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For a subset of infants with NAS, non-pharmacologic therapy 14 alone is insufficient to prevent significant morbidity, including the inability to sleep, feed, failure to thrive and seizures. Non-pharmacologic therapy should be the standard of care for all opioid exposed infants, regardless of the additional need for medication therapy required by some infants. Most, if not all, opioid exposed infants experience NAS to some degree 13.
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Symptoms of dysregulation and autonomic instability occur with variable severity in different infants, as well as in the same infant over the course of time. Duration of symptoms is also variable, and infants can exhibit subacute NAS symptoms for many weeks to months after birth 12. Presenting symptoms of the disorder occur generally within the first 48–72 hours after birth, but some infants can present with significant symptoms of NAS up to 4 weeks of age 11. Most researchers agree that NAS severity is not related to maternal methadone dose or cumulative methadone exposure in utero 9, 10. NAS occurs with notable variability, and the variability in NAS expression is not well understood currently. It is important to recognize that many opioid exposed infants are in actuality poly-drug exposed, and the contributory effect of other licit and illicit substances, including alcohol and nicotine, to the signs and symptoms of physiologic and behavioral dysregulation after birth must be considered, but is beyond the scope of this discussion. Any opioid used by the mother during pregnancy can produce NAS in the infant a list of some opioids that can cause this syndrome in exposed infants appears in Table 1. Maternal opioid and methadone use during gestation predisposes the infant to signs and symptoms of central and autonomic nervous system regulatory dysfunction, traditionally defined as Neonatal Abstinence Syndrome (NAS), which frequently results in significant morbidity and prolonged hospital stays.
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Buprenorphine may offer advantages, particularly for the neonate in the form of reduced severity of NAS, for this population 8, but has not been approved for use during pregnancy in the US. Buprenorphine, a partial opioid agonist, is being used more commonly as an alternative to methadone for treatment of opioid dependency during pregnancy. Methadone maintenance offers major advantages for opioid dependent pregnant women, including diminished illicit opioid use 5, 6, improved attention to maternal medical conditions and nutrition and the creation of a more stable postnatal environment for the infant 7. Methadone is currently the only accepted pharmacotherapy for opioid dependence during pregnancy in the U.S., and it has become the standard of care for this population. Illicit opioid use is found in 0.1% of all pregnant women in the US 1, and prescription opioid abuse is an increasing problem due to several reasons, including regulatory shortcomings and lack of public education 2 – 4. The problem of illicit drug use and abuse of licit drugs among women of child bearing age continues to be a public health concern in the U.S.