What is the most appropriate step for an infant exhibiting symptoms of neonatal opioid withdrawal syndrome?

Management of Neonatal Opioid Withdrawal Syndrome

The most appropriate initial step is to implement nonpharmacologic interventions as first-line treatment, including rooming-in with the primary caregiver, minimizing environmental stimuli (dark, quiet room), careful swaddling, skin-to-skin contact, and early response to infant cues, while using a standardized assessment tool like the modified Finnegan Neonatal Abstinence Scoring System to monitor withdrawal severity. 1

Immediate Assessment and Monitoring

• Use a standardized scoring tool to quantify withdrawal severity—the modified Finnegan Neonatal Abstinence Scoring System is the dominant tool in the United States 1, 2
• Keep the infant in the room with the caregiver during assessments and include the caregiver in the assessment process to build trust and engagement 1
• Conduct assessments after feedings and consider the entire period since the last evaluation 1
• Monitor for key withdrawal signs including CNS irritability (tremors, high-pitched crying, increased muscle tone), autonomic overreactivity (sweating, fever, temperature instability), and gastrointestinal dysfunction (poor feeding, vomiting, diarrhea) 1

First-Line Nonpharmacologic Interventions

Environmental modifications should be maximized before considering pharmacologic treatment 1:

• Rooming-in with the primary caregiver is the standard of care and reduces pharmacologic treatment need by 20-60%, decreases total opioid treatment days, and shortens hospitalization by 1-2 weeks compared to NICU care 1
• Reduce environmental stimuli by placing the infant in a dark, quiet environment with minimal noise and bright lights 1
• Implement careful swaddling and skin-to-skin contact to reduce hyperarousal 1, 3
• Cluster care times to limit disruptions to infant sleep 1
• Respond early to infant signals using appropriate positioning and comforting techniques 1

Feeding Strategies

• Support breastfeeding if the mother has no ongoing substance use at delivery, is engaged in prenatal care, and has no other contraindications—breastfeeding is associated with decreased severity and duration of NOWS symptoms 1, 3
• For formula feeding, standard infant formula is appropriate as recent studies show no benefit from low lactose or partially hydrolyzed formulas 1

Pharmacologic Treatment Indications

Escalate to pharmacologic treatment only when nonpharmacologic interventions fail to adequately control withdrawal symptoms 1:

• Morphine or methadone is the first-line pharmacologic agent, used by 83-94% of US and UK clinicians 1, 2
• Daily morphine doses typically range from 0.24 to 1.3 mg/kg per day 1, 2
• Phenobarbital is the most common second-line agent if opioid monotherapy doesn't adequately control withdrawal 1, 2, 4
• Clonidine is an alternative second-line agent, though phenobarbital is associated with shorter hospitalization 1, 4
• Continue nonpharmacologic interventions even after starting medications—the two approaches work synergistically 5

Critical Timing Considerations

The duration of hospital observation depends on maternal opioid exposure 1, 2:

• Heroin exposure: Withdrawal typically begins within 24 hours of birth; infants may be discharged if no signs appear by 3 days 1
• Methadone exposure: Withdrawal usually commences at 24-72 hours; observe for minimum 5-7 days before discharge 1, 2
• Buprenorphine exposure: Withdrawal peaks at 40 hours with most severe symptoms at 70 hours 1
• For any opioid, withdrawal may be delayed until 5-7 days of age, often after typical hospital discharge 1

Important Clinical Pitfalls

• Avoid paregoric—it contains toxic ingredients including camphor, anise oil, alcohol, and benzoic acid 1
• Avoid diazepam—it lacks efficacy compared to other agents and adversely affects infant suck and swallow reflexes 1
• Monitor for seizures—they occur in 2-11% of infants withdrawing from opioids, though abnormal EEG findings without overt seizures occur in >30% 1, 2
• Recognize that subacute withdrawal signs may persist up to 6 months after birth, requiring ongoing outpatient monitoring 1, 2

Monitoring Beyond Discharge

Outpatient pediatricians must monitor for 2:

• Ongoing withdrawal symptoms persisting up to 6 months
• Feeding difficulties and weight gain
• Developmental milestones and neurological status