Patient handout

Neonatal Abstinence Syndrome (NAS) / Neonatal Opioid Withdrawal Syndrome (NOWS)

PRODUCTION

1. Your condition

This handout is for neonatal abstinence syndrome (nas) / neonatal opioid withdrawal syndrome (nows). Your care team identified this based on: maternal in-utero opioid exposure (methadone or buprenorphine mat, heroin, prescription opioids) — applies to ~ 60-90% of opioid-exposed infants (hudak aap 2012 pmid 22291123).

Other reasons your team may use this plan: maternal polysubstance: opioid + benzodiazepines or opioid + ssri/snri or illicit poly (cocaine, methamphetamine) — drives delayed / prolonged / atypical course (hudak aap 2012); tremor / hypertonia / hyperreflexia / autonomic instability (tachycardia, sweating, sneezing, yawning) / gi features (poor feeding, loose stools, vomiting) / sleep disturbance / inconsolable cry in opioid-exposed neonate (aap 2024 nas/nows update); positive maternal urine drug screen at delivery — confirms opioid exposure axis (timing of last use vs delivery affects yield).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
rooming-in_with_caregiver	24-hour rooming-in with caregiver throughout NAS observation	environmental	continuous	AAP 2024; Young NEJM 2023 PMID 37125831 — rooming-in is core to ESC function-based approach; reduces LOS + pharm exposure
breastfeeding_when_eligible	On-demand breastfeeding when maternal HIV negative AND not on contraindicated meds (codeine, oxycodone, tramadol) AND no illicit poly-substance use	oral_maternal_milk	on-demand	ACOG 711 2017; LactMed — methadone + buprenorphine compatible with breastfeeding (low milk transfer); reduces NAS severity in dyad cohorts
swaddling	Snug swaddling with hands midline when not feeding / skin-to-skin	environmental	between feeds	AAP 2024 — reduces sensory overload + improves consolability
low_stimulation_environment	Dim lighting + minimal noise + cluster cares + minimal handling	environmental	continuous	AAP 2024 — reduces autonomic activation; improves sleep + console axes of ESC
kangaroo_care_skin_to_skin	Multiple daily skin-to-skin sessions with caregiver	environmental	multiple times daily	AAP 2024 — improves autonomic regulation + feeding + caregiver bonding
on_demand_feeding	Feed on cues rather than scheduled; advance volume as tolerated	oral	on-demand q2-4 h typical	AAP 2024 — supports Eat axis of ESC; do not over-feed (vomiting / discomfort)

Plan: NAS / NOWS acute management — Eat-Sleep-Console function-first per AAP 2024 + Young NEJM 2023

3. When to call your provider

Contact your care team if any of the following happen:

Recurrent NAS-like features (rare after wean) → urgent peds + addiction-medicine + meconium re-test
Developmental delay > 1 SD below age norms on ASQ / Bayley → developmental peds + early intervention intensify
Caregiver mental health crisis (EPDS / PHQ-9 elevated) → urgent mental-health referral + perinatal navigator
CPS / foster placement disruption → emergency social work + multi-disciplinary care meeting
New seizures OR neuro deterioration → urgent neuro + neuroimaging + HSV / sepsis differential
Failure to thrive → urgent peds + GI + nutritional assessment

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

ESC function impaired (unable to eat ≥ 1 oz per feed OR sleep ≥ 1 h after feed OR console within 10 min with non-pharm) × ≥ 3 consecutive feed cycles AFTER adequate non-pharm trial — initiate oral morphine 0.04-0.08 mg/kg q3-4h OR methadone 0.05-0.1 mg/kg q6-12h OR oral buprenorphine 5-10 mcg/kg q8h (Kraft BBORN); non-pharm continued (AAP 2024; Young NEJM 2023 PMID 37125831)
Documented maternal opioid + benzodiazepine in-utero exposure → delayed / prolonged / atypical withdrawal course; add phenobarbital 5 mg/kg load then 2-5 mg/kg/day to opioid pharm regimen; closer monitoring of CNS depression + cumulative respiratory depression risk (Hudak AAP 2012 PMID 22291123)
Severe NAS autonomic features persisting on Tier 2 monotherapy: tachycardia (HR > 180 sustained) + sweating + tremor severe + irritability not responsive to non-pharm + escalating opioid dose → add clonidine 1 mcg/kg q4-6h PO/IV; rule out non-NAS etiologies first (sepsis, hyperthyroidism / Graves baby, pheochromocytoma rare); BP / HR / QT monitoring (AAP 2024; Hudak AAP 2012 PMID 22291123)
NAS infant with feeding intolerance (vomiting, refusal, gagging) + weight loss > 10% birth weight + poor UO + signs of dehydration — IV hydration + careful feeding plan + NICU; do not discharge until tolerating feeds reliably (AAP 2024)
Seizure in NAS infant is ATYPICAL — must rule out HSV / sepsis / metabolic (hypoglycaemia, hypocalcaemia, hypomagnesaemia, hyperammonaemia, organic acidaemias) / IVH / structural CNS; empiric acyclovir 60 mg/kg/day q8h IV + HSV PCR + sepsis workup + neuroimaging + EEG + anti-epileptic loading (AAP Red Book 2024; Kimberlin Pediatrics 2013 PMID 23359576)(life-threatening)

5. Follow-up

Pediatric primary care within 24-48 h of discharge; perinatal navigator continuity; early intervention referral; developmental surveillance Q3 mo × 1 yr then annually × 5 yr; maternal MAT coordination postpartum (ACOG 711 2017; SAMHSA TIP 63 2021); breastfeeding support if continuing; ophthalmology if perinatal substance + CNS features; audiology if HSV / meningitis differential triggered; mental health for caregiver

6. Sources

Guideline: AAP Clinical Report 2024 NAS / NOWS update (Eat-Sleep-Console first-line) + Young et al, NEJM 2023 (ACT NOW ESC cluster RCT) PMID 37125831 + Hudak ML, Tan RC, AAP Clinical Report on Neonatal Drug Withdrawal, Pediatrics 2012 PMID 22291123 + Kraft WK et al, BBORN buprenorphine NEJM 2017 PMID 28468518 + ACOG Committee Opinion 711 (2017) maternal OUD in pregnancy + SAMHSA TIP 63 (2021) MOUD in pregnancy + AAP Red Book 2024