frequently asked questions and other information for parents about PCIT.

Know Your Script
When it comes to overdose and addiction, we all have a part to play in keeping ourselves, our loved ones, and our communities safe. “Know Your Script” is an initiative to empower each of us to make smart decisions and ask the right questions regarding prescribed medications. Champion your role against prescription drug misuse and always know your script.

Tools

Breaking through Bias in Maternity Care Training (March of Dimes)
This is an implicit bias training course that provides health care professionals with important insights to recognize and remedy implicit bias in maternity care settings. This unique learning experience delivered in-person or through a self-paced, e-learning platform provides authentic and compelling content for health care providers caring for women before, during, and after pregnancy. CME and CNE available.

Drug Abuse Screening Test (DAST-10) (PDF Document 161 KB)
A 10-item screen that assesses drug use, not including alcohol or tobacco use, in the past 12 months. A clinician-administered version and a self-report version are provided. The screen and scoring instructions can be downloaded or printed for free; developed and validated by Dr. Harvey A. Skinner at the Addiction Research Foundation.

Watch Me! Celebrating Milestones and Sharing Concerns - Training (CDC)
Target audience: early care and education providers. This free, 1-hour, 4-module course provides tools and best practices for monitoring the development of children in your care and talking about it with their parents. CE available. Centers for Disease Control and Prevention.

Services for Patients & Families Nationwide (NW)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Authors & Reviewers

Initial publication: August 2021; last update/revision: September 2021
Current Authors and Reviewers:
Authors: Jennifer Goldman-Luthy, MD, MRP, FAAP
Kimberly Stowers, MD
Senior Author: Bhanu Muniyappa, MD
Authoring history
2021: update: Kimberly Stowers, MDA
2020: first version: Jennifer Goldman-Luthy, MD, MRP, FAAPA
AAuthor; CAContributing Author; SASenior Author; RReviewer

Page Bibliography

Agency for Healthcare Research and Quality, Rockville, MD.
HCUP Fast Stats. Healthcare Cost and Utilization Project (HCUP). August 2020.
(2020) http://www.hcup-us.ahrq.gov/faststats/nas/nasmap.jsp. Accessed on 9/7/21.

Strahan AE, Guy GP Jr, Bohm M, Frey M, Ko JY.
Neonatal Abstinence Syndrome Incidence and Health Care Costs in the United States, 2016.
JAMA Pediatr. 2020;174(2):200-202. PubMed abstract / Full Text
This cross-sectional study examines the national incidence rate of neonatal abstinence syndrome using data from the 2016 Healthcare Cost and Utilization Project Kids’ Inpatient Database.