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Nas Research Report
Nas Research Report
Risk of Developmental Delays related to infants born with Neonatal Abstinence Syndrome
Kara Whitman, Celeste Cavanaugh, Kristy Farkas, Josh DeSalvo, Adeyemi Shodipo
04/05/2017
NURS 3947: Nursing Research
Dr. Patricia Hoyson and Ms. Nicole Kent-Strollo
RISK OF DEVELOPMENTAL DELAYS 1
Abstract
The purpose of this research was to look at the relationship between neonatal abstinence
syndrome (NAS) and its effect on child development. The prevalence of NAS along with the its
link to cognitive, motor, behavior, and speech/language development was examined. This
research was conducted by looking at a mixture of eighteen articles and literature reviews.
Research suggests that there is likely a correlation between NAS and developmental delays;
however, there is not enough concrete evidence to fully support that claim. Overall, the research
presented within this paper shows the connections we already know and discusses the need for
Neonatal abstinence syndrome is a syndrome that goes beyond the few weeks an infant
will likely spend in the neonatal ICU (NICU). It is becoming a problem that needs to be
addressed. The number of NAS cases within the United States is on the rise. There is limited
research on the long-term effects NAS has on infants. This presents an issue in the nursing
community due to the fact that nurses are caring for more of these children than ever before. It is
difficult to treat an infant with a drug withdrawal without knowing what the outcome will be.
The drugs themselves along with the process of withdrawal can create a delay in child
development. Therefore, the following research question was addressed: Are infants with NAS at
Literature Review
Introduction
Academic Search Complete, as well as Google Scholar. From these search engines, eighteen
articles were used to analyze the effect of NAS on child development. Cognitive, motor,
behavioral, and speech/language development in children that had NAS will be discussed.
NAS
exposure to addictive, illicit or prescription drugs while in a mother’s womb. It is a term given to
infants that are suffering from drug withdrawal. It most often manifests after exposure to opioids
but can also be seen with exposure to methadone, buprenorphine, antidepressants and
crying, poor feeding, vomiting, diarrhea, slow weight gain (or impaired) and sometimes seizures
RISK OF DEVELOPMENTAL DELAYS 3
(Jean Y. Ko, Stephen W. Patrick, Van T. Tong, Roshni Patel, Jennifer Lind, Wanda D. Barfield,
2016). Newborns with NAS have also been known to have respiratory complications and some
even face death due to the effects of withdrawal. The onset of the withdrawal symptoms can
range anywhere from minutes to two weeks after birth and can last for six days to eight weeks.
However, symptoms or irritability may continue for more than three months (Hutchings, DE.,
1982).
The prevalence of NAS has increased since 1999. While looking at NAS cases from 28
states, Ko et al., (2016) found that reported NAS cases increased by 300% between 1999 and
2013. “In 1999 (the first year), 2,419 NAS cases were identified among 1,610,733 births in 14
reporting states (1.5 per 1,000 births). In 2013, 8,270 NAS cases were identified among
1,385,371 births in 21 states (6.0 per 1,000 births)” (Ko et al., 2016). In a study conducted by
Veeral N. Tolia, Stephen W. Patrick, Monica M. Bennett, Karna Murthy, John Sousa, P. Brian
Smith, Reese H. Clark, Alan R. Spitzer (2015), there was an increase in number of NAS cases,
length of stay in the NICU, and number of NICU days where NAS was the prominent diagnosis.
At two out of the 157 centers involved in the study, more than 40% of the NICU days were
related to NAS babies (Tolia et al., 2015). A surprising ten percent of the clinical centers
reported having more than 10% of their NICUs day attributed to NAS infants. Although it may
not seem like a significant number, it is much higher than previous records. Tolia et al., (2015),
believe that their study was actually under representative of NAS cases. They did not include
infants that had suspected cases of NAS or infants that were admitted to the NICU after initial
discharge from the hospital. Infants that are less severely impacted by NAS may be treated in
settings other than the NICU which also lead them to believe that their reports were
underestimates. With that being said, NAS is a fast-growing medical problem. It is a problem
RISK OF DEVELOPMENTAL DELAYS 4
that extends beyond the first couple weeks of life. To explore the effects of NAS on a growing
child, this paper is going to give a brief insight into potential developmental delays related to
NAS.
