Snapshot A two-day old male infant presents with irritability, a high-pitched cry, poor oral intake, and loose stools. He was born at term to a 25-year-old mother with known heroin-use disorder. On exam, the infant is frequently yawing and sneezing. Tremors and hyperactive primitive reflexes are also noted. Introduction Mother with substance-abuse disorder may lead to acute withdrawal symptoms in the newborn refered to as neonatal abstinence syndrome (NAS) some causes of NAS opioid exposure (most common) nicotine Epidemiology increased incidence of opioid pain reliever use in mothers increases incidence of NAS Pathogenesis opioid withdrawal in utero exposure to opioids due to their lipophilic property and small size crosses placenta and blood-brain barrier birth disrupts drug exposure → withdrawal Presentation Symptoms irritability poor feeding high-pitched cry Physical symptoms sneezing yawning tremor hyperactive reflexes mottled skin Evaluation Diagnosis primarily based on symptoms and history of in-utero drug exposure Differential Neonatal hypoglycemia Neonatal sepsis Intracranial hemorrhage Electrolyte disturbances hypocalcemia hypomagnesemia Treatment Supportive reduce sensory stimulation nutrition to prevent delayed growth breast feeding skin care IV hydration and electrolyte replacement Pharmacologic opioids based on symptom severity, and responsiveness to supportive treatment Prognosis, Prevention, and Complications Prognosis low long-term mortality rate adverse neurodevelopmental outcome Prevention avoid maternal opioid use Complications seizures opioid withdrawal presents largest risk of seizure weight loss