Spanish for neonatal abstinence syndrome nurses — the mother who cannot understand why her baby is shaking when she is breastfeeding and was told breastfeeding was safe, the mother who experiences the NOWS score as a verdict on her parenting, and the mother being told her baby needs morphine when she was told opioids are the problem

Why these three conversations

Valentina Rojas is twenty-six years old. She grew up in Tucson, Arizona — the second of four children in a family that had always worked in construction and agriculture. She started using methamphetamine at seventeen when a boyfriend introduced it, switched to opioids at nineteen when she found they were cheaper, and was using fentanyl regularly by twenty-three. She overdosed once, in the parking lot of a strip mall, and a stranger gave her naloxone. She found out she was pregnant when she was already twelve weeks along. She found a prenatal methadone clinic the week after the positive test. She has been on methadone maintenance — stable, supervised, no positive screens for illicit substances — for fourteen months.

Her son Mateo was born at thirty-nine weeks, seven pounds two ounces, apgar 8 and 9. He is now three days old and in the newborn nursery transitional care unit. His NOWS scores have been 8, 9, 10, 8. The team started the oral morphine protocol yesterday when three consecutive scores above 7 triggered the clinical threshold. Valentina is breastfeeding every two to three hours. She came in at five in the morning yesterday when Mateo started crying in a way she had not heard before — high-pitched, inconsolable, different from hunger. She has not slept. She holds him skin-to-skin between feedings. She is doing everything the prenatal team told her to do, and Mateo is still shaking and still needing morphine, and Valentina cannot understand how that is possible.

Elena Castillo is thirty-one years old. She is from Albuquerque, the daughter of a schoolteacher and a mechanic. She used heroin for six years, lost two jobs, lost a relationship, and spent eleven months in a county treatment program before finding buprenorphine-naloxone maintenance eighteen months ago. She is in stable recovery. She has a sponsor. She has a therapist. Her daughter Ana was born four days ago at thirty-eight weeks and two days, six pounds seven ounces. Ana is in the NICU at University of New Mexico Hospital with NOWS scores ranging between 6 and 12. Elena has visited every visiting hour since admission. She watches the nurse score Ana every four to eight hours — the tremor assessment, the cry assessment, the muscle tone check, the mottling examination — and she reads the number on the whiteboard as though it is a grade. When the score went from 7 to 11 at the overnight check three days ago, she sat in the NICU chair next to Ana’s isolette and cried for forty-five minutes. She said, quietly, so that she thought no one could hear, “le hice esto.” I did this to her.

María Guerrero is twenty-eight years old. She was born in Sacramento, the daughter of parents who came from Michoacán thirty years ago. She began using heroin at twenty-one after a relationship ended and a friend offered her something to make it hurt less. She was using for five years when she found out she was pregnant. She was fourteen weeks along. The same week she got the positive test, she called a prenatal clinic that her case manager had told her about. A counselor there spent two hours explaining medication-assisted treatment: that continuing to use heroin during pregnancy would expose the baby to repeated cycles of intoxication and withdrawal, stressing the placenta, risking preterm labor, risking placental abruption; that methadone maintenance would stabilize the baby’s exposure and dramatically reduce those risks; that the baby would likely experience some withdrawal after birth because the methadone crossed the placenta, and that the medical team at the hospital would know how to manage it. María said yes. She stayed on methadone for the remaining twenty-six weeks of pregnancy and did not use anything else. Her son Emilio was born at thirty-eight weeks, six pounds eleven ounces. He is three days old and his NOWS score is 15. The neonatologist has ordered oral morphine. The nurse has come to the bedside with the syringe.

María looks at the syringe and says: “Me dijeron que los opioides le hacen daño al bebé. Por eso dejé de usarlos. Y ahora me dicen que le van a dar opioides a mi hijo.”

(They told me opioids harm the baby. That is why I stopped using them. And now they are telling me they are going to give opioids to my son.)

She is not confused. She is paying attention. Her counselor told her something and she took it seriously and acted on it for six months. She deserves an explanation that honors that.

