Treating Intrauterine Opioid Exposure in Infants Born Preterm

Treating Intrauterine Opioid Exposure in Infants Born Preterm 1024 575 Deborah L. Ungerleider, MD, FAAP

We need a protocol to evaluate and treat neonatal abstinence syndrome in preterm infants.

Neonatal abstinence syndrome (NAS) occurs when infants who are exposed to opioids in utero develop withdrawal signs and symptoms after birth.1 According to past studies, NAS occurs in 55% to 94% of infants exposed to opioids, with an increasing incidence between 2004 and 2013.1

However, despite many available and often-used protocols, there are no standardized and validated assessment tools or treatment strategies for preterm infants, particularly those who are born at 34 weeks gestation or earlier.

Preterm infants have been shown to have an increased frequency of some of the symptoms, such as hyperactive Moro reflex, tachypnea and poor feeding, but less sleep disturbance, tremors, nasal congestion, sweating and loose stools. Their total Finnegan scores have been found to be lower than those in full term infants. Past studies have proposed theories on why this is, but as of now, there are no conclusive answers.2

In a recently published study in Advances in Neonatal Care, Debra Armbruster, NNP, nurse practitioner in Neonatology at Nationwide Children’s Hospital, and Pavel Prusakov, PharmD, newborn intensive care unit (NICU) clinical pharmacist at Nationwide Children’s, along with their colleagues, investigated current practices in the care of preterm infants with intrauterine opioid exposure in NICUs in the United States and Canada, focusing on preterm infants born at less than 34 weeks gestational age. Their study highlighted the variability in care of preterm infants with NAS, demonstrating the need for both a validated assessment tool and improved treatment protocols for these infants.2

“Historically, NICU’s have used term newborn tools,” says Dr. Armbruster , who is also the first author of the recent publication. “This was aimed as a first step to identify and develop protocols specifically for preemies.”

“We wanted to know what other people are using and, going from there, trying to make sure we’re minimizing harm and maximizing the benefit,” adds Dr. Prusakov, who is the senior author of the publication.

They found that 50% of NICUs used the modified Finnegan scoring tool for both term and preterm infants. Additionally, most NICUs used maternal urine screening as their main screening test, followed by maternal history, meconium toxicology, urine toxicology and umbilical cord toxicology if the preterm infant had symptoms.2 However, maternal urine screens are not always accurate, and the more accurate testing strategies (umbilical cord toxicology and meconium toxicology [the gold standard]) have logistical issues. Although Dr Armbruster reports that both are done regularly at Nationwide Children’s, access to external laboratories for both and, for meconium, the need to collect all of the meconium over several days, then store it, and prepare the specimen, make it difficult for many other children’s hospitals.2

The authors also say that the biggest challenge to treating NAS in infants born preterm is identifying which babies require pharmacological treatment.2 Protocols for managing infants with NAS, irrespective of gestational age, were used in two-thirds of the study sample; one-third did not medicate infants who were less than 34 weeks of gestational age.2 This might be secondary to the difference in symptoms between preterm and term infants, in addition to the lack of knowledge of dosing and potential impacts on preterm infants. Drs. Armbruster and Prusakov concurred that preterm infants may need intermittent medication for a shorter course.

“This study highlights great variability in treating preterm infants who have NAS, and it supports the need for a validated assessment tool, as well as a better understanding of the appropriate treatment strategies for preterm infants born at less than 34 weeks of gestational age who have NAS,” says Dr. Prusakov. “Understanding and improving treatment for babies born preterm with NAS will help us to address, and hopefully mitigate, any long-term neurodevelopmental outcomes of the intrauterine opioid exposure.”2



  1. Wexelblatt SL, McAllister JM, Nathan AT, Hall ES. Opioid neonatal abstinence syndrome: an overview. Clinical Pharmacology & Therapeutics. 2018 June;103(6):979-981.
  2. Armbruster D, Schwirian C, Mosier A, Tam WM, Prusakov P. Neonatal abstinence syndrome and preterm infants: a look at current practice. Advances in Neonatal Care. 2021 April;21(2):107-114.

Image credit: Adobe Stock

About the author

Deborah Ungerleider, MD, FAAP, earned her medical degree from the University of Medicine and Dentistry of New Jersey (UMDNJ)/Rutgers Medical School in Piscataway, NJ in 1985, following earning a BA in biology at Barnard College/Columbia University. She went on to complete a pediatric residency and chief residency at New York University Medical Center/Bellevue Hospital. She is an experienced pediatrician with more than 30 years of working in private pediatric offices and being on staff at several community hospitals. She is board-certified in Pediatrics and is a fellow of the American Academy of Pediatrics.

Her medical writing and editing experience has included writing educational articles for her patients, in addition to editing medical journal articles for various specialty journals. Dr. Ungerleider now works as a freelance medical writer and editor, using her medical expertise, as well as her organizational and writing skills to assist clients with medical communication projects directed at both clinicians and lay audiences.