What is the distribution of care for a baby with neonatal abstinence syndrome (NAS) between hospital and outpatient pediatrician management?

Management of Neonatal Abstinence Syndrome: Hospital vs. Outpatient Care

Infants with neonatal abstinence syndrome (NAS) from heroin exposure require initial intensive hospital-based care, with most treatment occurring in the inpatient setting, followed by careful outpatient monitoring by pediatricians after discharge. 1

Initial Hospital Management

• Infants at risk for NAS should be carefully monitored in the hospital using standardized assessment tools like the modified Neonatal Abstinence Scoring System to evaluate withdrawal severity 1
• Initial treatment focuses on minimizing environmental stimuli by placing the infant in a dark, quiet environment, careful swaddling, and responding early to infant signals 1
• The appropriate duration of hospital observation depends on the maternal drug history, with heroin-exposed infants typically showing withdrawal signs within 24 hours of birth 1
• For infants requiring pharmacologic treatment, hospital stays average 21.1 days according to studies of Medicaid populations 2

Pharmacologic Management (Hospital-Based)

• 83% of US clinicians use an opioid (morphine or methadone) as the first-choice medication for treating NAS 1
• Phenobarbital is commonly used as a second-line agent if opioid therapy doesn't adequately control withdrawal symptoms 1
• Daily morphine doses typically range from 0.24 mg/kg to 1.3 mg/kg per day 1
• Paregoric is no longer recommended due to toxic ingredients, and diazepam has fallen out of favor due to lack of efficacy and adverse effects on feeding reflexes 1

Transition to Outpatient Care

• Hospital discharge timing depends on the specific opioid exposure:
  • Infants exposed to short-acting opioids may be safely discharged if no withdrawal signs appear by 3 days of age 1
  • Infants exposed to longer-acting opioids like methadone should be observed for a minimum of 5-7 days before discharge consideration 1
• Combined inpatient/outpatient methadone treatment regimens can significantly reduce hospital stays to an average of 11.4 days versus 25.1 days for infants treated entirely as inpatients (55% reduction) 2

Outpatient Management

• Outpatient pediatricians are responsible for monitoring:
  • Ongoing withdrawal symptoms which may persist up to 6 months after birth 1, 3
  • Feeding difficulties and weight gain 1
  • Developmental milestones and neurological status 1
  • Medication weaning if the infant is discharged on pharmacotherapy 2

Potential Complications and Monitoring

• Seizures occur in 2-11% of infants withdrawing from opioids and require close monitoring 1
• Abnormal EEG results without overt seizure activity have been reported in >30% of neonates with NAS 1
• All infants with NAS experience some adverse events, with 30% of those receiving pharmacotherapy becoming too sedated to feed properly 4

Special Considerations

• Breastfeeding is not contraindicated for mothers on methadone or buprenorphine maintenance therapy unless the mother is using street drugs, involved in polydrug abuse, or HIV-infected 5
• Polysubstance exposure is common (94% in one study) and may complicate withdrawal management and extend hospital stays 4
• Long-term neurodevelopmental follow-up is essential as subacute signs of opioid withdrawal may last up to 6 months 1

Evidence Gaps

• Studies have not definitively addressed whether long-term morbidity related to neonatal drug withdrawal is decreased by pharmacologic management 1
• There is limited empirical evidence guiding the management of infants with NAS, with many standard interventions never having been properly tested in this population 6