These three mothers — Valentina, Elena, and María — each have a different barrier, but all three are sitting inside a clinical situation they cannot fully interpret because no one has yet given them the mechanism. They came into motherhood doing the recommended thing, and the recommended thing produced an outcome that looks, from the outside, like harm. The NICU or newborn nursery nurse is the clinician who can change what these women understand about what is happening to their babies and, by extension, what they believe about their own choices.

Scenario 1 — Valentina Rojas, 26, methadone maintenance for fourteen months, breastfeeding faithfully, whose son Mateo’s NOWS score keeps triggering the morphine protocol

The nurse caring for Mateo that morning is Rosa Díaz, a transitional care unit nurse at Banner University Medical Center in Tucson who has worked with NOWS babies for six years. She has seen this moment before: the mother on stable MAT who is doing everything right and cannot reconcile the breastfeeding with the morphine. The moment requires more than reassurance. It requires a specific explanation of a specific mechanism that most people have never been told and that sounds, without that explanation, like a contradiction.

Rosa sits down next to Valentina and Mateo. She does not start with the morphine. She starts with what Valentina is doing correctly.

Rosa: “Lo que está haciendo — el amamantamiento, el piel a piel, venir a las cinco de la mañana — está ayudando. Los bebés que toman pecho tienen puntuaciones más bajas que los que toman fórmula, y generalmente salen del hospital antes. Eso no es poca cosa. Es una diferencia real que viene de lo que usted está haciendo.”

(What you are doing — the breastfeeding, the skin-to-skin, coming at five in the morning — is helping. Babies who breastfeed have lower scores than babies who receive formula, and they usually leave the hospital sooner. That is not a small thing. It is a real difference that comes from what you are doing.)

Valentina: “Pero sigue necesitando la morfina. Entonces no está funcionando.”

(But he still needs the morphine. So it is not working.)

Rosa: “Está funcionando — sin el amamantamiento, las puntuaciones habrían sido más altas y habríamos empezado la morfina antes. Lo que necesito explicarle es por qué el amamantamiento ayuda pero no puede evitar el retiro. Son cosas distintas, y si entiende la diferencia va a entender por qué Mateo necesita las dos cosas al mismo tiempo.”

(It is working — without the breastfeeding, the scores would have been higher and we would have started the morphine sooner. What I need to explain to you is why breastfeeding helps but cannot prevent the withdrawal. They are different things, and if you understand the difference you will understand why Mateo needs both at the same time.)

The placenta and the breast milk are different channels

Rosa draws a simple timeline on the back of a paper towel: nine months of pregnancy, then birth, then now.

Rosa: “Durante el embarazo, la metadona que usted tomó pasó por la placenta al bebé — directamente, en cantidades suficientes para que su sistema nervioso se acostumbrara a ese nivel. No pasa toda — pasa una parte — pero es suficiente para que los receptores del bebé aprendan a funcionar con la metadona presente. Eso pasó durante catorce meses mientras usted estuvo embarazada.”

(During pregnancy, the methadone you took passed through the placenta to the baby — directly, in quantities sufficient for his nervous system to become accustomed to that level. Not all of it passes — a portion does — but it is enough for the baby’s receptors to learn to function with methadone present. That happened for fourteen months while you were pregnant.)

Valentina: “Sí. Eso me lo dijeron.”

(Yes. They told me that.)

Rosa: “Cuando Mateo nació, ese canal se cerró. La metadona que llega por la leche materna es real — está ahí — pero está en una cantidad mucho menor que lo que llegaba por la placenta. El sistema nervioso de Mateo notó esa diferencia el momento en que nació. No fue gradual. Fue un cambio de golpe. El retiro es su sistema nervioso ajustándose a ese cambio.”

(When Mateo was born, that channel closed. The methadone that arrives through breast milk is real — it is there — but it is in a much smaller amount than what arrived through the placenta. Mateo’s nervous system noticed that difference the moment he was born. It was not gradual. It was an abrupt change. The withdrawal is his nervous system adjusting to that change.)

What the breastfeeding is actually doing

Rosa: “La leche materna hace dos cosas para Mateo. Una: una pequeña cantidad de metadona que llega suaviza un poco la caída — como un comodín que hace que el retiro sea un poco menos fuerte de lo que sería sin ella. Dos: el piel a piel, el succionamiento, el calor de su cuerpo reducen la activación del sistema nervioso de Mateo — bajan el cortisol, bajan la frecuencia cardíaca, reducen los temblores. Eso es real y está documentado. Es la razón por la que le pedimos que siga amamantándolo aunque necesite la morfina.”

