Neonatal opioid withdrawal syndrome

Gabrielle Arbour MD (

Dr. Arbour of CHU Sainte-Justine in Montreal, Quebec has no relevant financial relationships to disclose.

Sophie Tremblay MD (

Dr. Tremblay of Université de Montréal has no relevant financial relationships to disclose.

Elana Pinchefsky MDCM FRCPC MSc (

Dr. Pinchefsky of Centre Hospitalier Universitaire de Sainte-Justine/University of Montreal has no relevant financial relationships to disclose.

Michael V Johnston MD, editor. (

Dr. Johnston of Johns Hopkins University School of Medicine has no relevant financial relationships to disclose.

Originally released October 10, 2002; last updated January 19, 2021; expires January 19, 2024


Neonatal abstinence syndrome, including neonatal opioid withdrawal syndrome (NOWS), is a clinical diagnosis that describes the constellation of symptoms that result from the abrupt discontinuation of chronic fetal exposure to most commonly opioid use in pregnancy. Neonatal abstinence syndrome describes newborns at risk for polysubstance exposure, including opioids whereas neonatal opioid withdrawal syndrome describes opioid-only withdrawal symptoms (Sutter et al 2014). We will use the term neonatal abstinence syndrome for both opioid-only and polysubstance exposure. In this article, the authors provide a brief historical background, as well as information on the pathophysiology, clinical spectrum, and management of neonatal abstinence syndrome. The clinical or consulting neurologist will find this information useful in formulating a differential diagnosis when faced with a newborn with signs and symptoms pertaining to central nervous system/autonomic dysfunction.

Key points


• The incidence of neonatal abstinence syndrome has increased steadily over the last decade. From 2000 to 2014 there was a nearly 7-fold increase in the number of newborns born with neonatal abstinence syndrome (Winkelman et al 2018).


• Management of neonatal abstinence syndrome involves appropriately identifying infants at risk for withdrawal, along with assessment of symptoms with objective assessment tools and management of symptoms with supportive measures and with pharmacologic therapy where appropriate.


• Standardization of care, which includes standardization of scoring, use of nonpharmacologic and pharmacologic therapy, as well as strict adherence to treatment protocols, have all been shown to decrease the duration of pharmacologic therapy and length of hospital stay.

Historical note and terminology

Medical use of opium dates to Mesopotamian and Egyptian cultures. However, morphine, named after Morpheus, the Greek god of dreams, was only isolated from opium in 1806, followed by the isolation of codeine. Congenital morphinism was first described in Germany in 1875 in a newborn who had signs of opioid withdrawal at birth. The first report of successful treatment in an infant was in 1903 (Perlstein 1947).

Opioids can be divided into natural, semisynthetic, and synthetic opioids. Opium, morphine, and codeine are examples of natural opiates. Semisynthetic opioids are derived from opium and examples include heroine, hydromorphone, oxycodone, and buprenorphine. Examples of synthetic substances with morphine-like activities include meperidine, fentanyl, methadone, and propoxyphene (Hoegerman and Schnoll 1991).

Other substances such as alcohol, tobacco, benzodiazepine, and selective serotonin-reuptake inhibitors (SSRIs) can provoke symptoms similar to those occurring in neonatal abstinence syndrome.

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