Clinician-to-Clinician Update Clinician-to-Clinician Update

Addressing Neonatal Abstinence Syndrome

January 2018

As America’s opioid epidemic grows, health care providers face the challenge of treating increasing numbers of infants born with neonatal abstinence syndrome (NAS). The syndrome occurs in 55% to 94% of newborns whose mothers were addicted to or treated with opioids while pregnant.1,2 In Minnesota, from 2012 to 2015, the number of NAS diagnoses in children less than 1 year of age increased from 239 to 765. During that same period, the corresponding rate of NAS in infants per 10,000 population also increased from 35.4 per 10,000 to 1096 per 10,000 population.3

Symptoms vary, ranging from mild tremors and irritability to fever, excessive weight loss, and seizures.1 These typically develop within the first few days after birth, although the timing and severity can vary.

Medication-assisted therapy (MAT) (also known as opioid agonist pharmacotherapy) with methadone or buprenorphine is the accepted standard of care for mothers-to-be with opioid use disorders. Methadone and buprenorphine provide a steady concentration of opiate in the pregnant woman’s blood, thereby preventing the repeated highs and lows associated with illicit drug use and their adverse effects on the fetus. Because withdrawal is associated with high relapse rates and illicit drug use, MAT is recommended over medically supervised withdrawal.4

While buprenorphine is a relatively new drug, for 50 years, methadone has been the most widely used therapy for managing opioid dependence in pregnancy. In a large, randomized trial, no significant differences appeared in overall rates of NAS among infants exposed to methadone and buprenorphine, but the severity of NAS was found to be less among infants exposed to buprenorphine.5 Buprenorphine-exposed neonates required, on average, 89% less morphine for NAS and had substantially shorter hospital stays. Treatment retention was higher, however, for patients on methadone. Based on findings, the investigators recommended buprenorphine as a first-line treatment option in pregnancy but advised clinicians to take into account the reduced adherence to buprenorphine and its ceiling effect.6

— The licensed photograph is used for illustrative purposes only, and the persons depicted are models.

Expectant mothers with opioid use disorders also often experience a range of complicating conditions. “These women are at a higher risk of infectious diseases. They need nutrition counseling,” says Cresta Jones, MD, a University of Minnesota Health physician specializing in opioid use disorders during pregnancy. “About 80% are tobacco smokers, and 30% have an underlying mental health condition.” Care at delivery can also involve multiple specialists and additional care coordination, Jones notes. Current evidence-based recommendations for the management of opioid-dependent pregnant woman and infants include multidisciplinary treatment as early as possible, opioid maintenance, and regular monitoring.7

Physicians cannot predict which infants will have NAS, and the drugs received in utero do not necessarily correspond to specific symptoms. Treatment guidelines for NAS following opiate exposure include screening for maternal substance abuse, use of scoring systems to assess the severity of withdrawal symptoms, toxicology screening before starting drug treatment, and pharmacologic management of drug withdrawal.8

University of Minnesota Health specialists both treat mothers and infants with NAS and support community providers in this effort. Phillip Rauk, MD, chairs the Minnesota Hospital Association’s Neonatal Abstinence Syndrome Roadmap Committee, leading the effort to provide guidance to health systems treating these infants. Jones and team members offer consultations on patients.


  1. Finnegan LP, Connaughton JF Jr, Kron RE, Emich JP. Neonatal abstinence syndrome: assessment and management. Addict Dis. 1975;2:141-58.
  2. Hudak ML, Tan RC, Committee on Drugs, Committee on Fetus and Newborn. Neonatal drug withdrawal. Pediatrics. 2012;129(2):e540-560.
  3. Drug Overdose Deaths among Minnesota Residents, 2000-2015. (2015). Minnesota Department of Health. Saint Paul, MN.
  4. American College of Obstetricians and Gynecologists Committee Opinion Number 711, August 2017.
  5. Jones HE, Fischer G, Heil SH, et al. Maternal Opioid Treatment: Human Experimental Research (MOTHER)--approach, issues and lessons learned. Addiction. 2012 Nov; 107 Suppl 1:28-35.
  6. Jones HE, Kaltenbach K, Heil SH, et al. Neonatal abstinence syndrome after methadone or buprenorphine exposure. N Engl J Med. 2010;363:2320–2331.
  7. Winklbaur B, Kopf N, Ebner N, Jung E, Thau K, Fischer G. Treating pregnant women dependent on opioids is not the same as treating pregnancy and opioid dependence: a knowledge synthesis for better treatment for women and neonates. Addiction. 2008;103(9):1429-1440.
  8. American Academy of Pediatrics Committee on Drugs: Neonatal drug withdrawal. Pediatrics. 1998;101:1079-1088.

When to refer

University of Minnesota Health maternal-fetal medicine specialists provide innovative, interdisciplinary care for women experiencing maternal, fetal, or placental complications during pregnancy. As faculty members at the University of Minnesota Medical School, our specialists practice the latest evidence-based medicine and collaborate with other University of Minnesota Health specialists, including pediatric cardiologists, radiologists, neonatologists, addiction specialists, and social workers, among others. They are active partners with community referring physicians and serve as a resource for the physicians of the University of Minnesota’s CommunityUniversity Health Center who treat pregnant women with opioid use disorders.

Highly specialized imaging technology and genetics expertise for mothers and their unborn babies are available through our Fetal Diagnosis and Treatment Center and the Perinatal Assessment Center. Neonatologists and other pediatric subspecialists at University of Minnesota Masonic Children’s Hospital work closely with the maternal-fetal medicine team.

For referrals or consultations, providers can call 612-273-2223 (Minneapolis), 952-892-2270 (Burnsville), or 952-924-5250 (Edina). For information on the telemedicine consults available in Hibbing (ultrasound reviews and physician communication with the patient), call 612-273-2223. The clinic at Grand Itasca Clinic and Hospital in Grand Rapids, MN, is scheduled to re-open in 2018. Physicians in the Grand Itasca area can call the Minneapolis location for provider-to-provider consultations.

The Director of Maternal-Fetal Medicine Daniel V. Landers, MD, is available to discuss updates on services, new practice guidelines, and the maternal-fetal medicine staff and resources. Cresta W. Jones, MD, is available for consultations on neonatal abstinence syndrome, and the maternal-fetal medicine physicians also offer an update on obstetrical ultrasound every other year in the Twin Cities.

To request a free copy of the 2017 University of Minnesota Health Adult Specialty Directory, visit

To find current clinical trials available through University of Minnesota Health providers, visit

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