• Neonatal Abstinence Syndrome

    Opioid addiction is a national epidemic that touches every stage of life, including those of women who are pregnant and their babies. Neonatal abstinence syndrome (NAS) occurs when an infant is born having been exposed to opiates (such as methadone, subutex, heroin, morphine) and experiences withdrawal symptoms after birth. The dramatic rise in NAS in recent years has occurred in association with the increase in the use of opioids by pregnant women. According to the Centers for Disease Control and Prevention, from 1999 to 2013 the overall incidence of NAS increased 300% in the United States, from 1.5 per 1,000 hospital births in 1999, to 6.0 per 1,000 hospital births in 2013.

    Signs and Symptoms

    Babies born with NAS display signs that can manifest in the nervous system, stomach and intestines, and respiratory system, and are the result of the infants’ immediate lack of addictive opioids after birth. Infants with NAS often exhibit the following symptoms of withdrawal:

    • High-pitched crying
    • Shaking/jitteriness
    • Fussiness
    • Stiffness in arms, legs, back
    • Stuffy nose/sneezing
    • Vomiting/diarrhea
    • Feeding difficulties
    • Poor weight gain
    • Rapid breathing
    • Stomach gas/cramping
    • Skin issues around the bottom
    • Difficulty calming and sleeping

    Treatment

    NAS is treated through medication and intervention by a team of health care professionals. Specially trained physical therapists are an integral part of the team treating infants with NAS.

    In the Hospital

    Infants with withdrawal symptoms may need to remain in the hospital and be treated in the neonatal intensive care unit (NICU). Strategies used by physical therapists to treat babies with NAS may include:

    • Identifying the risk for delays in natural growth and development (developmental delays).
    • Controlling the baby’s environment. This can include dimming the lights, keeping the room quiet, assisting with sleeping patterns, introducing sensory input slowly, avoiding brisk or startling movements.
    • Educating caregivers about infant stress cues. Cues an infant is under stress can include looking away from the observer, arching the neck and back, making frantic and excessive movements, and frequently hiccuping, sneezing, or yawning.
    • Helping caregivers recognize engagement clues. Cues an infant is ready to interact may include looking at caregivers, bringing hands to mouth, snuggling, etc. Use of a pacifier can help with calming, and blankets can be used to make infants feel “contained” to decrease excessive movements.
    • Providing therapeutic touch and movement experiences. Physical therapists can provide instructions for gentle infant massage that will help with stiffness and jittery movements. Using a variety of positions and handling techniques can help babies have safe movement experiences, support skin care with caregivers, and more.
    • Helping to improve food intake. Treatment can include recognizing infant sucking patterns, using pacifiers, and other ways to strengthen the baby’s abilty to successfully take a bottle or breastfeed.
    • Family education. Physical therapists play a critical role in providing individualized caregiver education with an emphasis on helping parents understand their infant’s behavior cues.

    After Discharge From the Hospital

    The physical therapist in the NICU often becomes the supportive bridge for the infant and family after they leave the hospital and as community-based services commence. Physical therapy is an important part of the infant’s life as they eventually transitions into childhood. An infant with NAS may need extra care after going home, including:

    • Early intervention. Physical therapists treat young children (birth to age 3) at risk for delays in the typical development of skills such as physical movement.
    • Developmental (or neonatal) follow-up clinic visits. Some hospitals have clinics for families to return to, in order to track the development of infants at higher risk for developmental delays.
    • Outpatient physical therapy. Infants with NAS may be referred to an outpatient physical therapy department specializing in pediatric rehabilitation services. Pediatric physical therapists provide individualized and fun play times designed to help babies safely progress in their development.

    References

    Ko JY, Patrick SW, Tong VT, Patel R, Lind JN, Barfield WD. Incidence of neonatal abstincence syndrome – 28 states, 1999-2013. MMWR Morb Mortal Wkly Rep. 2016;65(31):799–802. Free Article.

    Patrick SW, Davis MM, Lehmann CU, Cooper WO. Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012 [published correction appears in: Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012. J Perinatol. 2015]. J Perinatol. 2015;35(8):650–655. Free Article.

    Tolia VN, Patrick SW, Bennett MM, et al. Increasing incidence of the neonatal abstinence syndrome in U.S. neonatal ICUs. N Engl J Med. 2015;372(22):2118–2126. Free Article.

    Kocherlakota P. Neonatal abstinence syndrome. Pediatrics. 2014;134(2):e547–e561. Free Article.

    MacMullen NJ, Dulski LA, Blobaum P. Evidence-based interventions for neonatal abstinence syndrome. Pediatr Nurs. 2014;40(4):165–172, 203. Article Summary in PubMed.

    Maguire D, Cline GJ, Parnell L, Tai CY. Validation of the Finnegan neonatal abstinence syndrome tool-short form. Adv Neonatal Care. 2013;13(6):430–437. Article Summary in PubMed.
     
    Logan BA, Brown MS, Hayes MJ. Neonatal abstinence syndrome: treatment and pediatric outcomes. Clin Obstet Gynecol. 2013;56(1):186–192. Free Article.

    Lucas K, Knobel RB. Implementing practice guidelines and education to improve care of infants with neonatal abstinence syndrome. Adv Neonatal Care. 2012;12(1):40–45. Article Summary in PubMed.

    Sweeney JK, Heriza CB, Blanchard Y; American Physical Therapy Association. Neonatal physical therapy; part I: clinical competencies and neonatal intensive care unit clinical training models. Pediatr Phys Ther. 2009;21(4):296–307. Article Summary in PubMed.

    Velez M, Jansson LM. The opioid dependent mother and newborn dyad: non-pharmacologic care. J Addict Med. 2008;2(3):113–120. Free Article.

    Department of Health and Human Services, Food and Drug Administration. Drug safety [letter]. Accessed August 3, 2017. Free.

    Authored by Roberta Gatlin, PT, DSc, PCS, Kara Boynewicz, PT, PCS, ATC, Sue Hausch, PT, DPT, and the Academy of Pediatric Physical Therapy Neonatal Special Interest Group