P3C075: Challenges with Oral Feeding in Infants Treated for Neonatal Abstinence Syndrome

Introduction: Neonatal Abstinence Syndrome (NAS) is a highly variable disorder primarily affecting the nervous system and gastrointestinal system. NAS is caused by in-utero exposure to opioids and is indicated by withdrawal symptoms following delivery, including slow progression to oral feeding, generalized irritability and hyper- or hypo-sensitivity to ordinary stimuli.

Case Description: Three patients diagnosed and medically treated for Neonatal Abstinence Syndrome (NAS) presented with hospital stays greater than 40 days largely due to inadequate oral intake persisting after pharmacologic treatment with morphine for withdrawal was completed. History of maternal polysubstance use involving opioids and hypertension during pregnancy was seen in all patients. Prenatal maintenance therapy differed, with women receiving methadone or buprenorphine. All children initially required formula feeding and nasogastric feeding with one patient receiving partial breast milk feeds.

Finnegan scoring for NAS symptom severity was initiated for each patient within 24 hours of birth due to substance use by mothers during pregnancy. Consecutive high scoring of symptoms on this scale in addition to positive urine drug screens in both mother and infant confirmed NAS as the diagnosis for each patient, however these patients also experienced unusually severe difficulties in achieving full oral feeds.

Common pertinent findings from physical exams performed over the days following each infant's birth included tachypnea, uncoordinated sucking reflex during feeding, hypertonicity, and excessive high-pitched crying.

Barium swallow studies confirmed normal upper gastrointestinal anatomy in all patients.

One patient achieved oral feeding while admitted, whereas the other two patients required gastrostomy tubes placed before discharge. Unique to these patients was cocaine, heroin, and tobacco use during pregnancy, with the patient not requiring gastrostomy tube being exposed to buprenorphine and barbiturates. The patient with nasogastric feedings achieved oral feeding by DOL 62, whereas one patient on gastrostomy tube feedings transitioned by DOL 166 while the other has not as of DOL 103.

Discussion: With the rising prevalence of opioid use disorder among pregnant women, NAS is an increasingly important public health concern. These cases exemplify an effect of polysubstance use during pregnancy that is uncommon but represents significant challenges for the family. It is unusual for feeding difficulties to persist for significant time after other withdrawal symptoms resolve.

Conclusion: Developing treatment plans encouraging oral feeding can reduce prolonged hospital stays and help achieve appropriate growth benchmarks. By better understanding prenatal exposure that may result in extensive difficulty with oral feeding, it will help the family and medical team better manage the feeding regimen.