Neonatal abstinence syndrome: a case series from Colombo-Sri Lanka

Abstract

Introduction

Neonatal Abstinence Syndrome (NAS) is an escalating global health challenge driven by rising illicit drug use during pregnancy, a condition that remains underreported due to the non-specificity of symptoms and limited access to toxicological testing. This case series explores the clinical complexities and systemic hurdles in managing NAS within a resource-limited setting.

Case presentation

We reviewed 23 neonates clinically diagnosed with NAS at two level III neonatal care centres in Sri Lanka over 18 months. A majority of mothers were aged below 25 years (70%), 86.9% disclosed substance use upon admission for delivery, and all (100%) had poor antenatal care. Twenty-one out of 23 neonates were symptomatic and neurological manifestations, including irritability and tremors, were present in all symptomatic neonates. Management involved the Modified Finnegan Score to guide therapy, with 17 infants requiring pharmacological intervention, primarily oral morphine.

Conclusion

This case series reports the alarming fact of substance abuse among women under 25 years. It also highlights the challenges of management of neonatal abstinence syndrome, which imposes a profound strain on the healthcare system due to prolonged hospitalisations in high-cost tertiary units and the complex physiological demands of withdrawal including low birth weight and delayed weight gain.

Introduction

Neonatal abstinence syndrome (NAS) is a collection of symptoms and signs manifested following delivery of a neonate, due to the abrupt cessation of an illicit or prescribed drug used/ abused during pregnancy [1]. Incidence is increasing due to the rising trend of chronic maternal illicit drug abuse, both in developed and developing countries [1]. It is highly underdiagnosed and underreported in South Asia, likely due to the non-specific nature of symptoms. However, it places a huge burden on the health system of a country owing to the need for prolonged hospital stay, extensive investigations to exclude differential diagnoses, assisted feeding and probation care due to adverse maternal behaviours, and longer follow-up for yet unknown neuro-developmental and psychological outcomes [2]. This case series presents the clinical complexities and challenges of managing NAS in a resource-limited setting.

Case series

We report 23 neonates clinically diagnosed and managed at two level III neonatal units (providing advanced and specialised intensive care for all high-risk neonates including extreme prematurity) in the Western province (De Soysa Hospital for Women and Colombo North Teaching Hospital) of Sri Lanka over an 18-month period. Mothers of all 23 neonates had a current or history of illicit substance use at the time of delivery. However, only two mothers were identified prior to conception through community screening and had been started on early rehabilitation. The majority (86.9%) of mothers reported substance use (heroin or polysubstance) upon questioning by healthcare personnel on admission. Three mothers denied the use but were identified through positive urine toxicology.

The age range of mothers was 18–34 years, with 70% of them aged under 25 years. Antenatal follow-up was significantly poor among all mothers of neonates with NAS; 15 (65%) had incomplete follow-up, while 8 (35%) had no antenatal care. Consequently, the period of gestation (POG) was uncertain in 13 (57%) cases.

The lack of antenatal care contributed to several birth complications. Five deliveries occurred outside of a healthcare facility. 12/23 (52%) of the babies were low birth weight with birth weight < 2.5 kg. Due to poor follow-up, fetal growth restriction was largely undocumented in antenatal records. One baby was delivered through thin meconium, and another required invasive ventilation due to a postnatally diagnosed congenital cardiac condition (Table 1).

Table 1.