Cognitive Development
Newborns are not fully developed upon birth and must go through many changes to
become the person that they will eventually grow into. Some changes a newborn is going
through may be easier to see than some other changes may be. A physical change a newborn is
going through, for example, may be easier to notice because it can be observed; a cognitive
change, however, may be impossible to observe and can easily be missed. “Children prenatally
exposed to opioids and polysubstances are at increased risk for neuropsychological dysfunction”
(Nygaard, Moe, Slinning, Walhovd, 2015, p. 330). Whereas newborns born to healthy mothers
have milestones that they achieve at a certain age, a newborn with NAS will most likely be
preterm with a low birth weight and be at a serious disadvantage to perform these milestones
The research that is available about the cognitive differences of children that had
previously been prenatally exposed to opioids and polysubastances as compared to those who
had no prenatal exposure are very limited. According to Nygaard, Moe, Slinning, and Walhovd
(2015), there is a consensus that children born to addicted mothers definitely have lower
cognitive ability than children born to healthy mothers (p. 330). Also, found by these
researchers, was that boys’ cognitive development was delayed on all assessments from age 1 to
age 8 ½; whereas the girls’ cognitive development was not noticeably different until the last
assessment at 8 ½ years of age (p. 331). The only explanation against why boys have more
cognitive deficits than girls is that they may be more susceptible to the effects of the opioids and
RISK OF DEVELOPMENTAL DELAYS 5
polysubstances that their mothers are ingesting than girls are (p. 333). These researchers have
hypothesized that girls are more susceptible to cognitive effects at a later age, 8 ½, than boys are
because, “Girls’ general preponderance for emotional problems arising in adolescence may also
begin to interact with the vulnerability of the exposed girls at an even earlier age” (p. 333).
Another set of researchers has broken up their research based on the differences between
prenatally exposed infants to drugs and infants not prenatally exposed to drugs. The difference
with this research is that it is broken into each specific drug and what effects each drug has on a
fetus and the delays the drugs may cause. Ross, Graham, Money, and Stanwood (2015) state
“Given the crucial roles for the major protein targets of drugs of abuse in shaping brain
development, it should not be surprising that fetal drug exposures have been linked to a wide
A common drug consumed during pregnancy, per Ross, Graham, Money, and Stanwood
(2015), is cocaine (p.7). Infants prenatally exposed to cocaine can have an array of problems
after birth and even into later childhood and adolescence. Research has shown that there are
effects on a child’s executive function from those who were born to mothers addicted to cocaine.
“Executive function is a set of mental processes for the management of cognitive operations that
(Ross, Graham, Money, and Stanwood, 2015, p. 8). These effects on executive function may last
until adolescence and there may be differences based on gender. “Females had greater problems
with initiation activities, working memory, and organization” (p. 8), whereas males had problems
Overall, the research has shown that there are longitudinal and long-term cognitive
effects on babies with Neonatal Abstinence Syndrome, NAS, as compares to babies born to a
RISK OF DEVELOPMENTAL DELAYS 6
healthy mother, not addicted to drugs. Although there is not an immense amount of research on
this topic, the research that is out there has come to the same conclusion about the effects on the
Motor Delays
Short and long term motor delays associated with NAS can vary with the majority of
motor delays occurring from the use of opiates and methadone. The length of time and degree of
fetal exposure to such drugs in-utero can be the determining factors in whether or not motor
abilities are affected. According to Logan (2013), “Methadone-exposed infants have been found
to exhibit increased motor rigidity, dysregulated motor patterns and decreased activity by
observation and maternal report on the Bayley Infant Behavior Record”. The Bayley Infant
Behavior Record (BSID-III) is used to assess developmental functioning in infants and young
children between the age of 1 month and 42 months of age with applications in cognition,
language and motor development making this scale an important assessment tool for NAS.