(Breast milk does two things for Mateo. One: the small amount of methadone that arrives softens the drop a little — like a cushion that makes the withdrawal a little less strong than it would be without it. Two: the skin-to-skin contact, the suckling, the warmth of your body reduce the activation of Mateo’s nervous system — they lower cortisol, lower heart rate, reduce tremors. That is real and documented. It is the reason we ask you to keep breastfeeding him even though he needs the morphine.)

Valentina: “¿Y la morfina?”

(And the morphine?)

Rosa: “La morfina le da justo lo suficiente para que la puntuación baje de 7 — el nivel en el que puede comer sin problema y dormir más de una hora. Una vez que la puntuación se estabiliza abajo, empezamos a bajar la dosis un poco cada día. La meta es que el sistema nervioso de Mateo se vaya adaptando despacio a no necesitar nada. Al final, no hay ningún medicamento. La leche de usted y la morfina no compiten — hacen cosas distintas y las dos están ayudando al mismo tiempo.”

(The morphine gives him just enough to bring the score below 7 — the level at which he can feed without difficulty and sleep more than one hour. Once the score stabilizes below that, we start to lower the dose a little each day. The goal is for Mateo’s nervous system to adapt slowly to not needing anything. At the end, there is no medication. Your milk and the morphine are not competing — they do different things and both are helping at the same time.)

Valentina is quiet for a moment. Then: “O sea que no hice nada malo.”

(So I did not do anything wrong.)

Rosa: “No hizo nada malo. Hizo todo bien. El retiro que tiene Mateo es lo que pasa cuando el bebé nace después de un embarazo con metadona estable. Es esperado. Es manejable. Y usted ya está haciendo las dos cosas más importantes que puede hacer: amamantarlo y estar aquí.”

(You did not do anything wrong. You did everything right. The withdrawal Mateo has is what happens when a baby is born after a pregnancy with stable methadone. It is expected. It is manageable. And you are already doing the two most important things you can do: breastfeeding him and being here.)

Mateo’s NOWS score reaches a peak of 11 on day four, then begins to fall. He is discharged on day nine, on a methadone taper that his pediatrician will complete over the following two weeks. He is breastfed throughout. At the two-week well-child visit, his weight is above birthweight and he is sleeping four-hour stretches. Valentina’s methadone clinic calls to coordinate care. The pediatrician notes in the chart: “mother highly engaged, skin-to-skin throughout NICU stay, breastfeeding well-established.”

Scenario 2 — Elena Castillo, 31, buprenorphine maintenance for eighteen months, whose daughter Ana’s NOWS score is a verdict she keeps giving herself

The perinatal substance use nurse at UNM NICU is María Villanueva, a registered nurse who has spent eleven years working with this population. She has seen a version of Elena in this NICU chair every week for those eleven years: the mother on stable MAT, in recovery, doing everything right, who has transferred the self-judgment of addiction — the accumulated shame of years of use — onto the NOWS score her baby is receiving. She knows that addressing this is not optional. A mother who believes she is harming her baby by being there will eventually stop coming. Mothers who stop coming have babies who score higher, stay longer, and receive less of the non-pharmacological care that matters most.

María sits down next to Elena the morning after the 11 score. She does not wait for Elena to bring it up.

María: “Vi que la puntuación de Ana subió a 11 en la noche. Quiero explicarle lo que significa ese número, porque me parece importante que lo entienda bien.”

(I saw that Ana’s score went up to 11 last night. I want to explain to you what that number means, because I think it is important that you understand it well.)

What the score actually measures

María draws the scoring table on a whiteboard next to Ana’s isolette. She writes twelve items and explains each one.

María: “Esta lista tiene doce señales del cuerpo del bebé. La primera: el llanto — ¿es agudo y difícil de calmar, o es normal? La segunda: el sueño — ¿puede dormir más de una hora? La tercera: el reflejo de Moro — ¿se sobresalta mucho cuando cambiamos su posición? Los temblores, el tono muscular, si se come la piel de los puños, la coloración moteada de la piel. Cada uno de estos es una señal de cómo está trabajando el sistema nervioso del bebé mientras se adapta. Nada de esto mide a la mamá.”

