Nonpharmacologic management of NAS

Nonpharmacologic management is the standard of care for infants with symptoms of NAS.7A number of supportive measures address the signs and symptoms of NAS and ensure that infants achieve adequate sleep and nutrition for consistent weight gain and begin to integrate into a social environment.6

However, drug therapy may be indicated to manage moderate-to-severe signs of NAS and prevent such complications as fever, weight loss, and seizures if the infant does not respond to a consistent program of nonpharmacologic supportive care.2

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Infants with NAS should be placed in a dark, quiet environment (see Box, page 7).2,12,13because just a small amount of stimulation can produce a hyperactive or underactive CNS response to the external environment in these infants.2,13Handling should be slow and gentle, and care should be clustered to promote longer periods of sleep.14

Tight swaddling and positioning of infants on the back or side to mimic the fetal position can prevent hypertonic and erratic movements.14Applying pressure to the infant’s head and body can have a calming effect.14

Other techniques such as rocking and swaying motions, and rubbing instead of patting when burping, also are comforting.2,14Non-nutritive sucking with a pacifier promotes self-soothing, decreases stress, and lessens erratic and uncoordinated movements and the risk of excoriations.2,14 

Ensuring optimal nutrition for infants with NAS

Infants with NAS have higher caloric requirements due to the energy expenditure associated with increased crying and activity, decreased sleep, and calories lost with regurgitation, vomiting, and/or diarrhea.2,15The caloric needs of these infants can be as high as 150 to 250 cal/kg per day. Hyperphagia is one sign of this increased need.15

Infants with NAS should undergo frequent, small feedings (every three to four hours) to minimize hunger and allow for adequate growth.2,15Feeding with hypercaloric formula (24 calories per ounce) may be required to meet nutritional needs and facilitate weight gain.15

While somewhat controversial for infants with NAS,13breastfeeding is beneficial for both the mother and the infant and is recommended by the AAP as first-line nutrition. It enhances maternal-fetal bonding, decreases the mother’s stress response to the infant’s withdrawal symptoms, and improves the infant’s sleep patterns.13,14

Several studies have shown that infants with NAS who were breastfed or fed breast milk had lower Finnegan scores, and fewer babies required pharmacologic therapy.2,16-18In addition, breastfeeding the infant or feeding the infant breast milk may allow for more aggressive weaning from methadone, resulting in earlier discharge and a shorter length of stay in the hospital.13

Breastfeeding can effectively decrease NAS symptoms because methadone and buprenorphine are transferred to the breast milk.2,14Maternal contact while breastfeeding also plays a role in ameliorating symptoms.14Unless 
otherwise contraindicated, mothers who adhere to a supervised drug-treatment program should be encouraged to breastfeed or to express breast milk, as long as the infant continues to gain weight.2,13

The previous recommendations of the AAP advised against breastfeeding for mothers receiving maintenance doses of methadone of more than 20 mg/24 h.16However, in an updated position statement, the AAP stated that methadone was compatible with breastfeeding.18Supplementary feedings with expressed breast milk or hypercaloric formula may be required until an adequate caloric intake is reached.10

Breastfeeding, however, is contraindicated in certain cases, such as if the mother is still using illicit drugs or is HIV-positive.18In such cases, frequent feedings with high-calorie commercial infant formulas are recommended.10