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Neonatal Opioid Withdrawal Syndrome (NOWS): What Families Need to Know

Across the United States, opioid use is on the rise. This has led to more pregnant women with opioid use disorder (OUD). Because of this, more infants are being born with symptoms of opioid withdrawal. This condition is called neonatal opioid withdrawal syndrome (NOWS).

What families should know about NOWS

The most important thing to know is that NOWS is treatable. If you're pregnant and have opioid use disorder, consider asking your doctor about medication like methadone or buprenorphine to treat it. Research has shown that treating OUD with medication improves how well babies do if they were exposed to opioids during pregnancy.

Your healthcare provider may ask you some questions before the baby is born. This helps them know what to expect. These questions might include:

  • What medications did you take during pregnancy?

  • Is there a possibility you have an infection such as HIV or hepatitis C virus (HCV)?

  • What is your living situation?

  • How is your emotional well-being?

  • Have you experienced domestic violence or other kinds of trauma?

It's important to be as honest as you can. This helps your healthcare provider decide on the best treatment plan for both you and your baby.

NOWS signs and symptoms

The signs of NOWS that the baby shows, how severe they are, and how long they last depend on several factors, including:

  • The mother's metabolism

  • The type of opioids she used (prescription and nonprescription)

  • How long the baby was exposed

  • If nicotine and/or other substances were also used

Both prescription and nonprescription opioid medications can cause signs and symptoms of NOWS. This includes the medications used to treat OUD. These signs begin in the first few days after birth and can include:

  • High-pitched crying and irritability

  • Tremors and uncontrolled movements

  • Difficulty sleeping and fragmented sleep

  • Loose stool and diarrhea

  • Vomiting

  • Sweating and fever

  • Frequent yawning and sneezing

What is the difference between NOWS and Neonatal Abstinence Syndrome (NAS)?

NOWS and NAS are similar terms. They both describe withdrawal symptoms in newborns. The difference is that NAS can be caused by prenatal exposure to any of a variety of substances, including opioids. NOWS is only caused by opioids, though other substances may hav​​e been used too.

NOWS treatment

Hospital teams use a variety of tools to diagnose, assess, and manage NOWS. Your baby will need to stay in the hospital for up to 7 days. If your baby needs treatment with a medication, they may stay for a few weeks.

Many babies with NOWS don't need to be in the neonatal intensive care unit (NICU). If possible, it's better for moms to “room-in" with their babies. This supports mom-baby bonding and breastfeeding. It also engages you and other caregivers in caring for your baby right away. You can all learn to read and respond to your baby's signs of withdrawal.

Managing NOWS symptoms is different for each baby. Some babies feel better when they're swaddled. Others can be soothed more easily in a dark room with skin-to-skin cuddling. In general, your baby's room should be quiet, with dimmed lights. There should also be limited visitors. This all helps lessen the discomfort your baby experiences from withdrawal.

Some newborns may need medication like morphine to manage severe NOWS symptoms. Medication is recommended if your baby has trouble feeding, is losing weight, and has loose stools.

Parents can find their baby's withdrawal symptoms challenging to manage. Remember that pediatricians, nurses, and other staff can coach and support you if you feel overwhelmed.


In general, women who are taking medications for OUD treatment and are in stable recovery can safely breastfeed. The AAP recommends breastfeeding as the sole source of nutrition for your baby for about 6 months and can be continued for as long as both mother and baby desire it.

Breastfeeding can help reduce your baby's withdrawal symptoms. It can also shorten their hospital stay. You can get personal breastfeeding recommendations while you're at the hospital. Your baby's pediatrician can help too.

Going home

Becoming a parent is hard. The hospital team knows that going from the hospital to home is an incredibly challenging time, especially for new moms with OUD. Everyone who has helped care for mom and baby during the hospital stay can help in planning for a safe discharge. They will work with your family to make sure that:

  • You are supported.

  • You know how to care for your baby.

  • You know who to reach out to if you have concerns.

  • You know what the next steps are in your baby's medical care.

Medical care

Both moms and babies need additional medical care after discharge. Your baby should be seen by a pediatrician in the first 48 hours after discharge. It's important to remember that while NOWS is treatable, some babies may have signs of withdrawal for a few months.

Your baby will also need to have regular checkups with their pediatrician to see how they're developing and get regular care, like vaccines. If your baby was exposed to hepatitis C, early testing is also important.

The mother has specific healthcare needs too. She'll need to see a gynecologist and/or her primary care provider, the provider that prescribes her medication for OUD, and an addiction specialist.

Moms with OUD are encouraged to continue medication treatment for OUD after the baby is born. Continuing medication treatment and counseling reduces the risk of returning to opioid use, or relapse. It also reduces the risk of the possibility of overdose.

Be sure to reach out for support if you are concerned about OUD symptoms that flare up or if you feel overwhelmed caring for your baby.

The child welfare system

Before delivery or during your hospital stay, your obstetrician or pediatrician may mention that they need to contact the child welfare agency. States have different laws and regulations for this. In some states, hospitals are required to report substance exposure to child protective services (CPS).

Child welfare agencies can play an important role in designing a plan of safe care. They can also team up with pediatricians and other medical staff, health, and community services to help your family access the recovery and treatment services you need.

Remember, your pediatrician is your partner during treatment and recovery. They can advocate for and support your family.

More information

Last Updated
American Academy of Pediatrics (Copyright © 2021)
The information contained on this Web site should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.
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