Neonatal abstinence syndrome (NAS)

Published on 03/06/2015 by admin

Filed under Neonatal - Perinatal Medicine

Last modified 22/04/2025

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CHAPTER 22 Neonatal abstinence syndrome (NAS)

Mark Davies, David Cartwright

[From: Guidelines for the management of babies of substance-using women. Norton B, Kuhnert L et al. Brisbane: Grantley Stable Neonatal Unit; 2001.]

Admission guidelines

Indications for admission to the special care nursery (SCN)

Babies of mothers who have a history of using:

• opiates (heroin, methadone)
• amphetamines (speed, Ritalin) — the evidence for NAS in infants of mothers using amphetamines alone is weak
• benzodiazepines (Serepax, diazepam)
• cocaine (crack).

Admission to the special care nursery (SCN)

1. Babies at risk for NAS are monitored using the Finnegan Neonatal Abstinence Score. The minimum stay is 72 hours.

Some units allow this monitoring on the postnatal ward.

2. Baby is then transferred to postnatal ward (until at least 5 days of age) to be with mother.

Pharmacological treatment

Commence pharmacological treatment once the Finnegan scores average >8 for three consecutive scores or average >12 for two consecutive scores. Pharmacological treatment should always be done in the special care nursery.

Morphine

Morphine is used for opiate withdrawal, e.g. methadone, heroin, pethidine.

• Dose:

— start at 0.5 mg/kg/day orally, given every 6 hours (0.125 mg/kg/dose).
— increase by 0.1 mg/kg/day orally daily until controlled or until dose is 1 mg/kg/day.

• If the baby is requiring 0.9 mg/kg/day or more to control withdrawal symptoms, it is necessary to monitor cardiorespiratory function.

Consider addition of phenobarbitone 5 mg/kg/day if still not controlled on 1 mg/kg/day of morphine.

• Weaning — reduce dose by 0.1 mg/kg/day every 4 days or longer.
• If baby vomits the dose within 5 minutes, it may be readministered once only.

Phenobarbitone

Phenobarbitone is used for non-opioid withdrawal.

• Dose:

— Start with a loading dose of 15 mg/kg — IV/oral (oral dose to be given via a nasogastric tube due to large volume).

Then start a maintenance dose of 5–10 mg/kg/day (in two divided doses), starting 12 hours after the loading dose. If 10 mg/kg/day is used it should be decreased to 5 mg/kg/day after 48 hours.

— If <10 mg/kg/day is used, then the dose can be increased by 2 mg/kg/day until NAS is controlled or the dose is at 10 mg/kg/day. Then decrease after 48 hours at this dose.

• Weaning — reduce the dose by 2–4 mg/kg/day every 3 days (or longer depending on the baby’s response).
• If the baby vomits the dose within 5 minutes, then it may be repeated once only.

Breastfeeding

• Heroin use — breastfeeding is contraindicated.
• Methadone — breastfeeding is encouraged.
• Methadone plus other drugs — breastfeeding is not recommended.
• Hepatitis C — temporarily discontinue breastfeeding if nipples become cracked or bleed. Express and discard milk until completely healed.
• Women who are HIV-positive should not breastfeed.

On discharge

Infants at risk for NAS may be at risk of significant social problems when discharged — these issues should be explored prior to discharge with the involvement of a social worker.

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