Logan’s (2013) study of 200 methadone and non-methadone participating families found
the following: At 9 months of age, 37.5 % of our sample of methadone exposed infants
showed clinically significant motor delays using the BSID-III compared to low but
typical development in the comparison group. Motor deficits were most prominent in the
The motor deficits found in the first study of methadone exposed infants are focused on gross
motor skills which are movements associated with large muscle groups and whole body
In the second study of opiate exposed infants the findings are directed more toward
psychomotor delays. Psychomotor refers to the relationship between cognitive functions and
physical movement. Psychomotor skills are physical skills such as movement, coordination,
manipulation, dexterity, strength, and speed all of which demonstrate the fine motor skills. 133
infants from opiate dependent moms and 103 healthy infants were tested with psychomotor
deficits being evident among the opiate exposed infants compared to the control group of healthy
development at 18 months, there was a significantly lower score on the McCarthy Motor Scale at
3 years of age for opiate-exposed children”. Hunt also states that, “Many investigators have been
less than willing than us to attribute significance to their finding because the opiate-exposed
infants had psychometric scores that fell within range. We challenge this premise and argue that
despite the small numbers studied, there are still clear differences in development between
opiate-exposed infants and controls. To clarify, findings for this study were based on the
Psychomotor Development Index pertaining to the Bayley Scales which tested both groups on
their level of psychomotor development by age and although the opiate-exposed infants were
technically within range, their scores were significantly lower than those of the control group
leading the researchers to believe that opiate exposed infants in fact have these delays due to
As mentioned above, many past researchers have failed to find the link between motor
delays and NAS because not meeting the age appropriate developmental milestones in motor
coordination can also be contributed to other factors such as; environment, parental involvement,
and genetic influences. Another big factor is that children all have their own unique pattern of
meeting milestones within a certain time frame. All of this considered, it has made it hard for
RISK OF DEVELOPMENTAL DELAYS 8
researchers to pinpoint motor delays strictly to NAS because most NAS infants fall into the
normal range. This range however, has been significantly lower than that of the control groups.
According to Logan (2013), “Few studies have used both biological and clinical measures to
evaluate developmental delays”. This can very well be part of the reason why the majority of
other studies done on developmental delays of NAS have limited information on motor deficits.
Not to mention, that most of the studies performed have had a hard time keeping participation
levels high (as was the case for Hunt), leaving them with a consistently low number of
participants over 42 months of age to assess for motor delays, which in turn has led to very
mixed findings. With all that being said, there is an extreme need for further research to
investigate short and long term motor delays seen with NAS as well as a need for more long term
participation.
Behavioral
Obstetrical complications have been found in connection with heroin addiction. These
polyglycolic and pulmonary hemorrhage. Factors contributing to this failure to take care of their
health may include financial difficulty, lack of health insurance, lack of education,
unemployment, home issues, poor diet, and the difficult lifestyle of the addicts such as being a
heavy smoker and various illegal activities/ crimes carried out to get money.
The two articles used for the research studied mostly methamphetamine (MA) as the drug
of use because methamphetamine is a worldwide problem with more users than cocaine and
opiates combined. MA users comprise mostly of women as first time users, as a result there is
increasing concern about the effect of prenatal use on women and newborns. According to the
Substance Abuse and Mental Health administration; in 2009, 6.7% of those seeking treatment of
RISK OF DEVELOPMENTAL DELAYS 9
MA abuse in the United States were pregnant women (Substance Abuse and Mental Health
Though the research on cocaine addicted pregnant women is illuminating because both
MA and cocaine are sympathomimetic agents, nevertheless MA’s Neurotoxicity outcome may
have a larger adverse effect than cocaine due to its longer half-life and multiplied effect (Mayes,
LC. 2002), MA has vasoconstrictive effects, resulting in decreased uteroplacental blood flow and
fetal hypoxia (Stek AM, Fisher BK, Baker RS, Lang U, Tseng CY, Clark KE, 1993).
Toddlers
According to Linda. L.L. Lagrasse et al (2012), their study found that developmental
years but not at 3 years however internalizing behaviors and syndrome scores for withdrawal
behavior and somatic complaints were found to increase from 3 years to 5 which may be
unrelated to MA because it is consistent with normal development trajectories but both ages are
characterized by higher emotional reactivity and anxiety and depression problems than compared
age groups.
and easily distracted with brief attention spans. Their goal directedness has been found to be
brief (Bauman P. S., Levine S. A., 1986). It has been suggested by some studies that these
toddlers may have immature object manipulation, especially with regard to fine motor skills,
cognitive, speech and perceptual disturbances and sleep disturbances. These characteristics may
put these children at high risk for child abuse because their mothers may become frustrated with
Preschool
According to Bauman and Levine (1986), the children of methadone maintained mothers
have increased incidences of adverse behaviors such as yelling, whining, and physical abuse of
their children in comparison to children of non-addicted mothers. These attributes may be due to
drug addicted mothers’ tendency to yell, command and disapproval of their children. Ramon et al
also suggested that these children showed lower intelligence quotient scores than children of
non-addicted mothers based on the Stanford-Binet intelligence scale. This may be due to the
children not receiving adequate intellectual stimulation at home because the mothers themselves
may have low average intelligence scores. Furthermore, these children may have lower levels of
learning and adapting to new situations at home. Bauman and Levine suggested that there may
Due to research still being in its early stages pertaining to the long-term
developmental effects of neonatal abstinence syndrome, research for language development had
to be more so directed at teratogen exposure, in particular, cocaine exposure in utero. The major
difference being evident in the fact that neonatal abstinence syndrome is characterized by
withdrawals and the only research available deals with exposure alone. Although more research
is available with a focus on prenatal cocaine exposure and future language deficits, studies have
found mixed results. Studies have looked to see the effects of cocaine exposure on the
Bandstra, Morrow, Accornero, Mansoor, Xue, and Anthony (2011), “The effect of prenatal
cocaine exposure(PCE) on the arousal and attention regulating systems of the brain may be
memory” (p. 25). In order to truly understand the effects of gestational cocaine exposure,
In continuation, links have been drawn to prenatal cocaine exposure and language
deficits. As pointed out by Bandstara et al. (2011) they found that infants exposed to higher
doses of cocaine compared to lighter doses or non-exposure, presented with lower auditory
comprehension and lower total language scores on the Preschool Language Scale-3 (p. 25-26).
