Chapter 145: Neonatal Abstinence Syndrome (NAS)

Opioid withdrawal · Eat, Sleep, Console (ESC) · Finnegan scoring · Nonpharmacologic care (rooming-in, breastfeeding) · Pharmacologic treatment (morphine, methadone, buprenorphine) · Discharge planning
🩺 Key fact: Rate of NAS increased sixfold in US (2000-2017). First-line treatment is nonpharmacologic; morphine if ESC criteria met.

🩺 Neonatal Abstinence Syndrome: Core Concepts

📊 Epidemiology
Rate 7.2 per 1,000 hospital births (US). Due to maternal opioid use (prescription, heroin, fentanyl). Also prenatal benzodiazepines, SSRIs, gabapentin may worsen withdrawal.
🩺 Clinical signs
CNS: tremors, irritability, high-pitched cry, hypertonia. GI: poor feeding, vomiting, diarrhea. Autonomic: sneezing, yawning, fever, tachypnea.
📝 Assessment tools
Finnegan (traditional) vs Eat, Sleep, Console (ESC). ESC: pharmacologic treatment if infant cannot eat (>10 min/feed), sleep (<1h after feed), or be consoled (>10 min).
💊 Nonpharmacologic care (first-line)
Rooming-in, skin-to-skin, breastfeeding, low-stimulation environment, swaddling, demand feeding.
💉 Pharmacologic treatment
Morphine (0.05 mg/kg q3h), methadone, buprenorphine. Wean after stabilization. Adjuvant: clonidine (if autonomic symptoms).
📈 Long-term follow-up
Refer to early intervention. Monitor for developmental delays. Breastfeeding safe with MOUD (buprenorphine/methadone).
⚡ ESC criteria for pharmacotherapy: Inability to eat (>10 min to feed or <10 mL), sleep (<1 hour), or be consoled (>10 min) despite optimal nonpharmacologic care.

🔍 Approach to infant at risk for NAS

1
Identify at-risk infant – Maternal opioid use disorder (methadone, buprenorphine, illicit opioids). Also polysubstance use (benzodiazepines, SSRIs, gabapentin, tobacco).
2
Observation period – Short-acting opioids (heroin): observe ≥3 days. Long-acting (methadone, buprenorphine): observe ≥5 days.
3
Use standardized assessment (ESC preferred) – Eat, Sleep, Console: evaluate after each feed. If unable to eat, sleep, or be consoled → pharmacotherapy.
4
Provide nonpharmacologic care – Rooming-in, breastfeeding (if no contraindications, e.g., HIV, active relapse), skin-to-skin, swaddling, quiet environment.
5
Exclude other causes of symptoms – Sepsis, hypoglycemia, hypocalcemia, CNS pathology, GERD.

📋 Stepwise management of NAS

1
Nonpharmacologic interventions (first-line) – Rooming-in with mother, breastfeeding, skin-to-skin, swaddling, low lighting, cluster care, demand feeding. Reduces need for pharmacotherapy.
2
Eat, Sleep, Console (ESC) assessment – Document inability to eat (>10 min or <10 mL), sleep (<1h after feed), or console (>10 min) despite optimal nonpharm care → initiate pharmacotherapy.
3
Pharmacologic treatment (morphine first-line) – Starting dose: 0.05 mg/kg q3h (oral solution). Adjust based on ESC/Finnigan. Wean after stabilization (usually 5-7 days).
4
Alternative medications – Methadone (long-acting), buprenorphine (sublingual). Clonidine as adjuvant for autonomic symptoms (tachypnea, fever).
5
Discharge planning – Infant must be off opioids or on stable weaning plan (outpatient weaning). Ensure follow-up with pediatrician, early intervention (IDEA Part C), and social services.
📌 Breastfeeding with MOUD: Encouraged if mother has no recent relapse (≥30 days abstinent, ideally ≥90 days) and no HIV or active IV drug use.

🧠 Rapid reflex prompts – NAS

📌 First-line treatment for NAS?
Nonpharmacologic care (rooming-in, breastfeeding, skin-to-skin, swaddling).
📌 ESC criteria for pharmacotherapy?
Infant cannot eat, sleep (<1h), or be consoled (>10 min) despite nonpharm care.
📌 First-line medication for NAS?
Oral morphine (0.05 mg/kg q3h).
📌 Observation period for methadone-exposed infant?
At least 5 days (long half-life).
📌 Can breastfeeding be done on buprenorphine/methadone?
Yes, encouraged if no contraindications (HIV, active relapse).
📌 Four Ps screening tool for prenatal substance use?
Parents, Partner, Past, Present – quick validated screen.
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