Neonatal Opioid Withdrawal Syndrome, often shortened to NOWS, is a growing healthcare concern that affects thousands of newborns each year. More families and healthcare teams are facing this condition as opioid use has increased across the general population. NOWS occurs when a baby who has been exposed to opioids during pregnancy experiences withdrawal symptoms after birth. These symptoms can range from mild to severe and may affect the baby’s nervous system, digestive system, respiratory function, and overall ability to thrive.
This guide provides a clear and complete overview of NOWS, including what causes it, how to recognize symptoms, and the treatment approaches that support the health and long-term well-being of affected infants. Whether you are a parent, caregiver, healthcare provider, or simply want to understand this important topic, the following sections will help you develop a full picture of what NOWS is and how it is managed.
What Is Neonatal Opioid Withdrawal Syndrome?
Neonatal Opioid Withdrawal Syndrome is a condition that occurs when a newborn experiences withdrawal after prenatal exposure to opioids. When a pregnant person uses opioids, either prescribed or not, these substances cross the placenta and enter the baby’s bloodstream. Over time the fetus becomes dependent on the presence of the drug. After birth, when opioid exposure suddenly stops, the infant’s body reacts by producing withdrawal symptoms.
In earlier years, NOWS was often described as a version of Neonatal Abstinence Syndrome. While NAS can refer to withdrawal from many substances, NOWS specifically refers to withdrawal caused by opioids. Medical communities use the term NOWS today to highlight the clear connection to opioid exposure, making it easier to study, standardize, and treat the condition.
Opioid exposure may come from several sources, including prescription medications for pain, medications for opioid use disorder, or illicit substances. Regardless of the source, infants can experience similar symptoms that require careful medical attention.
Understanding Opioids and Prenatal Exposure
Opioids are a class of drugs that affect the brain and nervous system. They are often used to treat pain but also have a potential for dependence. Common examples include hydrocodone, oxycodone, morphine, fentanyl, heroin, and methadone. Pregnant women may use opioids for many reasons. Some take prescribed medications for chronic pain or after surgery, while others use medications such as methadone or buprenorphine as part of treatment for opioid use disorder. There are also individuals who use illicit opioids, which increases health risks further due to variability in dosage and contaminants.
When opioids enter the bloodstream, they easily cross the placenta. The developing fetus absorbs and becomes physiologically adapted to the presence of the drug. Over time, the baby’s central nervous system adjusts to functioning with opioids present. After birth, this exposure ends abruptly, leading to withdrawal symptoms.
Not every baby exposed to opioids will develop NOWS. Severity depends on several factors, including the specific drug used, how long it was taken, whether multiple substances were involved, the timing of use during pregnancy, and individual differences in metabolism. Some infants show mild symptoms while others require extensive care in a hospital.
Causes and Risk Factors of NOWS
The primary cause of NOWS is prenatal opioid exposure, but the factors influencing whether a baby develops symptoms and how severe they become can vary widely. Healthcare teams carefully review these influences to better predict and manage the condition. Below are the main causes and risk factors associated with NOWS.
1. Type of Opioid Used
Different opioids have different effects on infants. Long-acting opioids such as methadone often lead to more prolonged withdrawal symptoms, while short-acting opioids like heroin may cause symptoms that appear sooner after birth. Buprenorphine generally results in milder withdrawal than methadone, although responses vary by infant.
2. Duration and Timing of Use
Long-term use throughout pregnancy increases the likelihood of withdrawal. Babies exposed closer to the time of birth are more likely to show stronger withdrawal symptoms than those whose exposure ended earlier.
3. Polysubstance Use
Exposure to additional substances including benzodiazepines, stimulants, alcohol, or nicotine can intensify withdrawal symptoms. Nicotine use alone has been shown to increase the severity of NOWS even without other drugs present.
4. Maternal Health and Metabolism
Each pregnant body processes drugs differently. Factors such as liver function, genetics, overall nutrition, and stress can change the transfer of opioids to the baby and influence symptom severity.
5. Fetal Health and Metabolism
Just like mothers, fetuses have individual differences in how they metabolize substances. This is why two infants exposed to similar conditions during pregnancy can experience completely different withdrawal patterns.
