For example, maternal screening for treatable problems, such as traumatic stress and depression, could be addressed by referral to evidence-based, dyadic-focused interventions, such as child-parent psychotherapy.86. Adapted from Velez M, Jansson LM. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent. If no clear in utero exposure is identified through maternal history, screening, or testing, NOWS is a diagnosis that should be used only if other potential causes of an infant’s symptoms have been evaluated fully and no other cause has been identified. In a recent study, of nearly 1000 infants with NOWS enrolled in the Tennessee Medicaid program, infants discharged from the hospital on medications had a shorter median length of hospital stay (11 vs 23 days; P < .001) but longer median lengths of treatment (60 vs 19 days; P < .001).87 Given the lack of long-term follow-up data, clinicians should avoid outpatient tapers when possible. ESC is appealing because of its ease of use and simplicity but has not been studied outside of quality improvement initiatives. Kraft et al74 found that when compared with morphine, buprenorphine used for NOWS resulted in a shorter median duration of treatment (15 vs 18 days; P < .001) and length of hospital stay (21 vs 33 days; P < .001). All pregnant women should have access to medications for OUD because they have been shown to reduce risk of overdose death and improve pregnancy outcomes. To improve the quality of clinical services for patients with ADHD, the AAP published clinical guidelines for diagnosis in … HCV-positive mothers with cracked or bleeding nipples should consider abstaining from breastfeeding. Clinical signs are weighted to reflect severity; for example, sleeping <1 hour after feeding reflects a score of 3, whereas sleeping <3 hours after feeding reflects a score of 1. American Academy of Pediatrics Committee on Drugs (2012). Vomiting and loose stools are associated with dehydration and poor weight gain and are relative indications for treatment. Onset of clinical signs of withdrawal tend to reflect the half-life of the opioid involved. For example, West Virginia has the highest reported rate of NOWS at 33.4 per 1000 hospital births, compared with Hawaii at 0.7 per 1000 hospital births.31 American Indian and Alaskan native populations have been disproportionately affected by NOWS. 2. Paregoric and deodorized tincture of opium should not be used. Nonpharmacologic treatment may include a variety of supportive care approaches. The literature to support specific nonpharmacologic approaches is sparse; however, evolving evidence suggests that effective nonpharmacologic care that engages the mother is an essential foundation to the care of an infant with opioid exposure. The opioid dependent mother and newborn dyad: non-pharmacologic care. All authors have filed conflict of interest statements with the American Academy of Pediatrics. In 2016, the Comprehensive Addiction and Recovery Act amended the Child Abuse Prevention and Treatment Act to ensure that “plans of safe care” are created for infants “being affected by substance abuse or withdrawal symptoms, or a fetal alcohol spectrum disorder.” Importantly, these plans should address the “health and substance use disorder treatment needs of the infant and affected family or caregiver.”101 Ideally, plans of safe care are well coordinated within state child welfare agencies, and planning begins before birth. NOWS occurs after chronic exposure to opioids (Table 1); therefore, exposure to opioids around the time of delivery, including opioids in an epidural or intravenous agonist and/or antagonist therapies (eg, nalbuphine, butorphanol), does not cause NOWS. This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. The pathophysiology of NAS is not completely understood. Notably, however, there remains limited evidence to inform observation periods, and excess observation could result in separation of the mother-infant dyad. Infants with opioid exposure are also at risk for adverse outcomes, including hospital readmission.87,88 Women may have to manage their own medical follow-up needs (eg, obstetrics, addiction medicine), their infant’s medical follow-up needs (eg, general pediatrician, pediatric infectious disease, lactation support), and additional services (eg, the Special Supplemental Nutrition Program for Women, Infants, and Children, early intervention, child welfare). HCV screening among pregnant women is not universal in the United States, potentially missing a window of opportunity to identify HCV in the mother-infant dyad. Among 52 of the state’s 54 neonatal care facilities, standardized pharmacologic treatment and increased use of nonpharmacologic treatment reduced both the length of treatment and the length of hospital stay from 13.4 to 12 days and from 18.3 to 17 days, respectively.109 Among a multistate, multicenter quality improvement collaborative, participating hospitals were able to reduce the median length of pharmacologic treatment from 16 to 15 days and the infant length of hospital stay from 21 to 19 days through a standardized scoring process for NOWS. Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. Trusted answers from the American Academy of Pediatrics. Of the pregnant women with a positive urine drug test result for opioids, 20% had a negative risk-based screen result.41 However, screening and testing processes are complex and have potential legal ramifications, and the AAP endorses informed consent for toxicology testing of pregnant women.14 Notably universal testing has resulted in disproportionately higher child protective services referrals for Black women compared with white women42,43 Pediatricians should be aware of and reduce institutional biases in implementing universal toxicology testing for infants, which could result in unequal consequences for mothers and infants on the basis of race, ethnicity, and/or socioeconomic status. 3. There is no gold standard definition for capturing NAS across clinical, research, and public health settings. The caregiver should know when and how to seek help if signs of infant withdrawal become unmanageable or if additional challenges present (eg, maternal depression, relapse). Discover Pediatric Collections on COVID-19 and Racism and Its Effects on Pediatric Health. For women in treatment of OUD who receive frequent toxicology testing, infant meconium and/or umbilical cord tissue testing may not be necessary. There is evidence to support the use of secondary medications for NOWS, either when initiating pharmacotherapy76 or, more commonly, as an additional medication when clinical signs continue to escalate despite pharmacotherapy with an opioid. Mothers frequently experience overwhelming feelings of guilt and anxiety in response to the dysregulated neurobehaviors associated with NOWS, and pediatricians are uniquely positioned to support mothers to manage their emotions while supporting the healing and development of their infants.64 Nonpharmacologic care should also include a thorough assessment of the hospital environment and infant handling and adaptations by the infant to each to minimize NOWS expression. Medical Necessity Guideline Clinical Performance Guideline Neonatal Resource Services Neonatal Abstinence Syndrome (NAS) Purpose: To provide guidelines for the monitoring and management of neonates with intrauterine exposure to illicit substance and for treatment of infants with neonatal abstinence syndrome (NAS). Ideally, clinicians should also assess the needs of the family, including the status of significant others and children as well as food and housing insecurity.