Neonatal Abstinence Syndrome (NAS)- Neonatal Clinical Guideline - V2.1 January 2021 - RCHT
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Neonatal Abstinence Syndrome (NAS)-
Neonatal Clinical Guideline
V2.1
January 2021Summary
This guideline outlines the management of infants exhibiting symptoms of Neonatal
Abstinence Syndrome (NAS) and infants born to mothers exposed to drugs in pregnancy.
Neonatal Abstinence Syndrome (NAS) – Neonatal Clinical Guideline V2.1
Page 2 of 161. Aim/Purpose of this Guideline
1.1. This guideline is aimed at hospital staff responsible for the management of
babies born to mothers exposed to drugs in pregnancy
1.2. This version supersedes any previous versions of this document.
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2. The Guidance
2.1. Background
2.1.1. Drug use in pregnancy can result in fetal malformation, intrauterine
death, preterm delivery, growth restriction and an increased risk of
Antepartum haemorrhage (APH) 1,2
2.1.2. After birth withdrawal symptoms are most commonly associated with
opiate exposure 3 but can occur with a wide range of substances
including SSRIs which have a separate guideline.
2.1.3. Babies developing Neonatal Abstinence Syndrome (NAS) risk
subsequent morbidity and SIDS mortality 4,5
2.1.4. A multi-disciplinary approach is needed to optimise care for often
complex social, psychological and support issues.
2.2. Antenatal Management
2.2.1. Low compliance with antenatal care can result in late pregnancy
booking, reduced monitoring or pregnancy concealment
Neonatal Abstinence Syndrome (NAS) – Neonatal Clinical Guideline V2.1
Page 3 of 162.2.2. Discussion, consistent support, a named Drug Liaison Midwife and drug
management during pregnancy can improve outlook and gives the
opportunity for perinatal planning, monitoring and support 5
2.2.3. Accurate history is essential, with details of current and previous drug
use (noting IV drug use at any time)
2.2.4. Hepatitis B, C and HIV status. If the mother presents late in pregnancy
rapid HIV testing should be offered
2.2.5. Safeguarding Children issues should be acted upon with adherence to
local policy
2.2.6. Details of discussions with clear documentation and written parent
information are required and should include:
Proposed length of hospital stay (minimum 72hours)
Proposed plan for baby’s care and monitoring needed
Consent for early urinalysis to check mother and baby’s drug
exposure (maternal urine sample prior to labour analgesia)
Mothers’ feeding intention
2.2.7. A multi-disciplinary meeting/liaison with the agreed plan of care should
be placed in the mother’s notes/ perinatal file/baby notes prior to
expected delivery date.
2.3. Delivery and breastfeeding considerations
2.3.1. Delivery should be in hospital. Neonatal attendance at delivery is not a
routine requirement but the neonatal team should be informed of the
birth and monitoring for NAS commenced.
2.3.2. In the event of baby needing resuscitation at birth Naloxone should be
avoided due to risks of sudden onset withdrawal/seizures 6
2.3.3. Breastfeeding promotes more effective mothering when drug use is well
controlled and drug type not contraindicated (see Table 1) Mother and
baby separation should be avoided whichever feeding method chosen 7,8
The best interests of the baby are paramount in any decision to support
breastfeeding
2.3.4. Advise maternal dosing post Breastfeeding times. Discuss with
Paediatric pharmacist if unsure
Neonatal Abstinence Syndrome (NAS) – Neonatal Clinical Guideline V2.1
Page 4 of 16Table 1. Breastfeeding
BREASTFEEDING CONSIDERATIONS 9
Maternal drug exposure/Positive serology Breastfeed advice
Methadone/ Prescribed opiates eg.Codeine, Buprenorphine10 Yes
Heroin No
Selective Serotonin reuptake Inhibitors (SSRI) Refer to SSRI guideline
Amphetamine /Cocaine No
Benzodiazepines/antipsychotics Individual discussion
Alcohol use (over 6 units/day) No
Cannabis Caution
Hepatitis B/C Yes
HIV No
Poly drug/street drugs/IV drug use No
2.4. Postnatal management
2.4.1. At birth record maternal past and current drug use, dosage and route
including time of last use. Partner’s drug use.