6. Prenatal Care and Treatment Support
Consistent prenatal care is one of the strongest protective factors against severe NOWS. Pregnant individuals in recovery programs who receive medication-assisted treatment and comprehensive prenatal monitoring generally have better outcomes for themselves and their babies.
Understanding these risk factors helps healthcare providers prepare for the needs of newborns and begin treatment early when symptoms appear.
Symptoms of Neonatal Opioid Withdrawal Syndrome
Although symptoms vary between infants, NOWS typically affects several body systems. Withdrawal symptoms may appear within hours after birth or may take several days to develop. Healthcare providers observe infants closely using scoring tools to track signs of discomfort or distress. Common symptoms fall into neurological, gastrointestinal, respiratory, and autonomic categories.
Neurological Symptoms
Neurological symptoms are among the most recognizable signs of NOWS. They reflect overstimulation of the baby’s nervous system after losing the calming effect of opioids. These symptoms may include:
- Excessive crying or high-pitched crying
- Irritability and difficulty soothing
- Tremors or shaking
- Increased muscle tone
- Poor sleep patterns
- Seizures in severe cases
- Hyperactive reflexes
- Sensitivity to light, sound, and touch
Babies experiencing neurological symptoms often struggle to sleep or remain calm, making feeding and bonding more challenging.
Gastrointestinal Symptoms
Digestive system symptoms can affect the baby’s ability to gain weight and stay hydrated. These symptoms often include:
- Poor feeding or difficulty coordinating sucking and swallowing
- Vomiting
- Diarrhea or loose stools
- Poor weight gain
- Excessive sucking
- Dehydration if symptoms are severe
Managing gastrointestinal symptoms is essential to helping the baby build strength and avoid complications.
Respiratory and Autonomic Symptoms
Respiratory changes and autonomic nervous system symptoms can be serious and require prompt medical attention. They may include:
- Rapid breathing
- Nasal congestion or sneezing
- Yawning frequently
- Fever or unstable temperature
- Sweating
- Fluctuating heart rate
- Skin irritation or mottling
These symptoms reflect the body working hard to adjust after losing the presence of opioids in the system.
How Infants Are Diagnosed With NOWS
Diagnosis begins with understanding the baby’s exposure history. Medical teams gather information from maternal health records, prenatal care providers, and toxicology screenings if necessary. Diagnosis typically involves:
1. Observation and Scoring Tools
Healthcare providers use tools such as the Finnegan Neonatal Abstinence Scoring System or the Eat, Sleep, Console (ESC) model. These tools help assess the presence and severity of symptoms over time. The ESC approach, which focuses on how well the baby eats, sleeps, and consoles, is increasingly used because it emphasizes functional well-being and supports family involvement.
2. Toxicology Testing
Testing may include urine, meconium, or umbilical cord tissue to confirm opioid exposure. These tests help identify specific substances and guide treatment decisions.
3. Physical Examination
Doctors examine the baby closely for physical signs of withdrawal, such as tremors, feeding difficulty, temperature instability, or respiratory changes.
Diagnosis is not based on a single test but rather a combination of history, clinical observation, and toxicology findings.
Treatment Approaches for Neonatal Opioid Withdrawal Syndrome
Treatment for NOWS focuses on reducing withdrawal symptoms, keeping the baby safe and comfortable, and supporting healthy growth. Most treatment plans include a combination of non-pharmacologic and pharmacologic approaches. Hospitals also emphasize involving families and supporting bonding whenever possible.
Non-Pharmacologic Treatments
Non-pharmacologic care is often the first and most important step in managing NOWS. These interventions aim to support the infant’s natural ability to self-regulate and reduce stimulation that may worsen symptoms. Many babies respond so well that they never need medication.
Key components include:
1. Skin-to-Skin Contact
Placing the baby on the parent’s chest provides warmth, comfort, and regulation of breathing and heart rate. This contact reduces stress hormones, supports bonding, and has been shown to decrease the need for medication.
2. Quiet, Low-Stimulation Environments
Limiting bright lights, noise, and unnecessary handling helps the baby stay calm. Soft voices and gentle movements create an environment that supports regulation.
3. Swaddling
Swaddling provides gentle pressure that helps soothe tremors and irritability. It can improve sleep and reduce crying.
