Newborn Withdrawal (NAS- Neonatal Abstinence Syndrome)

        Trying to research NAS was one of the most nerve-wracking things of the last weeks of Anne's pregnancy. Would Baby Girl go through withdrawal? How bad would it be? Would she have to go to the NICU? Would she suffer?
       I learned this week in the hospital that the reason there is no concrete information available about NAS is that it is totally unpredictable. The doctors told me that they have seen multiple instances of two women with the exact same medication/substance use profile, and one of their babies has absolutely no withdrawal symptoms but the other one will end up in the NICU for 3 weeks. They have seen women on extremely high doses of methadone give birth to a babies who end up with a couple of mild symptoms, while some women on doses of opiate pain relievers considered to be safe for pregnancy watch their babies suffer from serious withdrawal for days or weeks. Even in Anne's case, there were some doctors and nurses who looked at her chart and said "I wouldn't be worried about that baby" while others said "You should prepare yourself for the baby needing step-down therapy in the NICU." So, first and foremost, no one is going to be able to give you a prediction about if the baby you are hoping to adopt will go through withdrawal and if so, how bad it will be.

     Every substance has a different withdrawal profile, but there are some NAS symptoms that are pretty common. The only variation of NAS that I have become familiar with from this past week is opiate withdrawal. Anne had to continue her painkillers during her pregnancy, which were opiate based.  Depending on her pain level on a specific day, she would take either hydrocodone or oxycodone. I'm not entirely sure how opiate withdrawal specifically differs from some of the other drugs, but I do know that the most serious concern of opiate withdrawal is seizures. The other specific that I learned about opiate withdrawal is that it tends to peak on day 3 or 4. If a baby gets through day 3-4 without any serious symptoms, chances are good that the withdrawal will remain manageable. If things are starting to get serious at day 2, chances are good that they will get worse on day 3 or 4.
   
    Here are the most commonly seen symptoms in NAS/newborn withdrawal:

• Excessive or continuous crying
• Not sleeping
• Hyperactive moro reflex
• The moro reflex is the startle reflex involving the arms
• Tremors or trembling
• Twitching or jerking
• Convulsions
• Increased muscle tone/rigidity
• Rashes (usually labeled "excoriation") 
• Sometimes, rash is only considered a symptom if it is caused by constant rubbing. In other instances, a diaper rash or other form of skin rash can be a symptom. 
• Fever
• Frequent yawning
• Frequent sneezing (withdrawal sneezing usually involves 3 or more in a row)
• Skin mottling
• Stuffy nose
• Nasal flaring
• Fast breathing
• Excessive sucking (constant or near constant pacifier use)
• Poor feeding
• Spitting up or vomiting
• Loose or watery stools 

  Obviously, some of these symptoms are more serious than others. Baby Girl was having occasional sneezing episodes, some muscle rigidity in her arms, and skin mottling. She had some diarrhea on day 1 after passing her myconium, which caused her to have a diaper rash. There was a bit of a disagreement among the nurses about whether or not that diaper rash should count as a withdrawal symptom. 

     So, what will happen in the hospital is that every 4-6 hours, usually timed at an hour after a feeding, a nurse will come in and "score" the baby. This scoring involves using a system that converts these symptoms to a numerical value, based on their severity. These numbers are added up to create a score for that exam.  When the doctor did rounds in the morning, he or she would examine the scores since the previous day, do their own exam, and make a decision about whether or not they agreed with the nurses' scoring.  I'll talk about this more in a minute, as there were often some pretty serious disagreements between the doctor and nurses about the severity of Baby Girl's condition. 

    There are a few variations of the scale used for NAS scoring, but here is one that is nearly identical to the one used by our hospital. The hospital will have a policy in place about what to do about elevated scores. Our hospital would call a NICU consult for 3 scores over an 8 in any 24 hour time period, or a single score over a 12. Any score over a 14 would automatically cause the baby to be transferred to the NICU. Once in the NICU, a decision would be made about step-down/weaning therapy. At our hospital, either morphine or methadone is used for withdrawal step-down therapy. They will determine the dosage based on the severity of symptoms, and then require a certain score or a certain length of time (such as 3 consecutive scores of 3 or less, or an entire day of scoring 3 or less) before stepping down to a lower dose. The amount of time that a baby would need to be in the NICU for the step-down therapy is totally unpredictable, but it is not uncommon for it to take 3-4 weeks. 

      All of the nurses and doctors that we talked to agreed that holding (contact comfort) is very important for calming a baby going through NAS. In fact, Baby Girl's doctor at one point mentioned that he thought one of the reasons she did so well was because we held her nearly constantly while we were there-- skin to skin whenever possible. When we were there during the day, her scores would drop down to a 2-5, but when we would leave in the evening and she would be in the nursery, her scores would go up to 8-10. 

      This is where the disagreements between the nurses and doctor came in. The nurses were wanting to score Baby Girl based on how she was doing in the nursery when we were not there (i.e., being left alone and not being held), whereas the doctor was wanting to evaluate how she was doing when she was calm and relaxed. The nurse would rate her as being irritable and inconsolable, and then the doctor would come in and she would be sound asleep after being snuggled. The nurse would score her as having "excessive sucking behaviors," whereas the doctor would say that she wasn't using her pacifier any more than a normal baby. She would spit up once and the nurse would score her for vomiting, but the doctor would argue that every baby spits up after eating occasionally, and her otherwise healthy eating schedule and behaviors caused him not to be concerned about an occasional spit-up. This went on for 5 days-- low scores during the day, high scores at night, being greeted with a warning that today would probably be the day she went to the NICU, a morning checkup with a doctor who promptly scolded the nurses for being a bit too fast and loose with the scoring criteria, and another day of low scores.
    As a side note, you will want to get some side-snap baby shirts if you are expecting NAS checkups in order to make baby's life easier! Each check involves underarm temperature, heart rate and respiration rate, and diaper area examinations. Having to undo a onesie or sleep and play every couple of hours (in addition to the diaper changes that you are already doing) creates for a very frustrated baby, especially if they aren't feeling well from withdrawal symptoms. We really wished we had thought to bring some of these with us so that they could just unsnap her shirt and have the bottom area accessible with just a diaper on. Here are a few options for those:

• Carter's White 5-Pack Side-Snap Baby T-Shirts
• Baby Boys' 4 Pack Side Snap Tees
• Baby Girls' 4 Pack Side Snap Tees
• Unisex-Baby Newborn 2 Pack Long Sleeve Side Snap Shirt with Mitten Cuffs
• Organic Cotton Side Snap Baby Tee

   So, thankfully, that was our only experience with NAS! We know that things could have been much worse, and we thank you all for praying with us for Baby Girl's health.