2.4.2. Record relatives’ awareness of maternal drug use.
2.4.3. Check and document mother’s HBV, HCV and HIV viral status (Cross
reference: Local Hepatitis B, C, HIV management guidelines)
2.4.4. Record any Safeguarding Children concerns and social care
involvement with contact names, numbers and any current plan for on-
going care clearly stated in medical notes
2.4.5. Record mother’s choice of feeding method, noting prior discussions and
decisions
2.4.6. Collect urine sample from baby within 48hrs to check drug exposure
(maternal consent, check antenatal record of discussion)
2.4.7. Use supportive intervention measures; quiet area, minimal handling, dim
lighting, supportive positioning, barrier cream nappy area, small
frequent feeds, holding, swaddling, non-nutritive sucking 11,12,13 gentle
handling. Mothers will need guidance and help with this.
2.4.8. Commence withdrawal observations 4 hourly/ 1 hour post-feed times
for at least 72 hours and record severity level. See Assessment and
Intervention chart (Appendix 3 cross reference to local scoring
system)
Neonatal Abstinence Syndrome (NAS) – Neonatal Clinical Guideline V2.1
Page 5 of 162.5. Table 2. Timing of symptoms onset
Typical timing of symptom onset 13,14,15 Substance
Early 3 • 72 hours Alcohol, Heroin, Morphine,
Buprenorphine, Codeine, Diazepam,
SSRIs
24hrs -21 days Methadone, Benzodiazepines,
Barbiturates
2.6. Table 3. Typical system disturbances in NAS
MILD MODERATE SEVERE
CNS Increased muscle tone, High pitched cry, Severe tremors,
cry, irritable agitation, tremors when inability to settle post
Sleep disturbance, undisturbed, feed, frantic sucking
mild tremors when desire to feed constant high pitch
disturbed frequently crying, Seizures*
Metabolic, Yawning Mild pyrexia2.7. Pharmacological management of symptoms
Withdrawal symptoms are reduced when drugs from the same group are
reintroduced 13,14,15,16 Current drug treatment in the UK for babies with
moderate to severe symptoms commonly use the following options 17
although local policy may vary.
“Oramorph” is a brand name and refers to a particular strength of oral
morphine solution. The oral morphine used on NNU is a low concentration
(100 micrograms / ml), and should not be referred to as oramorph either on
prescription or verbally.
Table 4. Drug Treatment of NAS
PROBLEM DRUG TREATMENT OPTIONS 17,18,19
Oral Morphine Sulphate
Opiate withdrawal 40mcg/kg/dose 4 hourly
- Increase dose 20- 40mcg/kg/dose 8
hourly until symptoms controlled
- Suggested
maximum100mcg/kg/dose
[Cochrane review 2005 suggests addition
of Phenobarbitone may reduce symptom
severity]
Phenobarbitone
Non-Opiate withdrawal 20mg/kg orally loading dose
- maintenance dose 24hours later
4-5mg/kg daily in 2 divided doses
Chlorpromazine
500mcg/kg 6hourly orally
[Cochrane review suggests poor evidence
to support Chlorpromazine use]
Seizure management Oral Morphine Sulphate (for opiate
- any seizures should be fully withdrawal) 100mcg/kg stat dose oral/IV
investigated as per local seizure according to clinical status
management guideline - If on maintenance Oral
- Respiratory monitoring Morphine consider increasing dose
Phenobarbitone
Loading dose 20mg/kg oral/ IV if status
- maintenance dose 24 hours later
5mg/kg/day in 2 divided doses
Control period and weaning process options
Decrease dose NOT dose interval time. Discuss weaning difficulties with Consultant.