Although, there has not been consensus concerning this research. Betancourt, Yang, Brodsky,
Gallagher, Malmud, Gianeetta, Farah, and Hurt (2011) contributed that, “Our group found no
gestational cocaine exposure (GCE) effects on language functioning assessed using the
Preschool Language scale at age 2.5 years and the Battelle Developmental Inventory
Communication Subscale at ages 3 and 5 years” (p. 2). Much of the research that has been
conducted has been primarily interested on the deficits observed in infant, preschool, and early
school aged children without observing the more long-term effects of pre-adolescents and
adolescent children.
To elaborate, Bandstra et al. (2011) pointed out, “Only a few studies, including our own,
have evaluated language abilities in school-aged or preadolescent children” (p.26). In their study,
The Miami Prenatal Cocaine study, they looked to determine the effect of cocaine exposure in
utero on language development in children 3, 5, and 12. Included in the sample were a total of
451 children in which 242 were cocaine exposed and 209 who were not exposed in utero. Of
particular interest were areas of expressive, receptive, and total language measures where
measures evaluated word structure, ability to formulate sentences, ability to recall sentences,
sentence assembly, word association, semantic relationships, and ability to listen and discern
paragraphs (Bandstra et al., 2011, p. 27). Results of the Bandstra et. al (2011) study indicated
RISK OF DEVELOPMENTAL DELAYS 12
that for receptive, expressive, and total language, “…analyses did not indicate a deficit in the
developmental trajectory of receptive language over time” and later went on to conclude, “…the
observed PCE-related difference between prenatally cocaine exposed and non-cocaine exposed
children in language function from early childhood into early adolescence is approximately 3
standard units in total and expressive language scores” (p.32-35). This identifies that with
expressive and total language measures, there has been observed developmental delays in
language for 3, 5, and 12-year-old children compared to their non-exposed peers. Another study
women of low SES and their children were observed. The sample included 120 participants, of
which, 60 were exposed to cocaine in utero and 60 who were not. The children were then
observed at 12, 14.5, and 17 years of age. The study looked to observe measures in inhibitory
control, working memory, receptive language, and incidental memory. According to the study
conducted by Betancourt et al. (2011) pertaining to inhibitory control, working memory, and
receptive language tasks, “The targeted study design revealed little evidence of latent effects of
GCE in this sample of low SES adolescents” (p. 9). Although the studies did not find repeating
results for their research, both of the studies mentioned in this section state subtle deficits
attributed to prenatal cocaine exposure have potential for negative outcomes in the future,
according to Bandstra et al. (2011), “Research suggests that there is strong continuity between
early language delay in children and later reading and literacy difficulties” (p. 31). Betancourt et
al. (2011) backed this view as well, making the statement, “There is accumulating evidence for
the existence of subtle effects of GCE and their impact on the individual and society may be
Analysis
RISK OF DEVELOPMENTAL DELAYS 13
When examining the effect of NAS on child development, studies showed mixed results.
Studies showed that it is likely that NAS can lead to developmental delays but NAS cannot be
assumed as the only factor (as of research now). Factors such as socioeconomic status,
environment, as well as genetics can affect child development. Overall, there is a great need for
further research into the question of whether there is a connection between NAS and
developmental delays.
Conclusion
Educating pregnant women about the effects of potentially harmful drugs during
pregnancy is a key in preventing NAS. With further research, we would be able to teach mothers
about the possibility of developmental delays in their children. By reducing the prevalence of
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