Materia Medica

Symptoms of Withdrawal in Neonates

Symptoms of NAS can be categorized into three groups. Those groups are gastrointestinal (GI) symptoms, central nervous system (CNS) symptoms and metabolic/ respiratory symptoms. Common GI symptoms include poor feeding, regurgitation, projectile vomiting, diarrhea, and excessive sucking.1 CNS symptoms include high pitched crying, poor sleeping, tremors, myoclonic jerks, and generalized convulsions.1 Finally, common metabolic and respiratory symptoms include sweating, fever, frequent yawning, nasal stiffness and flaring, sneezing, and increased respiratory rate.1 When attempting to determine if a neonate is experiencing NOWS, it is important to rule out other diagnosis that have similar presentation. This would include diagnosis such as sepsis or hypoglycemia.

To evaluate the severity of withdrawal in neonates, a scoring system is often used. There are multiple different scoring systems that have been developed to help determine the proper treatment regimen of a neonate experiencing withdrawal. The most common scoring systems include Finnegan Scoring System, The Lipsitz Neonatal Drug-Withdrawal Scoring System, The Neonatal Withdrawal Inventory, and The Neonatal Narcotic Withdrawal Index.4,5 Of these, the Finnegan Scoring System is commonly used among institutions. It is the most complex of the scoring systems, but also the most comprehensive. The neonate is scored on 31 different items every 3-4 hours before feedings. The scoring directly correlates with severity of symptoms and institutions commonly have protocols in place on how to treat the neonate based off the scores.

Non-Pharmacotherapy Management

Nondrug therapy is the standard of care in the management of withdrawal symptoms associated with NOWS. To help alleviate the associated GI, CNS and respiratory/metabolic symptoms of withdrawal, neonates are often swaddled, kept in a dark room, and stimulated minimally. Other techniques used are breastfeeding, if the mother is a candidate, and skin to skin contact to soothe the infant.1

Pharmacotherapy Management of Withdrawal

Not all cases of NOWS require the addition of pharmacotherapy. Treatment is often based on a scoring system and the severity of withdrawal symptoms the neonate is experiencing.4 If scoring indicates pharmacotherapy, or if withdrawal symptoms are severe enough, it is key to know what substances the neonate has been exposed to. This information is what the treatment plan is based off.

Most hospitals or institutions have a set protocol on how to treat neonatal opioid withdrawal. Literature supports an opioid as first line therapy for the treatment of neonatal opioid withdrawal.7 Morphine is most commonly used in scheduled titration. The dose of morphine is often weight based and titrated until the infant’s withdrawal symptoms or score is stabilized. If the neonate is not showing a strong enough clinical response with morphine monotherapy, there is evidence to support the addition of clonidine or phenobarbital to the treatment regimen.8 These additional pharmacotherapy agents are also titrated to appropriate doses to help ease the symptoms of withdrawal. Eventually, all medications used in the treatment of withdrawal are titrated down and discontinued before the neonate can be discharged from the NICU.

Allegheny County Resources

To prevent NOWS, resources are needed for the pregnant population, their families, or anyone looking for help in Allegheny County. In Allegheny County there are “Centers of Excellence,” which are recognized for their ability to provide treatment for opioid use disorders. These centers include the Gateway Rehabilitation Center, Tadiso Incorporated, Magee Womens Hospital of UPMC, UPMC General Internal Medicine Center for Opioid Recovery, and West Penn Allegheny Health System.

Gateway Rehabilitation Center offers inpatient and outpatient drug rehabilitation care, substance abuse support programs for patients and for families, medically monitored withdrawal management, and medications for substance use disorders.13

Tadiso Incorporated offers methadone and suboxone therapy management, group and individual counseling services, family therapy as well as pregnancy, postpartum and childcare services.14

Magee Womens Hospital has the Pregnancy and Women’s Recovery Center that offers comprehensive care to women with an opioid use disorder. Through the recovery center they can receive routine medical care, behavioral health counseling, psychiatric care, social support services and medication for opioid use disorder such as buprenorphine products and naltrexone.10

UPMC Mercy contains the UPMC General Internal Medicine Recovery Engagement Program (IM-REP). This center offers programs such as medication management for opioid use disorder, behavioral health counseling, community-based support, guidance from recovery specialists, social service support and routine medical care.11

West Penn Hospital of Allegheny Health System offers the Perinatal Hope Program. Within the program patients can receive all-in-one appointments during pregnancy

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