Paediatrics: Neonatal abstinence syndrome

2021-03-05 12:00 AM

A cluster of symptoms caused by withdrawal from a dependency-inducing substance.

Neonatal abstinence syndrome

A cluster of symptoms caused by withdrawal from a dependency-inducing substance. In the UK this is commonly related to methadone (+/– heroin), or benzodiazepines, however, withdrawal is well documented with a number of other substances, for example; cocaine, amphetamine, SSRIs (e.g. fluoxetine), alcohol, caffeine, and nicotine.


  • Timing depends on substance: heroin and SSRIs often present soon after birth, methadone within 24hr, and benzodiazepines later.
  • CNS symptoms: include irritability, sleepiness, hyperactivity, tremors, seizures.
  • Non-CNS: poor/disorganized feeding, vomiting, diarrhoea (can cause a severe nappy rash), sneezing, tachycardia, sweating, respiratory depression, fever (be cautious—sepsis may co-exist or present with similar symptoms).


  • Observe ‘at risk’ infants for signs of withdrawal for several days after birth. Several scoring systems exist for quantifying withdrawal.
  • General and supportive measures: swaddling, minimal handling, dark and quiet environment, frequent low volume feeding.
  • A pragmatic approach to starting drug treatment (low dose oral morphine) would be to start if significantly symptomatic,e.g. sleeping <1hr after feeds, continuous high-pitched cry, unable to feed. Once stable, wean morphine slowly over several days.
  • Start apnoea monitor if preterm or require large doses of morphine.
  • Seizures should be controlled by phenobarbital (also a drug of choice to treat barbiturate withdrawal).

Other points to consider are:

  • Does the baby need a urine screen (remember this will effectively drug-test the mother)?
  • Ensure Social Services are aware as child protection and family support issues must be considered.
  • Consider associated pathologies, e.g. HIV or hepatitis B or C infection.
  • Breastfeeding is not contraindicated unless the mother is taking high doses of methadone (>20mg/day), amphetamines, cocaine, or is HIV +ve.


It is difficult to establish whether any adverse outcomes are directly related to drug exposure as literature is confounded by social and environmental factors. There is an increased risk of:

  • prematurity;
  • IUGR;
  • sudden infant death syndrome (SIDS);
  • congenital HIV/hepatitis B/C infection;
  • social problems;
  • neurodevelopmental impairment.