Neonatal Abstinence Syndrome



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Neonatal Abstinence Syndrome

Discontinuation of morphine:

  • Discontinue morphine when a single dose is <0.02mg/kg/dose
  • Monitor in hospital at least 48hr after last dose
  • Schedule PMD followup for <1 week

Failed morphine discontinuation:

If morphine discontinued and NAS scores ≥9 x3 (or ≥11 if >21 days old) AND functional impairment:

  • Restart morphine 0.01mg/kg/dose PO based on previous dosing weight
  • Either q3h x24hr, then discontinue OR
  • q6h x24h, then discontinue

Minimum observation period for neonates exposed to maternal:

  • THC or methamphetamines: normal newborn observation
  • Short-acting prescription narcotics: 4 days
  • Short-acting narcotics in addition to other agents: 4-7 days
  • Buprenorphine/Suboxone: 5-6 days
  • Heroin/methadone: 5-7 days

NAS “Bundle of Care”

Parent Contact:

  • Presence at bedside (or cuddler)
  • Skin-to-skin/held
  • Swaddling with infant hands near mouth
  • Non-nutritive sucking/pacifier)
  • Environment:
  • Quiet, low light
  • Limit number of visitors
  • Avoid excessive handling/stimulation
  • Do not walk or sway while feeding
  • Swing ok but stop if overstimulation

Feeding:

  • On-demand
  • Encourage breastfeeding/lactation consult if eligible (matenal methaone ok)
  • Lactose-reduced or partially hydrolyzed if formula
  • Consider 22kcal/oz after day 2-3

Skin:

  • Diaper cream on day 1
  • Treat all skin excoriation

References:

Neonatal Abstinence Syndrome. Internal JMH/VC document

Inclusion Criteria
  • Newborn with prenatal narcotic exposure
  • >=36wk gestational age
Exclusion Criteria
  • Any concomitant medical issues should be discussed with neonatologist

Withdrawal Assessment

  • Finnegan score (Neonatal Abstinence Score) assessment should begin within 4-6hr of birth
  • Assess infants q3-4hr with routine cares, after feeding
  • Preferably assess on parent skin-to-skin or held swaddled
  • Review parent diary

Optimize non-pharmacologic care

Ensure following as many elements of 'NAS Bundle of Care' as possible

Initiation of pharmacologic therapy

Consider initiation of morphine after a team huddle if:

  • Non-pharmacologic care optimized AND
  • NAS score ≥9 x3 consecutively, or ≥12 x2 consecutively AND
  • 'Functional impairment' AND
  • Non-NAS causes excluded

  • Admit to NICU and initiate morphine:
  • Initial morphine dose (use birth weight):
  •     Enteral: 0.04mg/kg/dose PO q3h
  •     IV: 0.02mg/kg/dose IV q3h (if unable to tolerate PO/NG feeds)
  • Continue scoring q3-4hr with cares
  • Continue non-pharmacologic support

Functional Impairment

  • Poor feeding due to NAS (unable to sustain feeding x10min or take age-appropriate volume) OR
  • Sleeps <1 hour after feeding OR
  • Unable to be consoled for over 10 minutes

Increasing morphine:

  • Increase morphine if, despite optimal non-pharmacologic care, NAS score remains ≥9 x2 in a row and functional impairment noted
  • Consider morphine bolus 0.02mg/kg PO once (or 0.01mg/kg IV)
  • Increase baseline dose by 0.02mg/kg/dose PO (or 0.01mg/kg/dose IV) to a maximum of 0.12mg/kg/dose PO q3h (or 1mg/kg/DAY)

Secondary Agents:

Consider adding a secondary agent if using max morphine dose AND:

  • Persistent NAS scores ≥9 (≥11 if >21 days old) AND functional impairment OR
  • Stalled weaning for 2-3 days (particularly with polypharmacy, after first attempting morphine re-stabilization)

1st Line: Clonidine 1mcg/kg/dose PO q4h

  • When off morphine x48h, wean to 0.5mcg/kg/dose PO q4h x48hr, then discontinue

2nd Line OR if exposed to benzodiazepine/barbiturates: Phenobarbital

  • Load 10mg/kg/dose PO q12hr x2 doses
  • Then 5mg/kg/dose PO q24hr maintenance
  • When off morphine x48hr, wean dose by 10-20% daily
  • Discontinue when stable on 2-3 mg/kg/dose

Wean off of morphine BEFORE weaning secondary agents

Monitor in hospital at least 48hr after last dose and schedule PMD follow-up for <1 week

Morphine weaning:

  • Initiate morphine weaning if NAS scores primarily <9 (no consecutive ≥9 in last 24h) after maintaining same dose x24-48h and able to eat/sleep/console
  • If stabilization dose is ≤0.1mg/kg/dose PO, then wean by 0.01mg/kg/dose PO (0.005mg/kg/dose IV)
  • If stabilization dose is >0.1mg/kg/dose PO, then determine 10% of original stabilizing dose and wean by this amount
  • Continue weaning morphine dose every 24 hours if NAS scores remain primarily <9 (if >21d old, wean if scores <11) OR infant continues eating, sleeping, consoling adequately

Failed morphine weans:

  • If, after a wean, persistent NAS scores ≥9 x3 (or ≥11 x3 if >21 days old) AND functional impairment eating/sleeping consoling:
  • Examine to ensure no organic pathology
  • Ensure non-pharmacologic care is maximized and symptoms are due to NAS
  • Option 1: Hold at current dose for up to 24hr, particularly toward end of weaning process
  • Option 2: Consider weight-adjusting or increasing morphine dose by 10%
  • Option 3: Consider adding secondary agent if <50% through wean and multiple failed weans