Neonatal Opioid Withdrawal Syndrome (NOWS)

Overview

Neonatal Opioid Withdrawal Syndrome (NOWS) describes symptoms caused when a newborn withdraws from opioids taken by the mother prior to delivery. NOWS is a type of Neonatal Abstinence Syndrome (NAS), a group of conditions caused when babies withdraw from certain substances or medications they were exposed to in the womb before birth. NAS is most often caused when a woman takes opioids during pregnancy but can include other withdrawal from other substances such as nicotine, stimulants, anti-depressants, and central nervous system depressants.
Withdrawal symptoms can include:
  • Tremors
  • Excessive or high-pitched crying
  • Sleep problems
  • Hypertonicity
  • Exaggerated reflexes
  • Yawning, stuffy nose, and sneezing
  • Poor feeding and sucking
  • Vomiting or diarrhea
  • Sweating
  • Fever or unstable temperature
  • Seizures
This page summarizes key points for primary care clinicians and health care professionals and provides links to useful resources and relevant service providers.

Key Points

Terminology

Avoid use of stigma-laden terms; research suggests they induce bias:
  • Abuser, addict: use “person-first” language. Rather than call someone an addict, say they suffer from addiction or a substance use disorder.
  • Drug: Use specific terms such as “medication” or “a non-medically used psychoactive substance” to avoid ambiguity
  • Clean, dirty: Use proper medical terms for positive or negative test results from substance use.
  • Lapse, relapse, slip: use morally neutral terms like “resumed” or experienced a “recurrence” of symptoms.
For more guidance, see the Recovery Research Institute’s glossary of addiction-related terms, Addiction-ary (Recovery Research Institute).

Testing

Due to high false-positive and false-negative rates, a “Urine Tox” is not recommended as a stand-alone test. Urine Tox screening needs to be confirmed with more accurate testing. This should be done with consent.

Pregnancy Medication Guidance

Detoxification,” lowering doses, or tapering opioids prior to delivery does NOT decrease NAS in newborns. It does increase the risk of relapse for the mother. Eighty percent of women who were abstinent in the last month of pregnancy returned to using at least 1 substance within 1 year postpartum. So pregnant women should be treated appropriately for their symptoms.
  • Buprenorphine
    • Same efficacy and rates of adverse events as methadone
    • Lower risk of overdose and fewer drug interactions
    • Less frequent and milder withdrawal symptoms in neonates
    • Significantly decreased morphine dose and duration of treatment for the withdrawing neonate, resulting in shorter hospital stay for the neonate
  • Methadone
    • More structure – better for patients in unstable situations (i.e., therapist and wrap-around services)
    • Decreased risk of diversion
    • More long-term data on outcomes
  • Naltrexone
    • Limited but increasing data – fewer short-term neonatal effects

Postpartum and Infant Care

  • Postpartum year – significant support needed, high return to use potential
  • Rooming in/paired care – skin to skin, breastfeeding, low stimulation environment, etc., helps treat NOWS, often without medication.
  • NAS/NOWS is a qualifying diagnosis for Early Intervention. Primary developmental areas of concern:
    • Gross motor skills – movement patterns and balance
    • Expressive and Receptive Language – limited babbling, poor imitation verbally and non-verbally

Service Providers

  • Opioid use disorder follow-up after delivery
    • Pharmacotherapy for parents: Superad clinic at the University of Utah (1 year)
    • Network of providers including CHCs
    • BRIDGE clinic for the babies at University Pediatric Clinic or South Main Clinic
  • Methamphetamine use
    • Behavioral therapy– county-based treatment providers

Resources

Information & Support

For Professionals

Addiction-ary (Recovery Research Institute)
Dictionary of terms to help de-stigmatized addiction and unify language use.

For Parents and Patients

Baby Your Baby: Taking Medications During Pregnancy Podcast (KUTV 2News)
Moms may feel like they shouldn’t take medications during pregnancy to protect the baby, but their illness or condition may be more harmful to the baby than the medication that treats it. Toughing out an illness usually isn’t better for a baby. Anchor Holly Menino sits down with Al Romeo, a registered nurse with the Utah Department of Health’s MotherToBaby/Pregnancy Risk Line program to discuss the risks and benefits of taking certain medications and vitamins.

Caring for a Baby Exposed to Drugs During Pregnancy (NMDOH) (PDF Document 258 KB)
Brochure for parents and other caregivers of infants exposed to drugs during pregnancy. Provides an overview of neonatal abstinence syndrome (NAS, also referred to as NOWS or neonatal opioid withdrawal syndrome), what causes it, and tips on how to console your baby; New Mexico Department of Health.

Caring for a Baby Exposed to Drugs During Pregnancy (NMDOH) (Spanish) (PDF Document 257 KB)
Brochure in Spanish for parents and other caregivers of infants exposed to drugs during pregnancy. Provides an overview of neonatal abstinence syndrome (NAS, also referred to as NOWS or neonatal opioid withdrawal syndrome), what causes it, and tips on how to console your baby; New Mexico Department of Health.

Tools

Drug Abuse Screening Test (DAST-10) (PDF Document 161 KB)
A 10-item screen that assesses drug use, not including alcohol or tobacco use, in the past 12 months. A clinician-administered version and a self-report version are provided. The screen and scoring instructions can be downloaded or printed for free; developed and validated by Dr. Harvey A. Skinner at the Addiction Research Foundation.

Services for Patients & Families in Idaho (ID)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Authors & Reviewers

Initial publication: August 2021
Current Authors and Reviewers:
Authors: Kimberly Stowers, MD
Jennifer Goldman-Luthy, MD, MRP, FAAP