Characteristics of the neonates and urine toxicology

	Maturity POG, in weeks+days or clinically assessed maturity (CM) in weeks	Apgar scores (at 1, 5, and 10 min)	Birth weight (kg)	Urine toxicology screening result	Additional perinatal or postnatal complications
Case 1	36	9,10,10	2.15	Morphine	Low birth weight
Case 2	37	8,10,10	2.54	Not available	None
Case 3	Uncertain-CM-33	Unknown	2.12	Not available	Low birth weight
Case 4	Uncertain-CM-38	Unknown	2.44	Not available	Low birth weight
Case 5	40 + 1	9,10,10	3.08	Morphine	None
Case 6	Uncertain-CM-37	7,8,10	2.7	Morphine	None
Case 7	Uncertain-CM- 38	8,9,10	3.15	Morphine and barbiturates	None
Case 8	Uncertain-CM-40+	9,9,10	2.0	Morphine	Born through Meconium stained liquor, Low birth weight
Case 9	36 + 4	Unknown	1.925	Not available	Low birth weight
Case 10	Uncertain-CM-34	Unknown	1.79	Morphine	Low birth weight
Case 11	Uncertain-CM-32	8,10,10	1.23	Morphine	Very low birth weight
Case 12	Uncertain-CM-40	1,10,10	3.15	Morphine and barbiturates	None
Case 13	37 + 4	Unknown	2.145	Methamphetamine	Low birth weight
Case 14	Uncertain-CM- 38	9,10,10	2.63	Methamphetamine	None
Case 15	Uncertain-CM- 38	9,10,10	3.23	Morphine	None
Case 16	35 + 6	9,10,10	2.665	Morphine	None
Case 17	37 + 5	9,10,10	2.6	Morphine, amphetamine, methamphetamine	None
Case 18	Uncertain-CM-37	9,10,10	2.34	Morphine, amphetamine, methamphetamine	Low birth weight
Case 19	37 + 3	7,9,10	3.055	Negative	None
Case 20	37	7,9,10	2.556	Not available	None
Case 21	Uncertain-CM-37	9,10,10	2.28	Morphine, amphetamine, and methamphetamine	Ventilated due to critical congenital heart disease and expired on day 28, Low birth weight
Case 22	38 + 4	8,10,10	2.25	Barbiturates	Low birth weight
Case 23	Uncertain-CM-38	7,9,10	2.05	Morphine, amphetamine, and methamphetamine	Low birth weight

Diagnosis was confirmed through a combination of maternal history, clinical symptoms, and toxicological screening. Seventeen (74%) had positive urine toxicology screening; of them, eight were positive for morphine alone, two were positive for methamphetamine alone, one was positive for barbiturates alone, and six were identified as polysubstance users (Table 1).

Twenty-one (91%) neonates manifested clinical symptoms within the first 72h of life. The most frequent symptoms were jitteriness/tremors (n = 21), irritability (n = 18), excessive high-pitched cry (n = 16), and hypertonia (n = 14). Eight neonates had loose stools. Differential diagnoses such as hypoglycaemia, hypocalcaemia, hypomagnesaemia, and congenital hyperthyroidism were excluded following biochemical investigations. Ultrasound scan brain excluded intraventricular haemorrhage in all.

Pharmacological intervention was guided by the modified Finnegan scoring system. Scores of ≥ 8 on > 2 occasions over a 4-6-hour period was the indication for initiation of pharmacological management [3]. Fourteen (61%) babies were managed with oral morphine (Table 2). Case 12 required add-on therapy with oral phenobarbitone due to severe symptoms, while Case 22 was treated exclusively with oral phenobarbitone for barbiturate withdrawal. Four babies with mild symptoms (cumulative Finnegan score < 24) did not require pharmacological treatment and were managed with observation.

Table 2.

