Neonatal abstinence syndrome: signs of withdrawal in newborns and how babies are cared for

North Lincolnshire and Goole NHS Foundation Trust describes neonatal abstinence syndrome as the symptoms that babies may have if their mother used certain drugs during pregnancy, often referred to as withdrawal. Worcestershire Acute Hospitals NHS Trust says that if a mother has used any prescribed medication or illicit drugs that can cause physical dependency during pregnancy, the baby may become dependent as well, and that withdrawal is similar to what an adult experiences when suddenly stopping a drug or medication.

Substances involved include both prescribed medicines and non-prescribed drugs. Worcestershire explicitly mentions medication, tobacco and alcohol as substances which pass through the placenta. The leaflets read for this page are written for families and focus on supportive care rather than on blame. Worcestershire notes that most women who use drugs or prescribed medication have a normal pregnancy, labour and delivery.

The condition is a consequence of the baby's exposure, not an illness the baby has "caught", and it is recognised and managed routinely on maternity, postnatal and neonatal units.

The two NHS trust leaflets list closely similar signs. Not every baby shows all of them, and severity varies. Most babies exposed to drugs during pregnancy, according to the North Lincolnshire leaflet, will experience some withdrawal symptoms, but some may require no different care from any other baby.

• A continuous high-pitched cry.

• Irritability, restlessness and scratching of the face.

• Shaking (tremor) of the arms and legs, whether disturbed or resting.

• Increased muscle tone, where the limbs feel stiff.

• Excessive wakefulness, not settling or sleeping after a feed.

• Feeding difficulties, including poor coordination of sucking and swallowing, or frantic sucking, and poor weight gain.

• Sickness or vomiting, and diarrhoea with a sore bottom.

• Fever and sweating.

• Fast breathing (tachypnoea), and excessive sneezing, yawning or hiccups.

• Less commonly, fits (convulsions).

North Lincolnshire says symptoms usually begin within two to three days of birth, though some start sooner and others after one to two weeks. Worcestershire says symptoms may not be apparent immediately and may develop over a few days or even weeks, and that most babies will be able to go home after 96 hours of observation if they do not need treatment.

Worcestershire says staff will always aim to keep mother and baby together on the postnatal or transitional care ward, and that babies are admitted to the neonatal unit only if they need medication and further monitoring for NAS. A baby may also be discharged still needing medicine. North Lincolnshire says in that case the medication is gradually reduced over time and not stopped suddenly, with weaning taking from a few days to several weeks, and that the family may be taught to monitor the baby at home with a withdrawal form and have support from neonatal community nurses.

Worcestershire says some babies can still experience withdrawal after discharge, and that parents should contact their midwife, health visitor or GP if concerned.

The first-line approach in both leaflets is supportive. Worcestershire says nurses and midwives monitor the baby with an assessment chart, scoring for symptoms approximately every 4 hours depending on feeding pattern and behaviour, and that severe withdrawal will need treatment. Where medication is needed, it is started on the neonatal unit; the dose may be increased if symptoms are not controlled and then gradually reduced as the baby improves. Worcestershire adds that after the medication is stopped, the baby needs to be observed for a minimum of 24 hours before discharge.

The leaflets describe the following practical measures that parents are encouraged to use, in addition to anything the clinical team recommends.

• Provide a quiet environment with dimmed lighting, and turn down loud music, television and voices.

• Give plenty of cuddles and skin-to-skin contact, and handle the baby very gently.

• Use gentle massage and bathing if it soothes the baby, and consider a sling.

• Dress the baby in cool clothing and change it if they are sweating; swaddle with a cool sheet if restless.

• Feed regularly with small frequent feeds and keep a record of feeds; speak to staff about sucking problems.

• Offer a dummy if the baby is sucking excessively, after talking to staff, especially if breastfeeding.

• Change nappies frequently and use a protective cream for a sore bottom.

• Keep the home, car and surroundings smoke-free.

Worcestershire says breastfeeding is encouraged to help with withdrawal symptoms and enable bonding, but that the use of some drugs may mean breastfeeding is not recommended, and that a midwife or obstetrician can advise. This varies with the substance, so it is a question to ask the maternity team rather than assume.

North Lincolnshire points out that sudden infant death syndrome is rare but that the risk is increased in babies whose mothers took drugs in pregnancy, and advises not to share a bed with the baby and to follow the Lullaby Trust guidance on safe sleeping. Worcestershire gives the same advice about not sharing a bed and following Safer Sleep guidelines.

The North Lincolnshire leaflet says to dial 999 immediately if the baby stops breathing and goes blue, is struggling for breath, is unconscious or seems unaware of what is going on, will not wake, or has a fit for the first time, even if they seem to recover. Worcestershire gives a similar list that includes a baby who appears pale, blue or grey, has breathing difficulties or appears to be panting, has a fit or convulsion, or is floppy.

For concerns that are less urgent, such as symptoms that seem to be getting worse at home, feeding that is not going well or a very sore bottom, Worcestershire says to contact your midwife, health visitor or GP, and North Lincolnshire says to liaise with the neonatal community nurses. NHS 111 is the number to call if you are unsure.

Worcestershire says many babies who are born experiencing drug withdrawal will recover fully in time, but that some may experience long-term consequences such as behavioural issues and developmental problems, and that follow-up by a consultant neonatologist after discharge may be arranged where appropriate.

Caring for a baby who is withdrawing can be demanding. Worcestershire acknowledges that this can be a difficult time and that some mothers feel guilt or blame, and says community midwives, specialist midwives, neonatal staff, health visitors and community drug and alcohol teams are available to talk through concerns. If you receive support from Children's Services, Worcestershire says they will be informed when the baby is born.

Care in the NHS is delivered through the maternity and neonatal units, with community follow-up. Private maternity care exists, but a baby needing medicated withdrawal is generally cared for on a neonatal unit.