Local policy may varyTable 5. Weaning regimen
DRUG WEANING REGIMEN
After 24-48 hours of symptom control
Oral Morphine Sulphate reduce dose by 10-20% each 24-48
hours as tolerated until dose of 20mcg/kg
reached then reduce frequency until
40mcg/kg/DAY/stable to discontinue
After 24-48 hours stability reduce dose
Phenobarbitone by 2mg/kg/dose 48 hourly as tolerated
After 48 hours stability reduce dose by
Chlorpromazine 100-200mcg daily
*Continue NAS assessments for 48 hours post-discontinuing medication
2.8. Hepatitis B Immunisation
Newborn infants born to a hepatitis B negative woman but known to be going
home to a household with another hepatitis B infected person may be at
immediate risk of hepatitis B infection. In these situations, a monovalent dose
of hepatitis B vaccine should be offered before discharge from hospital. They
should then continue on the routine childhood schedule commencing at eight
weeks.
Newborn infants born to hepatitis B negative women who are not known to be
going home to a household with a hepatitis B infected person do not need
hepatitis B vaccination in the newborn period and should be recommended to
receive the standard universal immunisation schedule.
2.9. Discharge planning
2.9.1. Plan to discharge at 3-5 days if symptoms mild or absent and social/
parenting circumstances permit. Involve drug liaison midwife.
2.9.2. Baby can settle to sleep supine
2.9.3. If baby needed drug treatment to control NAS observe for 48 hours
after last dose before discharge
2.9.4. Commonly pre-discharge, multi-disciplinary meeting/case conference
may be needed if social or child at risk concerns
2.9.5. Clear plan for readmission if symptoms recur
2.9.6. Arrange close weight monitoring as commonly increased
supplementary calorie intake is needed
2.9.7. Contact Health Visitor, GP before discharge
2.9.8. If discharged breastfeeding, advise mother not to stop feeding
abruptly
Neonatal Abstinence Syndrome (NAS)- Neonatal Clinical Guideline V2.1
Page 8 of 162.9.9. Recommend timely completion of universal infant immunisation
schedule.
2.9.10. Follow up should be considered by Senior Medical staff before
discharge
3. Monitoring compliance and effectiveness
Element to be Key Changes to practice
monitored
Lead Dr. Chris Bell
Tool Audit recorded in Excel
Frequency As dictated by audit findings
Reporting Child Health Directorate Audit and Neonatal clinical Guidelines
arrangements Group
Acting on Dr. Chris Bell. Consultant Paediatrician and Neonatologist.
recommendations
and Lead(s)
Change in Required changes to practice will be identified and actioned within
practice and 3 months.
lessons to be A lead member of the team will be identified to take each change
shared forward where appropriate.
Lessons will be shared with all the relevant stakeholders
4. Equality and Diversity
4.1. This document complies with the Royal Cornwall Hospitals NHS Trust
service Equality and Diversity statement which can be found in the 'Equality,
Inclusion & Human Rights Policy' or the Equality and Diversity website.
4.2. Equality Impact Assessment
The Initial Equality Impact Assessment Screening Form is at Appendix 2.
Neonatal Abstinence Syndrome (NAS)- Neonatal Clinical Guideline V2.1
Page 9 of 16Appendix 1. Governance Information
Neonatal Abstinence Syndrome (NAS) Neonatal
Document Title
Clinical Guideline V2.1
This document replaces (exact Neonatal Abstinence Syndrome (NAS) Neonatal
title of previous version): Clinical Guideline V2.0
Date Issued/Approved: January 2021
Date Valid From: January 2021
Date Valid To: December 2021
Directorate / Department
Dr. Chris Bell; Consultant Neonatologist
responsible (author/owner):
Contact details: 01872 252667
This guideline outlines the management of infants
exhibiting symptoms of Neonatal Abstinence
Brief summary of contents