Summary of the pharmacological management

	Onset of symptoms	Maximum Finnegan score	Drugs used for treatment (oral)	Maximum doses used with frequency	Weaning attempted/ started on	Duration of treatment	Rebound symptoms needing escalation of treatment
Case 1	D3	10 on D4	Morphine	0.05 mg/kg×q4hr	D9	20 days	No
Case 2	D2	12 on D2	Morphine	0.05 mg/kg×q4hr	D5, D14	24 days	Yes
Case 3	D2	11 on D3	Morphine	0.08 mg/kg×q4hr	D8	18 days	No
Case 4	D2	14 on D3	Morphine	0.05 mg/kg×q4hr	D4	7 days	No
Case 5	D3	12 on D3	Morphine	0.05 mg/kg×q4hr	D10, D15	35 days	Yes
Case 6	D3	10 on D7	Morphine	0.08 mg/kg×q4hr	D9, D24	48 days	Yes
Case 7	D2	12 on D8	Morphine	0.08 mg/kg×q4hr	D20	30 days	No
Case 8	D1	10 on D3	Morphine	0.05 mg/kg×q4hr	D10	25 days	No
Case 9	D2	09 on D2	Morphine	0.05 mg/kg×q4hr	D4	12 days	No
Case 10	D1	07 on D1	None	-	-	Observed for 5days	-
Case 11	D1	10 on D2	Morphine	0.05 mg/kg×q4hr	D4	11 days	No
Case 12	D1	14 on D1	Morphine phenobarbitone	Morphine-0.1 mg/kg×q4hr Phenobarbitone-2.5 mg/kg×q12hr	D10, D20	Morphine-31 days; Phenobarbitone-25 days; total 48 days	Yes
Case 13	D3	02 on D3	None	None	-	Observed for 5 days	-
Case 14	D2	02 on D2	None	None	-	Observed for 5 days	-
Case 15	D1	12 on D2	Morphine	0.15 mg/kg×q6hr	D19, D26	39 days	Yes
Case 16	D3	11 on D8	Morphine	0.15 mg/kg×q6hr	D18	35 days	No
Case 17	D3	12 on D4	Morphine	0.1 mg/kg×q6hr	D11	22 days	No
Case 18	D3	04 on D4	None	None	-	Observed for 5 days	-
Case 19	None	0	None	None	-	Observed for 5 days	-
Case 20	None	0	None	None	-	Observed for 5 days	-
Case 21	D2	08 on D2	Morphine	Sedation doses during ventilation 20microgrms/kg/hour	D8 and D12	21 days IV followed by oral weaning doses	Yes
Case 22	D1	14 on D2	Phenobarbitone	Phenobarbitone-2.5 mg/kg×q12hr	D10	Phenobarbitone- 8 days	No
Case 23	D3	12 on D3	Morphine	0.05 mg/kg×q4hr	D12	Morphine 15 days	No

D-Day of life, every 4hourly-q4hr, every 6hourly-q6hr, every12hourly-q12hr

Three cases had high C-reactive protein (CRP) suggestive of sepsis; however, blood culture was negative in all. Case 18 developed severe necrotising enterocolitis with a CRP of 322 mg/L on Day 16. One infant had bilateral grade I periventricular leukomalacia in the brain ultrasonography, but was neurologically normal at discharge. Case 21 expired due to critical congenital heart disease on day 28 of life.

Establishing adequate nutrition was a significant hurdle. Fifteen (65%) babies had poor weight gain, requiring more than the standard 14 days to regain their birth weight. Despite adequate breastfeeding support, seven infants required formula feeding from the beginning due to maternal refusal or the mother’s absconding. Of the others, seven infants were exclusively breastfed, and eight were on mixed breast- and formula-feeding during their hospital stay (Table 3).

Table 3.