4. Feeding Support
Infants with NOWS often need extra support during feeding. Short, frequent feedings can help prevent exhaustion. Breastfeeding is encouraged when safe because it provides comfort and may reduce symptom severity. Breast milk from mothers following supervised medication treatment programs is typically safe, though certain substances or infections may require formula feeding.
5. Rooming-In
Keeping babies in the same room as their parents encourages bonding and improves outcomes. Rooming-in programs have been shown to reduce hospital stays, lower the need for medication, and improve parent confidence.
6. Soothing Techniques
Techniques such as slow rocking, gentle patting, and the use of pacifiers can help babies self-soothe when overwhelmed by withdrawal symptoms.
Non-pharmacologic care is so effective that many hospitals prioritize this approach before considering medication, unless severe symptoms appear.
Pharmacologic Treatments
Medication is used when symptoms are too severe to manage with soothing techniques alone. The goal is to stabilize the infant so that they can eat, sleep, and grow. Medications most commonly used include:
1. Morphine
Morphine is often used because it acts quickly and can be carefully adjusted to match the baby’s needs. Doses are gradually reduced over time to wean the baby off opioids safely.
2. Methadone
Methadone is a long-acting opioid that provides more stable symptom control. It is helpful for babies with persistent or severe withdrawal and is also tapered gradually.
3. Buprenorphine
Buprenorphine is gaining attention for treating NOWS because some studies show it may shorten treatment time. It is typically administered under the tongue and may be an alternative to morphine or methadone.
4. Additional Medications
If symptoms remain difficult to manage, certain medications such as clonidine or phenobarbital may be used. These help control neurological overstimulation, although they are generally used when opioid tapering alone is not enough.
The length of pharmacologic treatment varies. Some infants complete therapy within a week, while others may need several weeks depending on symptom severity and overall health.
Hospital Care and Monitoring
Infants receiving treatment for NOWS are closely monitored in the hospital. Care teams usually include neonatologists, pediatricians, nurses, social workers, and lactation consultants. Monitoring focuses on:
- Feeding patterns
- Weight gain
- Breathing and heart rate
- Neurological symptoms
- Ability to sleep
- Comfort and responsiveness
Depending on hospital resources, babies may remain in the newborn nursery or may require admission to a neonatal intensive care unit.
Parents are encouraged to be active participants in care. Education on soothing techniques, feeding support, safe sleep practices, and the baby’s unique needs helps create a strong start for families.
Potential Complications Linked to NOWS
Although many infants recover fully, NOWS can increase certain health risks if not treated promptly. Possible complications include:
1. Poor Weight Gain
Digestive symptoms can make feeding more difficult, which impacts growth.
2. Dehydration
Vomiting or diarrhea may lead to fluid loss and require medical treatment.
3. Seizures
Severe neurological stress may trigger seizures, which require immediate intervention.
4. Respiratory Issues
Some infants develop breathing irregularities that require oxygen support.
5. Long-Term Developmental Concerns
Research on long-term outcomes is ongoing. Many infants exposed to opioids in utero do well, but some studies suggest a potential risk for challenges with attention, behavior regulation, and learning. These concerns are influenced by many factors including the home environment, early interventions, and ongoing family support.
Early developmental monitoring and intervention services can help identify and address any emerging concerns.
Long-Term Outlook and Development for Infants With NOWS
Most infants who receive proper care recover well, and many grow into healthy children without long-term complications. The long-term outlook depends on several factors outside of withdrawal itself, including:
- Stable home environment
- Access to pediatric follow-up care
- Early childhood interventions such as physical or occupational therapy
- Parental recovery and support resources
- Social determinants such as housing, nutrition, and stress levels
While medical experts continue to study the long-term effects of prenatal opioid exposure, supportive parenting, stable environments, and timely medical attention remain some of the strongest predictors of healthy development. Babies are resilient, and with consistent support, many overcome the challenges of NOWS with excellent outcomes.
Prevention of Neonatal Opioid Withdrawal Syndrome
Preventing NOWS begins with supporting pregnant individuals throughout pregnancy, particularly those using opioids for any reason. Strategies for prevention include:
1. Access to Comprehensive Prenatal Care
Regular prenatal visits help healthcare teams identify opioid exposure early and provide guidance on safe treatment.
