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Queensland Neonatal Abstinence Syndrome Clinical Guideline Neonatal abstinence syndrome Queensland Maternity and Neonatal Clinical Guideline: Neonatal abstinence syndrome Document title: Neonatal abstinence syndrome Publication date: August 2010 Document number: MN10.10-V4-R15 Document The document supplement is integral to and should be read in conjunction supplement: with this guideline Amendments Full version history is supplied in the document supplement Amendment date August 2013 Replaces document: MN10.10-V3-R15 Author: Queensland Maternity and Neonatal Clinical Guidelines Program Audience: Health professionals in Queensland public and private maternity services Review date: August 2015 Statewide Maternity and Neonatal Clinical Network Endorsed by: QH Patient Safety and Quality Executive Committee Queensland Maternity and Neonatal Clinical Guidelines Program at: Contact: Email: [email protected] URL: www.health.qld.gov.au/qcg Disclaimer These guidelines have been prepared to promote and facilitate standardisation and consistency of practice, using a multidisciplinary approach. Information in this guideline is current at time of publication. Queensland Health does not accept liability to any person for loss or damage incurred as a result of reliance upon the material contained in this guideline. Clinical material offered in this guideline does not replace or remove clinical judgement or the professional care and duty necessary for each specific patient case. Clinical care carried out in accordance with this guideline should be provided within the context of locally available resources and expertise. This Guideline does not address all elements of standard practice and assumes that individual clinicians are responsible to: · Discuss care with consumers in an environment that is culturally appropriate and which enables respectful confidential discussion. This includes the use of interpreter services where necessary · Advise consumers of their choice and ensure informed consent is obtained · Provide care within scope of practice, meet all legislative requirements and maintain standards of professional conduct · Apply standard precautions and additional precautions as necessary, when delivering care · Document all care in accordance with mandatory and local requirements This work is licensed under a Creative Commons Attribution Non-Commercial No Derivatives 2.5 Australia licence. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/2.5/au/ © State of Queensland (Queensland Health) 2010 In essence you are free to copy and communicate the work in its current form for non-commercial purposes, as long as you attribute the authors and abide by the licence terms. You may not alter or adapt the work in any way. For permissions beyond the scope of this licence contact: Intellectual Property Officer, Queensland Health, GPO Box 48, Brisbane Qld 4001, email [email protected] , phone (07) 3234 1479. For further information contact Queensland Maternity and Neonatal Clinical Guidelines Program, RBWH Post Office, Herston Qld 4029, email [email protected] phone (07) 3131 6777. Refer to online version, destroy printed copies after use Page 2 of 31 Queensland Maternity and Neonatal Clinical Guideline: Neonatal abstinence syndrome Flow Chart: Neonatal abstinence syndrome assessment and management Do not administer naloxone to babies of known or suspected opioid dependent women during resuscitation or in the newborn period Known risk of NAS Perform a clinical examination on all symptomatic babies ·Consider the presence of concurrent illness ·Review risk factors for neonatal sepsis ·Investigate to exclude infection, metabolic disturbances Give supportive care ·Treat concurrent illness · Start Finnegan scoring ·Review maternal documented history for licit/illicit substance use within 2 hours of birth ·Discuss possible undisclosed substance use with mother · Continue 4–6 hourly Two consecutive scores ≥12 or three YES consecutive scores average ≥8? Is maternal NO YES dependence NO opioid? For minimum of 7 days Care setting as per local facility Care setting as per local facility (<7 non-opioid) continue: Medication: Medication: · Postnatal observations · Start PO phenobarbitone · Start PO morphine 0.5 mg/kg/day · Finnegan scores 4–6 hourly · Give loading dose for rapid onset 6 hourly · Continue with maintenance dose · Increase dose to control NAS · Increase dose to control NAS as · Add phenobarbitone if NAS required uncontrolled on maximum morphine dose (1 mg/kg/day) and/ Cardiorespiratory monitor: ·If nursed prone or history of maternal poly drug use ·When dose 10 mg/kg/day Apnoea monitor: · When commencing morphine Are Finnegan Cardiorespiratory monitor: YES scores increasing? · If nursed prone · When dose 0.7 mg/kg/day Reduce medication · When scores are consistently < 8 for 48–72 hours NO Are criteria for NO YES discharge on medication met? Confirm: Ensure: Confirm: · Discharge plan · Baby remains in hospital · Discharge plan · Medical review 1 week until medication is · Weekly hospital review after discharge ceased · Community referrals · Community referrals Queensland Maternity and Neonatal Clinical Guideline: Neonatal Abstinence Syndrome MN10.10-V4-R15 Refer to online version, destroy printed copies after use Page 3 of 31 Queensland Maternity and Neonatal Clinical Guideline: Neonatal abstinence syndrome Abbreviations ATODS Alcohol Tobacco and Other Drug Services CNS Central nervous system CPLO Child Protection Liaison Officer DoC (CSS) Department of Community (Child Safety Services) GP General Practitioner HBV Hepatitis B virus HBsAg Hepatitis B surface antigen HCV Hepatitis C virus HIV Human immunodeficiency virus IU International units IUFD Intrauterine fetal death IUGR Intrauterine growth restriction IV Intravenous LFT Liver function test NAS Neonatal abstinence syndrome NHMRC National Health and Medical Research Council PCR Polymerase chain reaction RNA Ribonucleic acid RANZCOG The Royal Australian and New Zealand College of Obstetricians and Gynaecologists RSQ Retrieval Services Queensland SIDS Sudden Infant Death Syndrome SNRI Serotonin noradrenaline reuptake inhibitor SSRI Selective serotonin reuptake inhibitor SUDI Sudden and Unexpected Death of an Infant Refer to online version, destroy printed copies after use Page 4 of 31 Queensland Maternity and Neonatal Clinical Guideline: Neonatal abstinence syndrome Table of Contents Clinical practice points .......................................................................................................................................... 6 1 Introduction ................................................................................................................................................... 7 1.1 Definition.............................................................................................................................................. 7 1.2 Substances used or misused............................................................................................................... 7 1.3 Incidence ............................................................................................................................................. 7 1.4 Antenatal care ..................................................................................................................................... 9 1.5 Labour and birth .................................................................................................................................. 9 1.5.1 Pain relief ...................................................................................................................................... 10 1.5.2 Resuscitation................................................................................................................................. 10 1.5.3 Immunisation ................................................................................................................................. 10 1.5.4 Inter-hospital transfer .................................................................................................................... 10 2 NAS assessment and diagnosis ................................................................................................................. 11 2.1 Onset of withdrawal ........................................................................................................................... 11 2.2 Clinical presentation: ......................................................................................................................... 12 2.3 Differential diagnosis ......................................................................................................................... 13 3 Measuring NAS ........................................................................................................................................... 13 3.1 Finnegan and Modified Finnegan Neonatal Abstinence Severity Score ............................................ 13 4 Neonatal care.............................................................................................................................................. 14 4.1 Preterm babies .................................................................................................................................. 14 5 Therapy ....................................................................................................................................................... 15 5.1 Care setting ......................................................................................................................................
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