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 benzodiazepine, barbiturate and alcohol use. Data linking NAS with other maternal drug use is inconclusive, but use of chemically addictive substances during pregnancy — including selective serotonin reuptake inhibitor antidepressants (SSRIs) — can cause symptoms characteristic of withdrawal in newborns. Between 55% and 94% of infants exposed to opioids during gestation experience withdrawal symptoms. Opioid use during pregnancy has increased in the United States in the last 20 years, with corresponding increases in NAS.

Symptoms of NAS can include tremors, increased muscle tone, high-pitched crying, seizures, feeding difficulties, low birth weight and temperature instability. NAS can cause long-term symptoms in children as well, such as developmental delays, growth problems and hearing/vision problems.

Newborns with NAS stay in the hospital an average of 1.8 days longer than newborns without NAS, which is associated with an increased hospital cost of $1,685 per day. Medicaid covered 82% of NAS-related costs in 2014, costing the U.S. $462 million.

According to America’s Health Rankings analysis, the prevalence of neonatal abstinence syndrome is higher among:

• American Indian/Alaska Native and white infants compared with Black, Hispanic and Asian/Pacific Islander infants.
• Infants in non-metropolitan areas compared with infants in metropolitan areas. 
• Infants in lower-income areas compared with infants in higher-income areas.
• 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:

• Responsible opioid prescription practices and prescription drug monitoring. Providers can refer to the CDC Clinical Practice Guideline for Prescribing Opioids for Pain, which has a section on pregnant patients.
• Screening pregnant women for substance use and offering information and more detailed examination in order to provide and prescribe treatment for both mother and baby if necessary.

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 regarding opioid use during pregnancy, including: 

• Universal early 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.

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.

Bhatt, Parth, Jacob Umscheid, Narendrasinh Parmar, Rhythm Vasudeva, Kripa G. Patel, Akosua Ameley, Keyur Donda, Brian Policano, and Fredrick Dapaah-Siakwan. “Predictors of Length of Stay and Cost of Hospitalization of Neonatal Abstinence Syndrome in the United States.” Cureus 13, no. 7 (July 7, 2021): e16248. https://doi.org/10.7759/cureus.16248.

Charles, M. Katherine, William O. Cooper, Lauren M. Jansson, Judith Dudley, James C. Slaughter, and Stephen W. Patrick. “Male Sex Associated With Increased Risk of Neonatal Abstinence Syndrome.” Hospital Pediatrics 7, no. 6 (June 1, 2017): 328–34. https://doi.org/10.1542/hpeds.2016-0218.

Dowell, Deborah, Tamara M. Haegerich, and Roger Chou. “CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016.” MMWR. Recommendations and Reports 65, no. RR-1 (March 18, 2016): 1–49. http://dx.doi.org/10.15585/mmwr.rr6501e1.

Haight, Sarah C., Jean Y. Ko, Van T. Tong, Michele K. Bohm, and William M. Callaghan. “Opioid Use Disorder Documented at Delivery Hospitalization — United States, 1999–2014.” MMWR. Morbidity and Mortality Weekly Report 67, no. 31 (August 10, 2018): 845–49. https://doi.org/10.15585/mmwr.mm6731a1.

Hirai, Ashley H., Jean Y. Ko, Pamela L. Owens, Carol Stocks, and Stephen W. Patrick. “Neonatal Abstinence Syndrome and Maternal Opioid-Related Diagnoses in the US, 2010-2017.” JAMA 325, no. 2 (January 12, 2021): 146. https://doi.org/10.1001/jama.2020.24991.

Hudak, Mark L., Rosemarie C. Tan, Daniel A. C. Frattarelli, Jeffrey L. Galinkin, Thomas P. Green, Kathleen A. Neville, Ian M. Paul, et al. “Neonatal Drug Withdrawal.” Pediatrics 129, no. 2 (February 1, 2012): e540–60. https://doi.org/10.1542/peds.2011-3212.

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.

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.