Wales Neonatal Network Guideline

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1 Guideline on the Management of Neonatal Abstinence Syndrome Introduction Neonatal Abstinence Syndrome (NAS) is a constellation of symptoms and signs occurring in a baby as a result of withdrawal from physically addictive substances taken by the mother. These substances include methadone, benzodiazepines, opiates, cocaine and amphetamines as well as caffeine, nicotine and some antidepressant agents. It is not known how much nicotine withdrawal contributes to symptoms. Delivery Delivery of an infant of a drug misusing mother is not in itself an indication for paediatric attendance. The use of naloxone (Narcan) should be avoided to prevent the abrupt onset of withdrawal. Post-Natal Care Infants at risk of NAS are nursed on transitional care in the post-natal ward with their mother unless a specific indication for admission to NNU is present. Breastfeeding is encouraged (HIV positive mother is the only contraindication to breast feeding) and mothers perform all routine care. NAS babies are very demanding and require a lot of comforting; it is important that the infant is nursed together with his/her mother whenever possible. Babies must be observed for at least 5 days. Mothers known to be drug misusing in pregnancy may have had a multi-agency assessment during pregnancy where a care package for mother and baby after birth will have been formulated. Urine for toxicology should be sent, after informed consent has been obtained, as soon as possible after birth. Diagnosing NAS Signs and symptoms of NAS include excessive irritability, uncoordinated sucking, vomiting and diarrhoea and poor weight gain. Rarely, convulsions may occur. The diagnosis of severity of NAS (and the need for pharmaceutical treatment) is largely subjective, but various scoring systems have been used in an attempt to standardise treatment. The scoring systems currently used are the modified Lipsitz tool 1 or the modified Finnegan system 5. Both are validated for purpose in term babies and the choice of which to use rests with the individual neonatal unit. The aim of treatment is to control symptoms to allow oral feeding, tolerable irritability and adequate weight gain. NAS is the likely diagnosis in an infant who demonstrates the signs and symptoms listed above and whose mother was known to have used addictive substances in pregnancy. Other common causes of excessive irritability can generally be excluded by careful history taking, clinical examination and measurement of blood sugar, calcium and magnesium. Management of NAS Simple measures to control symptoms of NAS include swaddling, minimising sensory stimulation, the use of dummies (after parental consent) and prolonged nursing. The pharmaceutical treatment of choice is the substance from which the infant is withdrawing,,4. 1. Exclude other diagnoses by careful history taking and clinical examination.. Document maternal drug history as accurately as possible this should be assessed in conjunction with the mother herself, with staff and with the results of maternal urine toxicology (preferably in late pregnancy).. Infants at risk of hypoglycaemia must have their blood sugar measured, and if the infant does not respond to treatment within 4 hours, or if there are any atypical clinical features, plasma calcium, phosphate and magnesium should be measured. Pharmaceutical treatment: For threshold scores to commence pharmacological treatment using each scoring tool, see appendices. Choice of treatment will depend upon the mother s drug use during pregnancy. Mothers will usually fall into categories: A. Opiate use only B. Opiate plus benzodiazepine C. Non-opiate drugs only (This is the minority of babies) A) and B) Start oral morphine solution 60micrograms/kg four hourly If symptoms are not controlled within 4 hours, increase oral morphine daily by 10micrograms/kg per dose to a maximum of 80micrograms/kg/dose. If symptoms are not controlled after 48 hours on maximum therapy add phenobarbitone (dose as below). The addition of phenobarbitone is required only in a small number of babies where withdrawal symptoms cannot be managed by maximum morphine and supportive care. C) Start oral phenobarbitone loading dose 15mg/kg, followed by maintenance dose 8mg/kg once daily. Page 1 of 5

2 Weaning treatment: For scores to commence weaning pharmacological treatment using each scoring tool, see appendices. Wean oral morphine by 10micrograms/kg per dose, ideally in daily decrements. If symptoms worsen review maternal drug history and consider addition of oral phenobarbitone. A) Wean oral morphine by 10micrograms/kg per dose per day. If symptoms worsen add oral phenobarbitone (dose as above). Aim to withdraw oral morphine before weaning phenobarbitone. Wean phenobarbitone by mg/kg every two days if symptoms are controlled. Criteria for Admission to SCBU This will vary according to local policy and facilities. Units with transitional care units or other arrangements may not need to admit the following categories of babies. 1. Withdrawal score high enough to start medication.. Poor feeding requiring placement of a nasogastric tube.. Mother discharged before infant. 4. Infant for adoption. Hepatitis B / C Policy Hepatitis B: All infants of past or present intravenous drug using parents should be offered hepatitis B vaccine irrespective of the mother s hepatitis B status. Adequately treated hepatitis B is not a contraindication to breast feeding. Hepatitis C: Vertical transmission of hepatitis C occurs in around 5% of cases of hepatitis C antibody +ve, PCR +ve women. The rate of infection is doubled by co-existent HIV infection. Rates of vertical transmission in hepatitis C antibody +ve, PCR -ve cases are much lower. Babies born to mothers who are hepatitis C PCR +ve should follow the hepatitis C guideline. Hepatitis C is not a contraindication to breast feeding. Discharge Planning This must be multiagency and involve the named midwife for maternal drug misuse and social services to ensure that there are no concerns for the child s safety at home, and to provide appropriate support services for the family. The social work team may have met with the mother during pregnancy, and will have begun to formulate plans for discharge even before the baby is born. Every effort should be made to predict the infant s discharge so that arrangements can be made well in advance, particularly if the child is to be discharged to foster care. It is essential that any concerns raised by staff during the infant s admission are properly documented and relayed to the social work team prior to discharge. The ultimate decision of social services regarding discharge should be clearly documented in the case notes, and received in writing from them. At time of discharge: Inform social services that baby has been discharged. Document contact details for the family as well as (if relevant) details of the foster carer and foster GP. Check that consent has been obtained for Hep B vaccination (subsequent doses) and/or arrangements for follow up of infant if mother hepatitis C positive. Ensure that neonatal follow up arrangements have been made. References 1. Lipsitz PJ. A proposed narcotic withdrawal score for with newborn infants. A pragmatic evaluation of its efficacy. Clin Pediatr (Phila) 1975;14: Jackson L, Ting A, McKay S, Galea P, Skeoch C. A randomised controlled trial of morphine versus phenobarbitone for neonatal abstinence syndrome. Arch Dis Child 004;89:F Coyle MG, Ferguson A, Lagasse L et al. Diluted tincture of opium (DTO) and phenobarbital vs. phenobarbital alone for the treatment of neonatal opiate withdrawal. J Pediatr 00;140: Coyle MG, Ferguson A, LaGasse L, Liu J, Lester B. Neurobehavioural effects of treatment for opiate withdrawal. Arch Dis Child 005;90:F Australian national clinical guidelines for management of drug use during pregnancy, birth and the early developmental years of the newborn. Commissioned by the Ministerial Council on Drug Safety; 006. Page of 5