Syndrome (NAS) and infants born to mothers
exposed to drugs in pregnancy
Neonatal. Neonate. Newborn. Neonatal
Suggested Keywords:
Abstinence Syndrome. NAS. Drug withdrawal
RCHT CFT KCCG
Target Audience
Executive Director responsible
Medical Director
for Policy:
Approval route for consultation
Neonatal Guidelines Group
and ratification:
General Manager confirming
Mary Baulch
approval processes
Name of Governance Lead
confirming approval by specialty
Caroline Amukusana
and care group management
meetings
Links to key external standards None
1. Oei,J.Lui,K. Management of the newborn infant
affected by maternal opiates and other drugs of
dependency Journal of Paediatrics and Child Health
2007Jan-Feb;43(1-2) 9-18
2. Hunt,RW.Tzioumi,D. et al Adverse
neurodevelopmental outcome of infants exposed to
opiate in utero Early Human Development 2008
Jan,84(1)29-35
Related Documents: 3. Osborn,DA, Jeffrey,HE.Cole, MJCochrane
Database of Systematic Reviews
2005,vol/is/3(CD002053) 1469-493
4. Winklbaur, B.Jung, E.Fisher,G. Opioid dependence
and pregnancy Current Opinion in Psychiatry
May 2008. May21(3)255-9
5. Schempf, AH. Illicit drug use and neonatal
outcomes: a critical review
Neonatal Abstinence Syndrome (NAS)- Neonatal Clinical Guideline V2.1
Page 10 of 16Obsetric&Gynaecological Survey 2007 Nov,62(11)
749-57
6. Gibbs,J Newson,T et al Naloxone hazard in infant
of opioid abuser. LANCET 1989;2: 159-160
7. Abrahams, RR. Kelly,SA et al Rooming-in
compared with standard care for newborns of
mothers using methadone or heroin CanadianFam
Physician 2007 Oct,53(10):1722-30
8. Jansson,LM.Choo,R.et al. Methadone
maintenance and breastfeeding in the neonatal
period Pediatrics April 2008 Apr.121(4)869-70
9. UKMiCentral UK Drugs in Lactation Advisory
Service www.ukmicentral.nhs.uk
10. Hytinantti,T.Kahila,H.et al Neonatal outcome of 58
infants exposed to maternal buprenorphine in
utero. Acta Paediatrica May 2008
11. vanSleuwen,BE.Engelberts,AC.et al Swaddling: a
systematic review Pediatrics 2007 Oct.120(4)97-
106
12. Abdel-Latif,ME.Pinner,J et al Effects of breast
milk on the severity and outcome of
neonatal abstinence syndrome among infants of
drug- dependent mothers Pediatrics 2006
Jun;117(6)163-9
13. Maichuk,GT.Zahordny,W,Marshall,R Use of
positioning to reduce the severity of neonatal
narcotic withdrawal syndrome Journal of
Perinatology Oct 1999.vol.19(7) 510-13
14. Kutchel,C. Managing drug withdrawal in the
newborn infant Seminars in Fetal & Neonatal
Medicine 2007 Apr,12(2)127-33
15. Ebner,N.Rohmeister,K et al Management of
neonatal abstinence syndrome in neonates born to
opioid maintained women Drug & Alcohol
Dependency 2007 March16,87(2-3) 131-8
16. Kassim,Z.Greenough,A. Neonatal abstinence
syndrome: Identification and management Current
Paediatrics June 2006 vol.16/3(172-175)
17. O’Grady,MJ.Hopewell,J.White,MJ Management of
neonatal abstinence syndrome: a national survey
and review of practice Archives of Disease in
Childhood. Fetal Neonatal Ed. 2009;94 F249-252
18. BNF-C 2009 British National Formulary for
Children bnfc.org
19. Neonatal formulary 5, Drug use in pregnancy and
the first year of life 5th edition BMJ Books
2007 www.neonatalformulary.com
20. Cross references:
RCHT guidelines
Neonatal seizure management guideline
Hepatitis B Guideline
Hepatitis C Guideline
Management of HIV Guideline
Local Neonatal Formulary
Network Guidelines
Training Need Identified? No
Publication Location (refer to
Policy on Policies – Approvals Internet & Intranet Intranet Only
and Ratification):
Document Library Folder/Sub
Clinical/ Neonatal
Folder
Neonatal Abstinence Syndrome (NAS)- Neonatal Clinical Guideline V2.1
Page 11 of 16Version Control Table
Version Changes Made by
Date Summary of Changes (Name and Job
No
Title)
Author: Paul
Initial Issue - Approved at Neonatal Guidelines Munyard.
