Child Health and Wellness

NOWS is a drug withdrawal syndrome that occurs primarily among opioid-exposed infants shortly after birth. Common opioids that can lead to NOWS include short-acting opioids (hydromorphone, oxymorphone, hydrocodone, morphine, oxycodone, codeine, fentanyl and heroin) and long-acting opioids (methadone and buprenorphine). NOWS describes a constellation of signs including central nervous system irritability, autonomic instability, and gastrointestinal dysfunction. Clinical signs of NOWS depend on multiple factors including the type of opioid to which the fetus was exposed, purity of compounds, timing of exposure before delivery, maternal health, and maternal and infant metabolism.

Education should be provided to parents and families on:

• NOWS and newborn care
• Awareness of the signs and symptoms of NOWS
• Interventions to decrease NOWS severity (e.g. breastfeeding, smoking cessation)

Factors that influence how to manage an infant exhibiting signs of NOWS should include the clinical status of the infant, and an interview with the mother about substance use during pregnancy. Infants exhibiting mild signs of NOWS should be managed with non-pharmacological interventions and monitored for development of more severe symptoms. Whereas, infants displaying moderate to severe signs of NOWS should be managed with non-pharmacologic interventions as well as pharmacological interventions when needed. It is recommended that facilities have a formal protocol for the management of NOWS.

Withdrawal Signs

Neurologic signs: High pitched cry, Irritability, Sneezing, Tremor, Hyperrelexia, Frequent yawning, Seizures

Gastrointestinal signs: Vomiting, Diarrhea, Poor weight gain, Poor feeding, Uncoordinated sucking/swallowing, Sweating

Autonomic signs: Diaphoresis, Nasal congestion, Temperature instability, Hyperthermia, Increased respiratory rate, Increased blood pressure, Sweating

Non-pharmacologic treatment, or supportive care, is the preferred management for NOWS, is appropriate for all infants at risk for NOWS, and can begin at birth. The goal of non-pharmacologic interventions is to create a calm, quiet, and controlled environment where there is appropriate stimulation for the newborn to restore greater periods of quiet-alert state. Birthing centers may also consider other members of the health care team and additional support staff for help in providing:

• Rooming in
• Close mother/infant contact
• Skin to skin care
• Swaddling to reduce excessive neuromotor dysregulation
• Minimal sensory or environmental stimulation and appropriately timed stimulation
• Responsive infant cue reading by hospital staff, parents, and family
• Rocking by parents or providers with attention to infant cues.
• Using a pacifier for non-nutritive sucking
• Breastfeeding when appropriate
• Attention to quantity and of feedings avoidance of over feeding
• Grouping care and vital sign measurements to minimize interruptions newborn cares

Currently, there is no universally recommended dosing or weaning regimen for treating NOWS. Pharmacologic interventions include liquid oral morphine, liquid oral methadone, oral liquid clonidine, or oral liquid phenobarbital.

Pharmacological treatment is started dependent on a safe staffing ratio, mother-baby needs, and the facility’s capabilities. If infants reach the threshold for pharmacological treatment (as determined by clinical screening, provider and nursing comfort, and monitors), and treatment cannot be started due to unsafe staffing ratios, then infants should be transferred to a hospital that can provide them with the pharmacological treatment required.

Several scoring tools are available for measuring signs and symptoms of NOWS and are based primarily on observations from opioid withdrawal. The choice of which screening tool to utilize may vary depending on the needs of the site, community, and patient. Scoring should begin between 2 and 4 hours of life and continue every 4 hours for the duration of the observation period. It is very important to have a consistent approach to this scoring and to do so after the infant has been comforted in other cares (changing, feeding, swaddling, etc.). Parents can be educated about the scoring tool being used and may be invited to participate in scoring to the greatest extent possible. Commonly used scoring tools include:

• Modified Finnegan Scoring Tool Exit Disclaimer: You Are Leaving www.ihs.gov 
• Lipsitz Neonatal Abstinence Syndrome Scoring System

Supportive care practices, increased skin-to-skin contact, parent presence with infant, and increased breastfeeding may reduce infant dysregulation and the need for pharmacological treatment of NOWS. Rooming-in practices have shown reductions in infants requiring opioid replacement therapy and shorter duration of hospitalizations. Ideally, mothers and infants with risks for NOWS will have hospital rooms that increase opportunities for skin-to-skin contact, support frequent breastfeeding, are culturally supportive, and reduce environmental sound and light.

Training on providing trauma-informed care and awareness of cultural and tribal approaches for all staff, in addition to ongoing review of policies and procedures impacting care, improves the quality of care for mothers and substance-exposed infants during hospitalization. Leadership should demonstrate these skills through empathetic awareness of the effects of life-trauma on newly delivered mothers. This creates inpatient environments that support the best outcomes for care of mothers and infants and serves as a model for all employees working in a unit.

Planning and coordination of care should strive to model best infant care for the family including

• Environmental modifications around the infant
• Education about infant states
• Support of breastfeeding or appropriate formula feeding
• Appropriate sleeping arrangements
• Activities to support infant development
• Continuation of maternal substance use disorder care and counseling
• Preparation of the infant's home environment for safety considerations such as use of car seats, smoke detectors, and carbon monoxide detectors

Many infants who are at risk of or treated for NOWS are also at risk for potential late onset withdrawal symptoms. Families should receive education at discharge about signs and symptoms of seizures, feeding problems, excessive crying, and diarrhea and vomiting that accompany withdrawal. Families should receive contact information for the discharging hospital or primary care providers with experience in assessing late withdrawal for questions or concerns surrounding infant withdrawal.

Providers coordinating care of mothers and infants can partner with the family to identify outpatient providers and systems of care to optimize the health. Providers may consider identifying community and tribal agencies working with families to address social determinants of health including factors such as food insecurity, homelessness, poverty, and domestic violence that may affect mothers and families. Additionally, providers can partner with community and tribal programs to organize support and optimize development for infants with prenatal drug exposure. Potential agencies for collaboration may include:

• Residential care for parenting women with substance use disorders
• Early childhood programs such as public health nurses
• Infant nutrition and lactation support programs such as WIC
• Early childhood home visiting services utilizing
• Evidence-based or promising practice strategies
• Early intervention programs funded through Part C of the Individuals with Disabilities Act, tribal and state agencies
• Early Head Start and Head Start, and school systems

A comprehensive approach to the care of pregnant and parenting women, infants, and children affected by opioid use disorder starts with prenatal care and extends well into childhood. Comprehensive care for children’s health and wellness includes:

• Appropriate newborn care with early skin-to-skin opportunities for mother and infant
• Initiation of breastfeeding and ongoing lactation support, when appropriate
• Close observation of the newborn for signs of withdrawal
• Appropriate support and supplies that ease transition home
• Access to birth control and reproductive health care
• Appropriate treatment from supportive to pharmacologic until discharge of infant; and
• Established well childcare, child development, substance use disorder treatment, and well adult care through the child's 8th birthday

The role of home visitation services is also critical to establishing wrap-around care models. Involvement of home visitation programs in community response creates an opportunity to revitalize traditional cultural practices that support children and families across all treatment and service providers.