3 Lipsitz Score Tool Signs 0 1 Tremors (muscle activity of limbs) Irritability (excessive crying) Normal Minimally increased when hungry or Appendix A Lipsitz Scoring Tool and Chart Moderate or marked increase when un; subside when fed or held snugly None Slightly increased when or hungry Reflexes Normal Increased Markedly increased Stools Normal Explosive, but normal frequency Muscle tone Normal Increased Rigidity Explosive, more than 8 per day Skin abrasions No Redness of knees Breaking of skin and elbows / minute < Repetitive sneezing No Yes Repetitive yawning No Yes Vomiting No Yes Fever No Yes Adapted from Lipsitz et al. Clin Pediatr 14:59-594, Lipsistz Scoring Chart Score 0 mins to 1 hour after feeds. Record scores 6 hourly. SYMPTOM Date Time Marked increase or continuous even when un, progressing to seizure-like movements Marked even when un Tremor Irritability Reflexes Stools Muscle Tone Skin Abrasions Resp. Rate Sneezing Yawning Vomiting Fever TOTAL SCORE Action Taken Threshold scores for Commencing Pharmacological Treatment (Lipsitz) Start treatment if score 5 on two occasions 1 hours apart and infant is unable to be consoled if nursed/carried and/or there is poor feeding/ongoing weight loss after 5 days Threshold scores for Weaning Pharmacological Treatment (Lipsitz) Start weaning if score < 5 on at least one occasion in the past 4 hours and/or the infant is able to be consoled if nursed and/or he/she is sleeping for periods of at least two hours between feeds. Page of 5

4 Finnegan Score Tool System Sign Description score if Appendix B Finnegan Scoring Tool and Guideline CNS High pitched cry Cries intermittently or continuously for up to 5 mins despite caregiver intervention Continuous cry Sleep Hyperactive Moro Markedly hyperactive Moro Mild Cries intermittently or continuously for greater than 5 mins Scores based on longest period of sleep within score period Increased jitteriness at end of Moro Repetitive jerks of hands and arms during or at end of Moro Observable tremors of hands and feet on handling Observable tremors of arm/s or leg/s on handling Increased muscle tone Assess when awake but not crying. There is tight flexion of arms and legs Excoriation Myoclonic jerks Generalised convulsions GIT Excessive sucking Increased rooting Respiratory/ Vasomotor Poor feeding Regurgitation Projectile vomiting Loose stools Watery stools Sweating Fever Frequent yawning Mottling Nasal congestion Sneezing Nasal flaring Adapted from L P Finnegan (1986) Finnegan Score Chart Occurs on chin, cheeks, elbow toes or nose. Score when new lesions appear Twitching of facial muscles or jerking movements of limbs Generalised activity, or subtle e.g. staring Sucks poorly during feed. May be uncoordinated feeding Not associated with wind. Score if or more times per feed. 1 or more projectile vomit per feed or just after feed Liquid stool Loose motions Perspiration on forehead in absence of overheating See score sheet > times per score interval Score if mottling on chest, trunk, arms or legs Noisy breathing due to congestion > sneezes per score interval Score only if present without lung disease Do not assess when crying Score 0 mins to 1 hour after feeds. Record 4 hourly. System Sign Score CNS High pitched cry Continuous high pitched cry Sleep <1hr after feed Sleep <hr after feed Sleep <hr after feed 1 Hyperactive Moro Markedly hyperactive Moro Mild 1 Page 4 of 5

5 Mild un un Increased muscle tone Excoriation 1 Myoclonic jerks Generalised convulsions GIT Excessive sucking 1 Respiratory/ Vasomotor Poor feeding Regurgitation Projectile vomiting Loose stools Watery stools Sweating 1 Fever 7. to 8.C 1 Fever 8.4C and above Frequent yawning 1 Mottling 1 Nasal congestion 1 Sneezing Nasal flaring 1 >60/min >60/min and recessions Total Score Threshold scores for Commencing Pharmacological Treatment (Finnegan) Start treatment if score >8 on three consecutive occasions or scores >1 and infant is unable to be consoled if nursed/carried and/or there is poor feeding/ongoing weight loss after 5 days Threshold scores for Weaning Pharmacological Treatment (Finnegan) Start weaning if consecutive scores < 8 and/or the infant is able to be consoled if nursed and/or he/she is sleeping for periods of at least two hours between feeds. Page 5 of 5

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