(This list has twelve signs from the baby’s body. The first: the cry — is it high-pitched and hard to calm, or is it normal? The second: sleep — can she sleep more than one hour? The third: the Moro reflex — does she startle a lot when we change her position? The tremors, muscle tone, whether she sucks on the skin of her fists, the mottled coloring of her skin. Each of these is a sign of how the baby’s nervous system is working as it adapts. None of this measures the mother.)

Elena: “Pero la puntuación subió porque yo hice algo mal.”

(But the score went up because I did something wrong.)

María: “No. La puntuación subió anoche porque Ana recibió más estimulación de lo usual — cambiamos la sonda gástrica al mismo tiempo que la ropa de cama, y el NICU tuvo más movimiento de lo normal. Los bebés en retiro son muy sensibles a la estimulación. La puntuación reflejó eso. Esta mañana, con menos estimulación, está en 8. La puntuación sube y baja — eso es la curva normal del retiro en la primera semana.”

(No. The score went up last night because Ana received more stimulation than usual — we changed the gastric tube at the same time as the bedding, and the NICU had more movement than normal. Babies in withdrawal are very sensitive to stimulation. The score reflected that. This morning, with less stimulation, she is at 8. The score rises and falls — that is the normal curve of withdrawal in the first week.)

The score is not a report card

María: “Quiero preguntarle algo. Cuando ve el número subir, ¿qué piensa?”

(I want to ask you something. When you see the number go up, what do you think?)

Elena is quiet for a long time. Then she says: “Que soy la razón por la que ella está ahí.”

(That I am the reason she is here.)

María: “Le escucho. Y entiendo por qué piensa eso. Quiero decirle algo sobre eso, y quiero que lo escuche completamente antes de responder.”

(I hear you. And I understand why you think that. I want to tell you something about that, and I want you to hear it completely before responding.)

She pauses.

María: “Usted estuvo dieciocho meses en tratamiento con buprenorfina. Eso significa dieciocho meses sin recaer, sin usar, sin exponerse a la hepatitis C o al VIH de jeringas contaminadas, sin overdosis, sin parto prematuro por un ciclo de intoxicación y retiro que la placenta no puede absorber. Usted tomó la decisión médicamente correcta. El retiro que tiene Ana es un efecto conocido de ese tratamiento correcto — lo dice la literatura científica, lo dicen las guías de la Academia Americana de Pediatría. No es una sorpresa. No es un fallo. Es algo que los equipos de NICU manejan todos los días, exactamente por esto.”

(You were eighteen months in treatment with buprenorphine. That means eighteen months without relapse, without using, without exposure to hepatitis C or HIV from contaminated needles, without overdose, without premature birth from an intoxication-and-withdrawal cycle that the placenta cannot absorb. You made the medically correct decision. The withdrawal Ana has is a known effect of that correct treatment — the scientific literature says so, the guidelines of the American Academy of Pediatrics say so. It is not a surprise. It is not a failure. It is something that NICU teams manage every day, precisely for this.)

Elena: “¿Lo sabrán siempre? ¿Que su mamá usaba drogas?”

(Will they always know? That her mother used drugs?)

María: “Lo que Ana va a saber es lo que usted le enseñe. Los bebés que salen del NICU con retiro neonatal manejado y que crecen con una mamá en recuperación tienen resultados a largo plazo similares a los de la población general cuando hay estabilidad en el hogar. La estabilidad es lo que usted le está dando ahora — dieciocho meses de recuperación, tratamiento, y usted aquí en este sillón todos los días.”

(What Ana will know is what you teach her. Babies who leave the NICU with managed neonatal withdrawal and who grow up with a mother in recovery have long-term outcomes similar to the general population when there is stability at home. Stability is what you are giving her now — eighteen months of recovery, treatment, and you here in this chair every day.)

