Neonatal Abstinence Syndrome (NAS)

Maternal History & Presentation

• Maternal use of opioids (methadone, buprenorphine, heroin) or polysubstance abuse.
• High-pitched persistent cry, severe tremors, jitteriness, exaggerated Moro reflex.
• Gastrointestinal: Poor feeding, excessive active sucking without latch, explosive diarrhea, vomiting.
• Autonomic: Sweating, frequent yawning, sneezing (>3x/interval), tachypnea, fever without infection.

Assessment Protocol

• Initiate Eat, Sleep, Console (ESC) care tool or Finnegan Neonatal Abstinence Scoring System (FNASS).
• Begin scoring at 2 hours of life, then every 3-4 hours strictly locked to feeding cycles.
• Obtain meconium toxicology screen and umbilical cord stat testing for comprehensive drug panel validation.
• Rule out concurrent conditions mimicking NAS: Hypocalcemia, hypoglycemia, sepsis, hyperthyroidism.

Non-Pharmacologic Care (Phase 1)

• Rooming-in with the mother is the primary non-pharmacologic intervention; drastically reduces length of stay.
• Swaddling tightly, swaying vertically, minimal sensory stimulation (low light, quiet env).
• Demand feeding, offering frequent small highly-caloric feeds.
• Promote breastfeeding strictly UNLESS contraindicated (e.g., maternal HIV, active illicit poly-substance use, hepatitis C with cracked nipples).

Pharmacologic Treatment (Phase 2)

• Morphine initial dosing: typically 0.04-0.05 mg/kg/dose PO every 3-4 hours if ESC failure or high Finnegan scores (>8 times three).
• Clonidine (alpha-2 agonist) dosing: 0.5-1 mcg/kg/dose PO every 3-6 hours as adjunct therapy for refractory symptoms.
• Strict weaning protocol: Wean opioid dose by 10% every 24-48 hours once clinically stable for continuous 48 hours.
• Monitor strictly for respiratory depression resulting from escalating opioid administration.

Diagnostic & Management Algorithm

• NAS Assessment and Wean: [START] In utero opiate exposure -> [MONITOR] Finnegan/Eat-Sleep-Console scoring -> [DECISION] Scores > 8 x 3 or poor ESC? -> [YES] Initiate Morphine/Methadone -> [GOAL] Stabilize, then wean by 10% daily

References

1. Patrick SW, Barfield WD, Poindexter BB. Neonatal Opioid Withdrawal Syndrome. Pediatrics.
2. Wachman EM, Grossman M, Schiff DM, et al. Quality improvement initiative to improve care for neonatal abstinence syndrome. Pediatrics.