Words Matter

M. Cody Smith, MD is a board-certified Pediatrician and Neonatologist with clinical, research, and quality improvement expertise in the area of Neonatal Abstinence Syndrome.

Abby Baker studied Child Development and Family Studies at West Virginia University, she has four years’ experience working in childcare and more recently has focused on substance use.

Questions:

Does an infant born exposed to illicit substances automatically receive a diagnosis of Neonatal Abstinence Syndrome?

In my experience, multiple petitions filed through the Circuit Court by the WV DHHR involving infant substance exposure mention having a Neonatal Abstinence Syndrome score, but do not always use the terminology of NAS diagnosis or mention withdrawals. Does a NAS score mean they have been diagnosed with NAS or that the scores are being monitored to determine the diagnosis? When having the diagnosis of NAS, are withdrawal symptoms definitely present?

I often see and/or hear professionals use the terminology “infant born addicted” or “the infant is addicted to substances.” I believe it’s important to use the correct verbiage if we want to see change and end stigmas. My hope is that by using the correct verbiage in my Court Appointed Special Advocate (CASA) reports that the Multidisciplinary Team (MDT) involved in child abuse and/or neglect cases will follow the lead.

Neonatologist Response:

Totally agree with using non-stigmatizing and correct language so I take the opportunity to discuss wherever I can, and am also open to receiving correction myself!

Intrauterine/fetal substance exposure is when a baby is exposed to certain substances, including psychoactive substances such as opioids, amphetamines, cocaine, and even things like caffeine, nicotine, SSRIs etc. in utero. As you can see, this can involve prescribed, non-prescribed, illicit, or even a combination of these. We don’t usually call it substance exposure for things like caffeine, nicotine, SSRI but do document those as separate exposures at least at WVU.

NAS is when a baby that had fetal exposure to certain psychoactive/neuroactive/psychotropic substances, such as opioids, develop symptoms consistent with withdrawal (increased tone, jitteriness, irritability, feeding difficulties, sleeping difficulties, etc) since they no longer have that exposure after the umbilical cord is clamped and cut (hence babies being dependent on a certain substance if they show signs of withdrawal but not addicted since they don’t have seeking behaviors, they had no choice in the matter).

NOWS, or neonatal opioid withdrawal syndrome is a newer term that is specifically describing withdrawal symptoms from opioid exposure.

There is also the often forgotten about toxicity that can be seen from these exposures that is different than withdrawal but usually I think it gets captured as NAS or NOWS (we see this sometimes with SSRIs).

From the state level, here is how they define: https://www.wvdhhr.org/birthscore/substance_Exposure_NAS.html 

There is still the issue that some still give intrauterine/fetal substance-exposed babies the diagnosis of NAS or NOWS but this is inaccurate since not all exposed babies show signs of withdrawal (many do). For instance, we are seeing more methamphetamine exposures and there is not a well-described withdrawal syndrome from this exposure. Ironically there can be signs of withdrawal to heavy caffeine or nicotine-exposed babies…so technically could call them NAS but we don’t. So different centers/providers could be documenting/coding things that way which adds to the confusion.

What’s good for the mom is good for the baby. Meaning, if being in a MAT program and having her anxiety/depression treated with SSRI helps the mom, then, that is better for the baby since the alternative is worse (recurrent illicit substance use) even though the baby may require treatment for NAS/NOWS. There are known benefits to both mother and baby if the mother is receiving medication or opioid use disorder such as improved prenatal and obstetric health outcomes, being encouraged to breastfeed, decreased likelihood of removal of custody, stronger bonding, decreased risk of preterm delivery and better birth weights and head circumference measurements. If a baby that needs to be treated for NAS doesn’t mean the mother did anything wrong; she could have remained very compliant with her treatment plan. We know there are differences in certain genes that are associated with increased risk for withdrawal in both adults and babies.

Babies exposed to opioids are routinely scored [Finnegan Scoring System and Eat Sleep Console (ESC) are the two main systems currently used] but this doesn’t necessarily mean they have NAS/NOWS. Some places only diagnose NAS/NOWS if a baby has consistently elevated scores (8s or more for WVU), which is how we interpret significant symptoms consistent with withdrawal. There is a study that looked at normal non-exposed babies where they scored up to 8 (Zimmermann-Baer et al)!

Zimmermann-Baer, U., Nötzli, U., Rentsch, K., & Bucher, H. U. (2010). Finnegan neonatal abstinence scoring system: Normal values for first 3 days and weeks 5-6 in non-addicted infants. Addiction, 105(3), 524–528. https://doi.org/10.1111/j.1360-0443.2009.02802.x