What the non-pharmacological care actually does to the score

María shows Elena the NICU protocol for non-pharmacological NOWS care: the low-stimulation environment (dimmed lights, reduced noise, minimal handling during sleep), swaddling, skin-to-skin contact during feeding windows, non-nutritive suckling. She shows Elena the data the NICU keeps: babies whose mothers are present for more than four hours per day average 1.2 points lower on daily NOWS scores than babies whose mothers are less present. The difference is measurable. It is documented. It appears in the NICU’s own data from the last three years.

María: “Cuando usted está aquí, la puntuación de Ana es más baja. No porque usted la calma con un cuento o porque le habla bonito. Porque el contacto con su mamá, el olor de su mamá, la temperatura del cuerpo de su mamá reducen la activación del sistema nervioso autónomo del bebé. Eso tiene un número. Ese número es lo que usted le está dando.”

(When you are here, Ana’s score is lower. Not because you calm her with a story or because you speak to her sweetly. Because contact with her mother, the smell of her mother, the temperature of her mother’s body reduce the activation of the baby’s autonomic nervous system. That has a number. That number is what you are giving her.)

Elena does not say “le hice esto” again after this conversation. She asks María to teach her how to do the non-nutritive suckling technique correctly. Ana’s NOWS score reaches a peak of 12 on day five and falls steadily from day six. She is discharged on day eleven on a buprenorphine taper. Elena brings her to every scheduled follow-up appointment. At the six-month developmental assessment, the pediatric nurse practitioner notes: “Appropriate growth and development. Mother highly attuned, responsive, and engaged.”

Scenario 3 — María Guerrero, 28, who stopped heroin and followed the recommended treatment, whose son Emilio has a NOWS score of 15 and a nurse standing at the bedside with a syringe of oral morphine

The nurse is Claudia Reyes, a NICU nurse at UC Davis Medical Center in Sacramento who has been in this specialty for nine years. She has learned that the mothers who ask the clearest questions are often the ones who trusted the system most and cannot reconcile what they were told with what they see. María’s question — you told me opioids hurt the baby, and now you are giving my baby opioids — is the right question. It deserves a real answer.

Claudia sets the syringe on the counter. She does not give it yet. She sits down.

Claudia: “Tiene razón en preguntar eso. Es la pregunta correcta. Y quiero explicarle la respuesta antes de que le demos nada a Emilio.”

(You are right to ask that. It is the right question. And I want to explain the answer before we give Emilio anything.)

Two kinds of opioid exposure

Claudia: “Lo que le dijeron es verdad: la heroína hace daño durante el embarazo. El daño específico que hace es este: la persona que usa heroína tiene niveles muy altos de opioides cuando usa y luego los niveles caen cuando no tiene. Eso es un ciclo — intoxicación, retiro, intoxicación, retiro. El bebé en el útero sufre ese mismo ciclo a través de la placenta. Cada vez que los niveles caen en la mamá, el bebé también entra en retiro adentro del útero. Eso puede causar contracciones, desprendimiento de la placenta, parto prematuro. Es el ciclo de subida y bajada lo que es peligroso — no el medicamento en sí.”

(What they told you is true: heroin causes harm during pregnancy. The specific harm it causes is this: the person who uses heroin has very high opioid levels when using and then the levels fall when they do not have it. That is a cycle — intoxication, withdrawal, intoxication, withdrawal. The baby in the uterus experiences that same cycle through the placenta. Every time levels fall in the mother, the baby also goes into withdrawal inside the uterus. That can cause contractions, placental abruption, preterm labor. It is the cycle of rising and falling that is dangerous — not the medication itself.)

María: “¿Y la metadona?”

(And the methadone?)

Claudia: “La metadona es un nivel estable. No hay subidas ni bajadas. El bebé recibe el mismo nivel todo el día. Eso es lo que protege — la estabilidad. El bebé no entra en retiro adentro del útero porque el nivel nunca cae. Lo que sí pasa es que el sistema nervioso del bebé aprende a funcionar con ese nivel estable presente. Cuando Emilio nació, ese nivel desapareció de golpe porque la placenta se fue. Eso es el retiro que está teniendo ahora.”

(Methadone is a stable level. There are no rises and falls. The baby receives the same level all day. That is what protects — the stability. The baby does not go into withdrawal inside the uterus because the level never falls. What does happen is that the baby’s nervous system learns to function with that stable level present. When Emilio was born, that level disappeared abruptly because the placenta was gone. That is the withdrawal he is having now.)

