Prenatal opioid exposure increased broadly across the US from 2000 to 2017. Although some states have seen a decline since then, specific areas and populations continue to see increases, including rural areas, New England, and Appalachia, with disproportionate impact on pregnant persons who are publicly insured and lower income. Infants who have become physiologically dependent on opioids in utero experience an abrupt discontinuation at delivery and present clinically with signs and symptoms of neonatal opioid withdrawal syndrome (NOWS), including nervous system irritability and autonomic dysfunction, leading to difficulties with feeding, sleeping, and consoling.
In a recently released “State of the Art” article in Pediatrics, Dr. Margarida Mascarenhas and colleagues in Boston give a comprehensive, current overview of the identification, evaluation, and care of infants with prenatal opioid exposure from delivery through early childhood, and outline research in progress that will further understanding (10.1542/peds.2023-062871).
The authors’ well organized and logical approach walks the reader through the following elements:
- advances in standardizing the clinical diagnosis of NOWS, including a list of guidelines that hospital teams can use to standardize approaches, crucial to equitable care;
- assessment strategies and the evidence in support of each, with a focus on the new Eat, Sleep, Console (ESC) approach with use of a standardized ESC Care Tool;
- treatment strategies including both pharmacologic and non-pharmacologic strategies, with comparison of current evidence supporting specific medication regimens, breastfeeding, formula choice, and newer modalities like vibrating cribs;
- factors that have been shown to affect severity of NOWS presentation, such as prenatal care and maternal treatments for opioid use disorder, potential poly-substance exposure, and infant genetic factors; and
- post-hospital care, including developmental surveillance, family well-being and support, and early childhood considerations.
Throughout the article, the emphasis is on research: comparing completed studies, flagging current ongoing and relevant studies, and outlining areas for future studies. I believe a key take-home point is that discontinuing the use of stigmatizing and inaccurate language regarding NOWS is an important change each of us can make. The words we use matter, and a non-judgmental approach supports equitable care and research. A substance-exposed newborn with NOWS should no longer be labelled as “addicted” or referred to as a “NOWS baby”; the infant’s mother is a person with opioid use disorder, not an “addict” or “addicted mother.” Dr. Mascarenhas and colleagues end on a positive note, emphasizing the “potential for major breakthroughs in understanding the effects of opioids on the developing brain” as well as the need for research in this area that incorporates personal, social, developmental, and environmental factors for optimal outcomes.