Summary of the details on feeding and discharge plan

	Mode of feeding	Maximum weight loss	Birthweight regained by	Age at discharge/ demise	Decision on caregiver given following case conference or by the Children’s Magistrate Courts
Case1	BF	16.4%	D21	D28	Prospected guardian
Case2	Mixed	8.6%	D22	D133	Parents under supervision
Case3	Mixed	13.7%	D30	D21	Parents under observation
Case4	AF	0%	No loss	D49	Probation care
Case5	AF	12.8%	D35	D50	Probation care
Case6	AF	14.4%	D18	D90	Probation care
Case7	AF	10.4%	D33	D85	Probation care
Case8	AF	8.5%	D19	D28	Prospected guardian
Case9	BF	8.8%	D20	D14	Parents under supervision
Case10	BF	9%	D6	D6	Prospected guardian
Case 11	BF	10%	D14	D15	Prospected guardian
Case 12	BF	16.3%	D28	D85	Parents under supervision
Case 13	BF	3%	D04	D22	Parents under supervision
Case 14	Mixed to AF	9.2%	D20	D27	Probation care
Case 15	Mixed to AF	8.2%	D16	D42	Probation care
Case 16	Mixed to AF	6.9%	D13	D47	Probation care
Case 17	Mixed to AF	15.5%	D03	D48	Probation care
Case 18	AF	0%	No loss	D29	Probation care
Case 19	Mixed to AF	15.5%	D24	D32	Probation care
Case 20	Mixed to AF	3.8%	D12	D57	Probation care
Case 21	Mixed	10.4%	D16	D28 (expired)	Expired due to critical congenital heart disease
Case 22	BF	8.2%	D18	D24	Parent under supervision
Case 23	AF	7.6%	D22	D46	Probation care

BF Breastfeeding, AFArtificial formula, D day of life

The mean duration of pharmacological treatment among infants in the breastfed group was 14.1 (SD ± 16.5) days compared with 22.9 (SD ± 16.7) days in the formula-fed group. Infants receiving breast milk required a shorter duration of pharmacological treatment on average compared to the formula-fed group. The mean peak Finnegan score was lower in the breastfed group (9.14 ± 4.18) compared with the mixed-fed group (10.57 ± 3.21).

The social complexity of these cases required intensive legal and social intervention. Only six (26%) babies were discharged to their parents under supervision. Twelve (52%) babies were handed over to probation care following legal proceedings. Even when mothers were rehabilitated (Cases 19 and 20), guardianship was often granted to probation due to a lack of financial support or permanent residence.

Discussion

NAS occurs in approximately 55–94% of neonates exposed to opioids and less commonly to sedatives, antidepressants, alcohol and barbiturates in utero [4]. Global data shows a steady increase in the incidence of NAS, and our case series confirmed a similar trend in a Sri Lankan setting, predominantly involving opioids (morphine/ heroin) and polysubstance. The demographic profile in this series, where 70% of mothers were under 25 years old, highlights the alarming fact of substance abuse among young women of childbearing age.

The economic and health sector burden of NAS is profound. In our study, the average hospital stay for babies with NAS was significantly prolonged; for instance, Case 12 remained hospitalised for 85 days, and Case 2 for 133 days. Such extended stays in level III neonatal units, which are high-cost settings, pose an immense strain on the healthcare economy, especially in resource-limited settings.

NAS is a complex multisystem disorder resulting from neuro-behavioural dysregulation within the central and autonomic nervous systems [1]. In this series, 100% of symptomatic cases presented with neurological manifestations, including irritability, high-pitched crying, jitteriness and hypertonia. The physiological toll on the neonate is evident in their metabolic demands. Withdrawal symptoms such as hyperthermia, tachypnoea, and excessive crying lead to high energy expenditure [5]. This explains why 65% of the infants in this series took more than 14 days to regain their birth weight despite being on full feeds (a normal healthy baby is expected to regain their birth weight by 14 days following a physiological weight loss). Furthermore, 52% of babies were born with low birth weight, complicating their initial stabilization.

The diagnosis of NAS remains primarily clinical, relying on maternal history and the emergence of withdrawal signs [6]. However, our series highlights a critical gap where 87% of mothers only disclosed substance use upon direct questioning on admission, and three mothers denied use entirely despite positive toxicology. While amniotic fluid testing offers a wider detection window, neonatal urine toxicology remains the standard due to its ease of collection [7]. In this series, 17 neonates underwent Enzyme Immuno-Assay at the National Narcotic Laboratory. The detection of methamphetamine and barbiturates alongside morphine confirms that polysubstance abuse is a significant factor in 65% of cases, which typically results in more severe and prolonged withdrawal.