What oral morphine does that abrupt discontinuation cannot

Claudia: “Ahora el cuerpo de Emilio tiene una puntuación de 15 — está temblando, el llanto no para, no puede comer bien, casi no puede dormir. Si no hacemos nada, la puntuación puede seguir subiendo. En los casos más severos, los bebés tienen convulsiones. No son comúnes, pero pasan cuando el retiro es muy intenso y no se trata. La morfina no es para darle más del problema. Es para darle justo lo suficiente para bajar la puntuación a un nivel donde pueda comer y dormir.”

(Now Emilio’s body has a score of 15 — he is trembling, the crying does not stop, he cannot eat well, he can barely sleep. If we do nothing, the score can keep rising. In the most severe cases, babies have seizures. They are not common, but they happen when the withdrawal is very intense and is not treated. The morphine is not to give him more of the problem. It is to give him just enough to bring the score to a level where he can eat and sleep.)

María: “¿Y no se va a volver adicto?”

(And he is not going to become addicted?)

Claudia: “No. La adicción es un patrón de comportamiento que los bebés no pueden tener — es buscar el medicamento por el efecto que produce en el cerebro, quererlo más aunque cause daño. Un recién nacido no tiene esa capacidad. Lo que Emilio tiene es dependencia física — el cuerpo acostumbrado a un nivel y tratando de funcionar sin él. Eso es distinto. La dependencia física se maneja con una reducción gradual. La adicción es una enfermedad crónica del cerebro que se maneja con tratamiento a largo plazo. Son cosas distintas.”

(No. Addiction is a behavioral pattern that babies cannot have — it is seeking the medication for the effect it produces in the brain, wanting more even when it causes harm. A newborn does not have that capacity. What Emilio has is physical dependence — the body accustomed to a level and trying to function without it. That is different. Physical dependence is managed with a gradual reduction. Addiction is a chronic brain disease managed with long-term treatment. They are different things.)

The staircase out

Claudia draws a staircase going downward on the whiteboard: a high first step labeled “nivel al nacer,” then steps descending at measured intervals, each labeled “día 1, día 2, día 3” until the bottom step is labeled “sin medicamento.”

Claudia: “La morfina que le vamos a dar es la escalera. Empezamos con justo lo suficiente para que la puntuación baje de 7. Una vez que la puntuación se estabiliza, bajamos la dosis un poco cada día — generalmente entre el cinco y el diez por ciento por día. El sistema nervioso de Emilio tiene tiempo de ir adaptándose a cada escalon&cito en lugar de caer de golpe desde arriba. Al final de la escalera, no hay ningún medicamento. Emilio sale del hospital sin morfina, sin metadona, sin nada. La escalera fue la manera de llegar abajo sin que el cuerpo sufriera la caída.”

(The morphine we are going to give him is the staircase. We start with just enough to bring the score below 7. Once the score stabilizes, we lower the dose a little each day — generally between five and ten percent per day. Emilio’s nervous system has time to adapt to each small step rather than falling from the top all at once. At the end of the staircase, there is no medication. Emilio leaves the hospital without morphine, without methadone, without anything. The staircase was the way to get to the bottom without the body suffering the fall.)

María: “¿Cuantos días?”

(How many days?)

Claudia: “Para Emilio, con una puntuación de 15, probablemente entre dos y tres semanas en total. Algunos bebés son menos, algunos son más. Depende de cuán rápido bajan las puntuaciones. Usted puede estar aquí todo ese tiempo — de hecho, estar aquí hace que el proceso sea más rápido.”

(For Emilio, with a score of 15, probably between two and three weeks total. Some babies are less, some are more. It depends on how fast the scores come down. You can be here all that time — in fact, being here makes the process faster.)

María looks at the staircase drawing for a moment. Then she looks at the syringe on the counter.

María: “¿Puedo sostenerlo mientras se lo da?”

(Can I hold him while you give it to him?)

Claudia: “Sí. Es mejor así.”

(Yes. It is better that way.)