Meeting Consultant
17:8:2016 V1.0 Paediatrician and
Neonatologist.
Formatter: Kim
Smith. Staff Nurse
Hepatitis B Immunisation removed from Section
2.7. Information updated and added as an Dr Andrew
July 2018 V2.0
additional section (2.8) before Discharge Collinson
Planning (now 2.9)
Dr Chris Bell;
December Removed reference to Oramorph and clarified
V2.1 Consultant
2020 solution for use on NNU
Neonatologist
All or part of this document can be released under the Freedom of Information
Act 2000
This document is to be retained for 10 years from the date of expiry.
This document is only valid on the day of printing
Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy for the Development and Management of Knowledge, Procedural and Web
Documents (The Policy on Policies). It should not be altered in any way without the
express permission of the author or their Line Manager.
Neonatal Abstinence Syndrome (NAS)- Neonatal Clinical Guideline V2.1
Page 12 of 16Appendix 2. Equality Impact Assessment
Section 1: Equality Impact Assessment Form
Name of the strategy / policy /proposal / service function to be assessed
Neonatal Abstinence Syndrome (NAS) Neonatal Clinical Guideline V2.1
Directorate and service area: Is this a new or existing Policy?
Neonatal Existing
Name of individual/group completing EIA Contact details:
Neonatal Guidelines Group 01872 252667
1. Policy Aim This guideline is aimed at clinical staff responsible for the care of
Who is the infants born to mothers exposed to drugs in pregnancy
strategy / policy /
proposal / service
function aimed at?
2. Policy Objectives As above
3. Policy Intended Audit
Outcomes
4. How will Audit
you measure
the outcome?
5. Who is intended Patients.
to benefit from the
policy?
6a). Who did you Local External
Workforce Patients Other
consult with? groups organisations
X
b). Please list any Please record specific names of groups:
groups who have
been consulted Neonatal Guidelines Group
about this procedure.
c). What was the
outcome of the
consultation?
Approved- 12th January 2021
Neonatal Abstinence Syndrome (NAS)- Neonatal Clinical Guideline V2.1
Page 13 of 167. The Impact
Please complete the following table. If you are unsure/don’t know if there is a negative impact
you need to repeat the consultation step.
Are there concerns that the policy could have a positive/negative impact on:
Protected
Yes No Unsure Rationale for Assessment / Existing Evidence
Characteristic
Age
X
Sex (male, female
non-binary, asexual X
etc.)
Gender
reassignment X
Race/ethnic Any information provided should be in an
communities accessible format for the parent/carer/patient’s
/groups X
needs – i.e. available in different languages if
required/access to an interpreter if required
Disability
(learning disability, Those parent/carer/patients with any identified
physical disability, additional needs will be referred for additional
sensory impairment, support as appropriate - i.e to the Liaison team
X
mental health or for specialised equipment.
problems and some Written information will be provided in a format to
long term health meet the family’s needs e.g. easy read, audio etc
conditions)
Religion/
other beliefs X
Marriage and civil
partnership X
Pregnancy and
maternity X
Sexual orientation
(bisexual, gay, X
heterosexual, lesbian)
If all characteristics are ticked ‘no’, and this is not a major working or service
change, you can end the assessment here as long as you have a robust rationale
in place.
I am confident that section 2 of this EIA does not need completing as there are no highlighted
risks of negative impact occurring because of this policy.
Name of person confirming result of initial
Neonatal Guidelines Group
impact assessment:
If you have ticked ‘yes’ to any characteristic above OR this is a major working or
service change, you will need to complete section 2 of the EIA form available here:
Section 2. Full Equality Analysis
For guidance please refer to the Equality Impact Assessments Policy (available
from the document library) or contact the Human Rights, Equality and Inclusion
Lead debby.lewis@nhs.net
Neonatal Abstinence Syndrome (NAS)- Neonatal Clinical Guideline V2.1
Page 14 of 16Appendix 3. Neonatal Abstinence Syndrome Symptom Assessment Chart
Assess the baby for signs of withdrawal detailed below. Symptoms should be documented by severity. If symptoms are mild, nursing
interventions supporting mother and baby should enable non- pharmacological treatment of the withdrawal (see management guide rear of
chart) Babies displaying any consecutive assessment as ‘Moderate’ symptoms should be conveyed to the neonatal SHO for review and
possible drug treatment. Severe symptoms should be reported immediately. Frequency of assessment should depend on severity of
symptoms but 4 hourly as a minimum for the first 72 hours after birth. NNU admission and separation from the mother should be avoided.