The Modified Finnegan Score was utilised in this series to tailor treatment. Universal recommendations advocate for non-pharmacological management as the first-line approach [3, 7, 8]. This includes tender loving care, skin-to-skin contact, and minimising environmental stimuli (light, sound, and handling) [3]. However, implementing this in busy local neonatal units is challenging due to infrastructure and staffing constraints. Breastfeeding was encouraged in 15 cases to reduce withdrawal symptoms and shorten hospital stays. However, maternal absconding or refusal led to 7 infants being started on formula feeds.

Morphine remained the first-line treatment for the 14 babies requiring intervention. Phenobarbitone is used effectively as an adjunct for severe opioid withdrawal [8] (Case 12) or as a primary agent for barbiturate-specific withdrawal (Case 22). This highlights the importance of urine toxicology testing for targeted pharmacotherapy in NAS [7].

Perhaps the most significant challenge identified in this case series is the post-medical management phase. Medical stability does not equate to social readiness for discharge. The legal complexities of ensuring a safe environment for the child often extend the hospital stay far beyond the duration of medical treatment [9]. Only 26% of babies were discharged to parents under supervision. 52% were placed in probation care due to safeguarding concerns. Even for mothers who underwent antenatal rehabilitation, social factors like lack of permanent residence led to the loss of guardianship.

The high rate of recidivism is a major concern. Except for one mother who entered residential rehabilitation, almost all others returned to high-risk environments involving drug trafficking or prostitution. This cycle endangers both the mother and the infant and necessitates a move toward “Family-Centred Care” where the mother’s addiction and the baby’s NAS are treated as a single, intertwined healthcare priority. Consensus between the health sector and non-health sectors (Department of Probation and Child Care Services, Sri Lanka Police and National Child Protection Authority) should be further strengthened to expedite guardianship assessments and discharges.

The importance of antenatal detection of substance abuse cannot be overstated [1, 10]. As seen in Cases 19 and 20, early identification reduces the immediate clinical burden [11]. A unified policy must address standardised screening for substance use in all antenatal clinics. Long-term neuro-developmental follow-up for infants affected by NAS, which is currently at risk due to “incompetent parenting” and follow-up defaults, should also be ensured.

Conclusion

This case series highlights the escalating burden of NAS in Sri Lanka, particularly noting an alarming fact of substance abuse among women under 25 years of age. The management of these neonates imposes a profound strain on the healthcare system due to prolonged hospitalisations in high-cost tertiary units and the complex physiological demands of withdrawal, which often result in low birth weight and delayed weight gain.

Moving forward, Sri Lanka urgently needs a national policy mandating standardised antenatal screening to facilitate early rehabilitation and reduce immediate clinical burdens. Advancing toward a “Family-Centred Care” model is essential to address maternal addiction and neonatal health as a single priority, necessitating stronger collaboration between health, legal, and social sectors to expedite safe discharge and guardianship assessments. There is a critical need for structured, long-term neuro-developmental surveillance for these infants, as they face significant risks from social instability and incompetent parenting. This area remains understudied and warrants further research.

Abbreviations

NAS

Neonatal Abstinence Syndrome

POG

period of gestation

CM

clinically assessed maturity

CRP

C-reactive protein

Authors’ contributions

SW, US, HP, OM, NG and SM contributed to the diagnosis and management of the infants. SW, US, HP and SM prepared the manuscript for publication. All authors read and approved the final manuscript.

Funding

The authors received no financial support.

Data availability

The data supporting the findings of this study are not openly available and are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

Informed consent was obtained from parents or guardians of neonates reported in this case series. Ethics approval was not obtained, as case series do not require ethical approval in Sri Lanka, as per the Guidelines published by the Forum for Research Ethics Committees in Sri Lanka.

Consent for publication

Informed consent was obtained from the participants and the guardians of the neonates reported in this case series for publication.

Competing interests

The authors declare no competing interests.