Emilio’s NOWS score reaches a peak of 16 on day four, then begins its descent. He is discharged on day seventeen, fully weaned off morphine. María’s methadone clinic arranges a care coordination meeting with Emilio’s pediatrician before discharge. At the one-month well-child visit, his weight is at the 35th percentile, he is eating every three hours and sleeping four-hour stretches at night, and María has not missed a single pediatric appointment or a single methadone clinic visit since his birth.

Key phrases for neonatal abstinence syndrome nurses working in Spanish

Explaining why breastfeeding helps but does not prevent NOWS: “El amamantamiento ayuda — baja la puntuación y acorta el tiempo en el hospital. Pero el retiro viene del nivel de medicamento que el bebé recibió antes de nacer, a través de la placenta. Ese nivel era más alto que lo que llega ahora en la leche. El bebé se acostumbró al nivel del embarazo — el retiro es su sistema nervioso adaptsándose al cambio.” (Breastfeeding helps — it lowers the score and shortens the hospital stay. But the withdrawal comes from the level of medication the baby received before birth, through the placenta. That level was higher than what arrives now in the milk. The baby became accustomed to the pregnancy level — the withdrawal is his nervous system adapting to the change.)

Before scoring while the mother watches: “Voy a revisar doce señales del cuerpo del bebé. Mientras reviso, le explico qué mide cada una. Nada de esto mide a la mamá.” (I am going to check twelve signs of the baby’s body. While I check, I will explain what each one measures. None of this measures the mother.)

For a rising score: “El número subió desde ayer. Eso pasa normalmente en la primera semana — el pico suele ser entre el segundo y el cuarto día. Después de eso, en la mayoría de los bebés, empieza a bajar. Subir primero es la curva normal.” (The number went up since yesterday. That happens normally in the first week — the peak is usually between the second and fourth day. After that, in most babies, it starts to come down. Going up first is the normal curve.)

The score as nervous system measurement, not maternal verdict: “Esta puntuación mide lo que está pasando en el sistema nervioso del bebé mientras se adapta. No mide si es usted una buena mamá. No mide si hizo algo mal. Mide si el bebé necesita más apoyo para hacer la transición.” (This score measures what is happening in the baby’s nervous system while it adapts. It does not measure whether you are a good mother. It does not measure whether you did something wrong. It measures whether the baby needs more support to make the transition.)

Explaining why MAT and NOWS are not contradictory: “El tratamiento que usted siguió fue el correcto — la metadona o la buprenorfina estabilizó el nivel del bebé durante el embarazo y evitó los ciclos de intoxicación y retiro que podrían haber causado parto prematuro o problemas con la placenta. El retiro que tiene el bebé ahora es un efecto conocido de ese tratamiento correcto. Es manejable. Es para eso que estamos aquí.” (The treatment you followed was the correct one — the methadone or buprenorphine stabilized the baby’s level during pregnancy and avoided the cycles of intoxication and withdrawal that could have caused preterm birth or placental problems. The withdrawal the baby has now is a known effect of that correct treatment. It is manageable. That is what we are here for.)

Explaining oral morphine for NOWS: “La morfina no le da más del problema — le da justo lo suficiente para bajar la puntuación a un nivel donde pueda comer y dormir. Después bajamos la dosis un poco cada día, despacio, para que el cuerpo del bebé se vaya adaptando. Al final, no hay ningún medicamento. Es la bajada gradual que el sistema nervioso necesita en lugar de caer de golpe.” (The morphine does not give him more of the problem — it gives him just enough to bring the score to a level where he can eat and sleep. Then we lower the dose a little each day, slowly, so the baby’s body can adapt gradually. At the end, there is no medication. It is the gradual descent the nervous system needs rather than falling all at once.)

Physical dependence versus addiction in a newborn: “Los recién nacidos no pueden ser adictos — la adicción es buscar el medicamento por el efecto que produce en el cerebro, algo que requiere una capacidad del cerebro adulto. Lo que el bebé tiene es dependencia física — el cuerpo acostumbrado a un nivel. Eso se maneja con una reducción gradual. Al final de esa reducción, no hay dependencia.” (Newborns cannot be addicted — addiction is seeking the medication for the effect it produces in the brain, something that requires an adult brain capacity. What the baby has is physical dependence — the body accustomed to a level. That is managed with a gradual reduction. At the end of that reduction, there is no dependence.)

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