Neonatal abstinence syndrome (NAS), also known as neonatal withdrawal syndrome, is a complex disorder with two major causes. NAS can be either due to the prenatal maternal use of substances, or secondary to the discontinuation of opioid analgesia in the newborn.

Maternal substance abuse is a leading preventable cause of mental, physical, and psychological problems in infants and children. Approximately 3 percent of the 4.1 million women of child-bearing age who abuse drugs are believed to continue drug use during pregnancy (USDHHS, 2009).

Postnatal NAS results when an abrupt discontinuation of opioid analgesia occurs, usually after prolonged drug exposure. Withdrawal symptoms may occur within the first 48 hours postpartum, or only manifest after discharge. Symptoms generally peak between 10-21 days, and may last up to six weeks. (Wilbourne et al.,2001). Drugs frequently associated with neonatal problems include codeine, fentanyl, methadone, meperidine (Demerol), diazepam and lorazepam, as well as barbiturates.

Addiction in the infant is caused by the movement of maternal drugs across the placental barrier. This transfer occurs in varying degrees, depending on the pharmacokinetic properties of the individual drugs. Substances that act on the central nervous system are usually highly lipophilic (having a chemical affinity for lipids) with a relatively low molecular weight. These characteristics facilitate the movement of the drug across the placenta. These drugs then tend to accumulate in the fetal circulation because of the relative immaturity of the fetal renal system. The subsequent discontinuation of the drug at birth then results in the development of a withdrawal syndrome.

Clinical signs and symptoms of NAS depend on various factors, such as the type of drug used, its dose, frequency of use and the infant's own metabolism and excretion of the active compound. In general, common signs and symptoms of NAS include a high-pitched cry, restlessness, hyperactive reflexes, jitters and tremors, or generalized convulsions. Fever with frequent yawning and sneezing may also be early signs of NAS. Respiratory distress (nasal flaring, tachypnea or apnea) are also evident in NAS. Gastrointestinal dysfunction often manifests as poor feeding, projectile vomiting and loose stools.

The nursing management of an infant with NAS centers around the creation of a therapeutic environment. The infant should be nursed in a controlled environment, with low stimuli, soft lighting, minimal noise levels and routine to minimize excessive handling. Swaddling also helps the infant to simultaneously control his or her body, breathe, and suck at the same time, to improve feeding. It is also important for the nurse to work together with the mother in a nonjudgmental manner, so that maternal infant bonding can occur. Breastfeeding should also be encouraged if the mother has stopped abusing drugs. Breastfeeding will not shorten or worsen infant withdrawal symptoms, and it may enhance a mother’s self-esteem and promote care involvement (Jansson, L. et al., 2008).