Neonatal Abstinence Syndrome-Learning What We Don’t Know

As the opioid epidemic continues to be a prominent public health issue, the health and well-being of thousands of children across the United States are at risk from opioid exposure and neonatal abstinence syndrome, or NAS. However, we know disturbingly little about these young victims, especially in their first year of life.   

In 2012 alone, more than 21,000 infants were born with NAS. Further exacerbating the problem are the number of pregnant women—one in five—who are prescribed and fill a prescription for opioids. And while not all are born with NAS, an increasing number of newborns are at risk. Because our knowledge is limited, we need to have a better understanding about the impact of environment on these young children, and the treatment or interventions that are needed beyond their immediate symptoms after birth. Equally as important are defining the needs of their parents and caregivers to best support these children.  

Why is the first year important? 

Research is clear on infant brain development: the brain develops at an extremely fast rate during the first several years of life, with each second producing more than a million neural connections. During this period—as well as during the prenatal period—an infant’s brain development is influenced by environmental factors, the most important being interactions between child and caregiver.  

Social-emotional and cognitive development also takes place prenatally and continues through infancy and beyond. During their first year of life, infants achieve a number of milestones, including responding to touch, smiling and laughing, recognizing familiar faces, imitating facial expressions, and expressing emotions. Environmental stressors can affect how well they achieve these milestones, and the relationship between infant and caregiver is important in mitigating the stress and improving developmental outcomes. 

Early Development and NAS 

Newborn infants with NAS experience a number of symptoms of withdrawal, including tremors, excessive crying, sleep problems, vomiting, diarrhea, poor weight gain, and even seizures. They are also irritable and have difficulty being comforted. Some treatments may include swaddling and fluids, though some infants need medication to help wean them off the opioids.  

What happens when these infants return to their home environments, however, is less clear. Even through their first year of life, they are vulnerable, and this time is especially critical for their development. Not only do we need to better understand their needs, we need to learn how to foster positive infant and caregiver relationships that will best support their development.  

Yet, do we know who is caring for these children? Many affected by the opioid epidemic may be living with their biological parents, grandparents, or another relative. However, data show a considerable increase in the number of children entering the foster care system since 2012. Specifically, the percentage of children entering due to parental drug or alcohol use jumped to 35 percent in 2016 from 26 percent in 2006.   

We also need to know more about the short-and long-term effects of prenatal opioid exposure. The research is still emergent, but a recent study found that prenatal opioid exposure combined with other stressors often associated with opioid use—such as maternal mental health, nutritional deficiencies, increased exposure to violence, and the effects of poverty—can affect developmental outcomes, both short and long term. Moreover, we also need to learn how caregivers and providers can help mitigate these negative outcomes, especially during the first year of life. 

Next Steps 

Lawmakers have proposed bills to address the opioid epidemic and to provide support to the families and children impacted by it. In November 2018, the SUPPORT for Patients and Communities Act, a bipartisan bill, was signed into law. This allows Medicaid to cover residential facilities for NAS recovery rather than NICUs in hospitals in order to foster optimal recovery. However, this trend in bipartisan support for encouraging healthy development of infants with NAS needs to continue into policies regarding interventions beyond the first few weeks of life.  

While there are programs for comprehensive family and infant support during NAS recovery, most do not extend past the immediate recovery. Many focus on services for recovery and healthy development postnatally. But these services should be expanded to support these families through the first year of life.  

Furthermore, supporting these children and families requires action from Congress, as recommended in a recent Roll Call op-ed, by Linda Smith, director of BPC’s Early Childhood Initiative and one of this post’s authors. Congress should fund longitudinal research to determine the effects of NAS on children’s development over time. Funding should also support research that examines the effects of environmental factors, including home environments and caregiver interaction, on their development. Finally, Congress should provide federal dollars towards interventions and training programs for adult caregivers and providers, so they can best support infants with prenatal opioid exposure after neonatal care.   

The crucial developmental processes that occur during the first year of life make this time a perfect opportunity to foster healthy development and mitigate the effects of prenatal opioid exposure. Research efforts along with actionable strategies focused on the first year of life are needed to protect these infants from suffering the consequences of this country’s opioid epidemic.