What Is Neonatal Opioid Withdrawal Syndrome?

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What Is Neonatal Opioid Withdrawal Syndrome?

Neonatal Opioid Withdrawal Syndrome

Neonatal Opioid Withdrawal Syndrome (NOWS) refers to the withdrawal symptoms that newborns experience at birth when they’ve been exposed to opioids in the womb. When a birthing person uses opioids during pregnancy, the drugs can cross the placenta and affect infants. Babies are then born dependent on these drugs and experience withdrawal symptoms.

As the opioid crisis in America has worsened, more and more infants are born to parents who experience opioid addiction. According to the Centers for Disease Control and Prevention (CDC), the number of birthing parents experiencing opioid addiction rose by 131% between 2010 and 2017. In 2019, 7% of pregnant people reported using prescription opioid pain relievers, and 1 in 5 of these parents reported misusing opioids.

Thankfully, as devastating as NOWS can be to infants, it is treatable with both medical and non-medical techniques. Read on for what to know about NOWS, including symptoms, causes, treatments, and coping.

The term Neonatal Abstinence Syndrome (NAS) is often used interchangeably with Neonatal Opioid Withdrawal Syndrome (NOWS), and they both describe withdrawal symptoms that infants experience after being exposed to illicit substances. However, NOWS specifically describes infants born addicted to opioids, whereas NAS includes other drugs, and may or not not include opioids.

Symptoms of Neonatal Opioid Withdrawal Syndrome

Every infant who was exposed to opioids during pregnancy will experience withdrawal symptoms a little differently. Factors that may influence an infant’s symptoms include:

  • Characteristics of the birthing parent’s metabolism
  • The particular types of opioids used during pregnancy, including whether they were prescription or non-prescription
  • The length that the infant was exposed to the opioid
  • What other substances the birthing parent consumed, including other illicit substances and/or nicotine

The symptoms of NOWS are varied and many differ in intensity from one infant from another. The most common symptoms to watch for include:

  • Irritability and agitation
  • Crying, usually high-pitching screaming
  • Trouble sleeping and settling
  • Hyperthermia (high body temperature)
  • Sweating
  • Diarrhea
  • Nasal congestion and sneezing
  • Tremors
  • Higher muscle tone than most babies
  • Rashes and other skin issues

NOWS may also cause feeding or growth issues in some babies. This is usually addressed with high calorie feedings and/or shorter, more frequent feeding sessions.

In additions to withdrawal symptoms, being exposed to opioids in the womb can cause some immediate and longer term health effects, such as:

  • Low birth weight
  • Possible birth defects
  • Smaller than normal head circumference
  • Preterm birth
  • Cognitive issues throughout life
  • Developmental issues during childhood

Diagnosis of Neonatal Opioid Withdrawal Syndrome

In order for an infant to be diagnosed with NOWS, the birthing parent would need to share information about their drug use during pregnancy. Usually, if a healthcare provider suspects NOWS, they will ask the infant’s birthing parent a series of questions about drug use during pregnancy, including what types of drugs were used and with what frequency.

There are certain tests that infants may undergo if it’s suspected that they are experiencing NOWS. These may include:

  • Screening and evaluation of the infant’s urine and bowel movements, and possibly the infant’s umbilical cord
  • Use of an assessment system that gives points to different drug withdrawal symptoms and their intensity
  • Evaluation with a test called ESC (eat, sleep, console)

Causes of Neonatal Opioid Withdrawal Syndrome

NOWS happens when infants are exposed to opioids taken by their birthing parent during pregnancy. These drugs are able to cross the placenta and enter the infant’s bloodstream. The infant becomes dependent on these drugs. When they are born, they are suddenly cut off from the drugs, and experience withdrawal symptoms.

Opioids represent a category of drugs called narcotics. Some common examples of opioids include:

  • Codeine
  • Oxycodone
  • Morphine
  • Heroin
  • Meperidine
  • Fentanyl

Some babies may be more prone to the effects of opioid exposure during pregnancy, and more susceptible to withdrawal effects. Genetic and epigenetic factors may make certain infants more vulnerable to the effects of opioid withdrawal.

Treatment for Neonatal Opioid Withdrawal Syndrome

There is no one agreed-upon treatment for NOWS. Treatment plans will vary based on an infant’s symptoms, the infant’s overall health, and a parent’s ability to care for their baby. Treatment can last anywhere from 7 days to up to 6 months. Whatever the case, babies who are diagnosed with NOWS will usually need to stay in the hospital for at least one week after birth.

Medical Treatments

Some symptoms of NOWS can be managed with non-medical care targeted at soothing a baby and calming their symptoms. But some babies may need medication to help them cope, especially if their withdrawal symptoms are interfering with feeding, growth, or if they are having diarrhea.

In these cases, babies may be given medication such as morphine. Babies may also be treated with methadone, buprenorphine or clonidine.

Non-Medical Treatments

Most babies can “room in” with their parents, even while experiencing NOWS, and during this time, babies may respond well to soothing techniques that quiet their nervous system and calm them. Different babies will respond to various techniques differently. Some of the most common techniques used include swaddling, dimming the lights, skin-to-skin time, and rocking.

Coping With Neonatal Opioid Withdrawal Syndrome

Even after a baby with NOWS is released from the hospital, symptoms may persist and the baby will likely need ongoing care. Similarly, the baby’s birthing parent will need to be cared for and monitored, so that their Opioid Use Disorder (OUD) is well-managed as they care for their baby.

Babies will likely need to visit their pediatrician within a day or two after release from the hospital. After that, regular visits to the pediatrician will be necessary to continue treatment, to check growth and development, and for general health and wellness.

Birthing parents will need to make sure that their OUD is being properly treated. This may involve substance abuse counseling, support groups, and taking prescribed medications (such as methadone or buprenorphine). Depending on the laws in each state, local child welfare chapters may need to be contacted, and babies and their parents may need to be monitored for some time.

If you are a parent of a baby who is dealing with NOWS, you should know that you are not alone, and that help is out there for you. In order to properly care for your baby, and not risk relapsing, it’s vital that you stay in touch with your care team. They are there to support you.

Remember: you need to make taking care of yourself a priority in order to be the best parent you can be for your child.

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7 Sources
Verywell Mind uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Weller AE, Crist RC, Reiner BC, Doyle GA, Berrettini WH. Neonatal Opioid Withdrawal Syndrome (NOWS): A Transgenerational Echo of the Opioid Crisis. Cold Spring Harbor Perspectives in Medicine. 2021;11(3):a039669. doi:10.1101/cshperspect.a039669

  2. Centers for Disease Control and Prevention. About Opioid Use During Pregnancy.

  3. American Academy of Pediatrics. Neonatal Opioid Withdrawal Syndrome (NOWS): What Families Need to Know.

  4. American Academy of Pediatrics. Neonatal Opioid Withdrawal Syndrome (NOWS): What Families Need to Know.

  5. Nemours Children's Health. Neonatal Abstinence Syndrome (NAS).

  6. Devlin, L.A., Young, L.W., Kraft, W.K. et al. Neonatal opioid withdrawal syndrome: a review of the science and a look toward the use of buprenorphine for affected infants. Journal of Perinatology. 2022;42:300–306. doi:10.1038/s41372-021-01206-3

  7. American Academy of Pediatrics. Neonatal Opioid Withdrawal Syndrome (NOWS): What Families Need to Know.

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