SSRI: ADVISE 48 hours observations for SSRI use in agreement with the family. Give leaflet to mother. All babies monitored for SSRI
withdrawal should have Pulse Oximetry checked with obs in the first 24hrs. TICK symptom box for most severe symptom displayed
SYMPTOM MILD MODERATE SEVERE
Increased muscle tone, irritable. High pitched cry, agitation, tremors when undisturbed, Severe tremors, inability to settle post feed,
CNS Sleep disturbance, mild tremors when disturbed desire to feed frequently frantic sucking, Constant high pitch crying,
Seizures*
Metabolic, Sweating, unstable temperature/pyrexia over
Yawning, Sneezing, ‘Snuffly’ Pyrexia, temperature to 37.6°C in light wrap 37.6°C, excess weight loss. Hypoglycaemia
Vasomotor, Respiratory Hypoglycaemia (pre feed blood glucoseAppendix 4. Non Pharmalogical Interventions to Support Care
Various interventions are suggested in the literature to support and educate mothers/carers to recognise symptoms
of NAS and manage these babies who are extremely responsive to external stimuli. Symptoms can significantly
increase in severity with environmental or physical over stimulation
SYMPTOM INTERVENTION
Soothe infant by swaddling, holding firmly and close to the body, preferably before he/she is out
High pitched of control
cry/irritability A baby carrier can be encouraged with slow movements and gentle talking. Avoid stroking or
‘jiggling’ baby up and down
Encourage use of a dummy whilst symptoms persist
Reduction of environmental stimuli (noise, light, smell)
Inability to sleep Reduce extra visitors to a minimum
Organise care to minimise handling
Lightly wrap baby/ provide ‘nest’ barrier to support limbs
Use mittens to prevent skin trauma
Frantic sucking Offer dummy for non-nutritive sucking
of fists
Suction nasopharynx when necessary. Can be treated with saline nasal drops.
Nasal stuffiness If hindering feeding, rest between sucking attempts.
Feed small amounts more frequently, may need 2—3hourly feeds.
Poor or Check blood glucose pre feed if intake concerns/associated tremors
disorganised
feeding
Maintain fluid and calorie intake required for infant’s weight:
60ml/kg/24hrs day1, 90ml/kg day 2, 120ml/kg day 3, 150ml/kg day 4 onwards
Observe and support breastfeeding
Consider tube feeding to maintain hydration.
Wrap securely during feed and reduce stimuli to allow baby to organise him/herself.
Avoid over feeding a demanding baby – limit ‘constant’ breastfeeding with alternative measures
Measure and record intake Observe nappies for urine output
Regurgitation/
vomiting
Elevate head of the cot
May need IV fluids if vomiting persists Weigh baby each 48hrs of observation period
Use soft sheets to reduce pressure & change position frequently.
Hypertonicity of Put baby in a side lying position and flex the spine as well as the head to bring the infant out of
limbs the hyperextended position( with monitoring)
Place a soft roll in between the knees to abduct the legs and reduce muscle tone.
Use regular warm baths and gentle massage with passive limb exercises if tolerated.
Slow gentle handling.
Change position frequently to prevent excoriation, use barrier cream.
Tremors Closely observe bony prominences; knees, chin, etc.
Minimise handling. Support limbs during care giving.
Frequent nappy changes to prevent sore bottom.
Loose stools / Use barrier cream FROM DAY 1 to prevent soreness. Observe for dehydration
Sore bottom
Neonatal Abstinence Syndrome (NAS)- Neonatal Clinical Guideline V2.1
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