2. Medication-Assisted Treatment
For individuals with opioid use disorder, medications such as methadone or buprenorphine, combined with counseling, reduce risks for both mother and baby.
3. Mental Health and Substance Use Support
Counseling, social work support, and peer recovery programs give pregnant people a safer pathway toward recovery.
4. Educating Patients About Opioid Risks
Understanding the risks of opioid use during pregnancy helps individuals make informed decisions about their health.
5. Family Support Plans
Involving the baby’s parents and extended family in care planning can ensure a smoother transition after birth.
Reducing stigma is also essential. Pregnant individuals may avoid prenatal care out of fear of judgment or legal consequences. Compassionate, non-punitive approaches lead to far better outcomes for babies and families.
Family and Caregiver Support
Caring for a baby with NOWS can bring emotional and physical challenges. Families often need support as they learn to manage symptoms, soothe their baby, and adjust to new routines. Helpful resources may include:
- Parent support groups
- Home visiting services
- Lactation support
- Counseling and addiction treatment
- Social work services
- Early intervention programs
Hospitals often connect families with community programs before discharge to ensure continued support at home. This holistic approach benefits both the baby and the parent, strengthening the bond and promoting healthier long-term outcomes.
FAQs Neonatal Opioid Withdrawal Syndrome
1. Can Neonatal Opioid Withdrawal Syndrome occur even if the mother took opioids exactly as prescribed?
Yes. Even when a pregnant person uses opioids exactly as a doctor prescribed, the drug can still pass through the placenta and cause dependence in the baby. Safe medical use does not eliminate the possibility of NOWS.
2. How soon after birth do symptoms of NOWS typically start?
Symptoms can begin anywhere between 12 hours to 7 days after birth depending on the type of opioid used, duration of exposure, and whether the infant was exposed to multiple substances.
3. Is breastfeeding allowed for mothers receiving opioid addiction treatment?
In many cases, breastfeeding is encouraged for mothers in stable treatment programs using methadone or buprenorphine. Exceptions apply if the mother is using illicit substances, has certain infections, or is medically unstable.
4. Do all babies exposed to opioids during pregnancy need medication to treat NOWS?
No. Many babies respond well to non-medication approaches, such as swaddling, skin-to-skin contact, and rooming-in. Only a portion of infants require pharmacologic therapy.
5. How long do babies with NOWS usually stay in the hospital?
Hospital stays vary widely. Some infants can go home within a week while others may require several weeks of monitoring and treatment depending on symptom severity and medical needs.
6. Are there long-term developmental delays associated with NOWS?
Some babies experience long-term challenges, but many do not. Developmental outcomes depend on complex factors including home environment, early childhood interventions, and overall health rather than the withdrawal experience alone.
7. Can an infant be discharged home while still on medication?
Sometimes. If an infant is stable, feeding well, and gaining weight, some hospitals allow the baby to finish the medication taper at home under close medical supervision.
8. Does NOWS only happen with illicit drug use?
No. Prescription opioids, medications for opioid use disorder, and illicit opioids can all lead to NOWS. The key factor is exposure in utero, not the legal status of the drug.
9. What is the difference between NOWS and NAS?
NAS (Neonatal Abstinence Syndrome) refers to withdrawal from multiple substances including opioids, benzodiazepines, and antidepressants. NOWS refers specifically to opioid withdrawal, making it a more focused diagnosis.
10. What role do social services play in NOWS cases?
Social workers help connect families to support resources, assess home safety, provide counseling, and assist with addiction treatment or housing needs. Their involvement helps ensure the family has what they need to care for the newborn safely.
Conclusion
Neonatal Opioid Withdrawal Syndrome is a complex but treatable condition. Understanding the causes, recognizing the symptoms, and applying timely treatments are key to helping infants recover and thrive. With compassionate medical care, family support, and community resources, babies with NOWS can overcome withdrawal and begin life with a strong foundation. Awareness, prevention, and early intervention remain essential in improving outcomes for families and reducing the overall impact of opioid exposure on newborns.
Disclaimer – This guide is for educational purposes only and is not a substitute for professional medical advice. Always consult a qualified healthcare provider with any questions about medical conditions, diagnosis, or treatment.
