Neonatal Abstinence Syndrome

Publication: 01/01/2005  --
Last review: 03/07/2018  
Next review: 03/07/2021  
Clinical Guideline
CURRENT 
ID: 274 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Neonatal Abstinence Syndrome
Neonatal/Transitional Care Ward Guideline

The use of illicit drugs has become an increasing problem over the last decade. This protocol will work as a guide treatment of neonatal abstinence.

Babies born to mothers using opiates during pregnancy are at risk of developing withdrawal symptoms during the neonatal period. The symptoms and signs of drug withdrawal are very similar to those seen in the adult and may effect all systems - as charted by various scoring systems devised for neonatal use. There is a lot of overlap with the signs of septicaemia and as babies born to drug using mothers are also at risk of congenital infection this must always be borne in mind.

Babies born to mothers known to use or suspected of using opiate drugs should never be given naloxone (Narcan ®) because of the risk of precipitating a sudden and severe withdrawal.

  • Mothers with a history of drug use will be admitted with their babies to transitional care ward for up to 7 days observation. The duration of admission may be modified on the recommendation of the Leeds drug addiction unit, who know the mothers well.
    In general minimum stay:
    • Amphetamines 2 day stay
    • Crack Cocaine 2 day stay
    • Single drug usage 5 day stay if no symptoms
    • Poly drug usage 7 day stay if no symptoms
  • Urine toxicology is no longer routinely indicated in the baby, as supported by recent evidence.
    • The mother will have provided regular samples to the Leeds Addiction Unit antenatal clinic and on admission in labour
    • These toxicology results should be reviewed and recorded in the baby’s notes.
    • If the mother is not known to LAU or there are postnatal concerns regarding NAS in the first 48 hours of life then a urine toxicology on the baby may be indicated (with maternal consent). This should be discussed with the attending consultant.
  • As complete a record as possible must be in baby's notes of the type of severity and duration of the mother's drug habit - gestation at which started, drugs used, dose used (max. and min.) and whether intravenously injected. This information should be on the green sheet in the mother's notes. If in doubt contact the drug liaison midwife for further history. It is the responsibility of the admitting neonatal doctor to move the green sheet from the mother's notes to the baby's and complete it.
  • Maternal serology (HIV, Hepatitis B and C) should be recorded on the green sheet. If not available, serology for Hep B and HIV should be obtained within 48 hrs of birth (to allow treatment) and Hep C before discharge. If necessary serology may be obtained from the baby (but only after maternal consent). Results must be known prior to discharge.
  • Record other complications of pregnancy and delivery as usual. Weight, occipito-frontal head circumference (OFC), Blood glucose must be recorded as with any other neonatal admission. Plot weight and OFC on a centile chart at birth and at time of discharge.

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Scoring & Assessment:

  • Use the Leeds Withdrawal Score sheet (47kb). A score of > 6 on the Leeds Withdrawal Score must be followed up by 2 hourly recording.
  • Infants should be scored regularly after feeds (minimum 4 hourly)
  • There is little evidence in the literature on the sensitivity and specificity of scoring systems alone, and therefore decision to treat should be used in conjunction with general observation.

Starting treatment:

  • 2 consecutive scores of > 8 indicate treatment should be commenced
  • Treatment may also be commenced following clinical concern from experienced staff. Such infants may not always reach the scoring threshold for starting treatment.

Treatment Choice

  • In the majority of women an opiate is the primary drug of abuse and in such women the available evidence supports the use of oral morphine for symptomatic neonatal drug withdrawal.
  • A starting dose of 40micrograms/kg/dose 4 hourly is suggested (total daily dose 240micrograms/kg/day). Doses should be tailored to suit the infants feeding regime.
  • If symptoms are not controlled quickly or within 24 hours 60micrograms/kg/dose (total daily dose 360micrograms) should be used.
  • A second increase to 80micrograms/kg/dose (480micrograms/kg/day) can be used if symptoms remain uncontrolled. 2 dose increases can therefore be made within 48 hours or sooner if clinical condition necessitates this.
  • Ongoing symptoms may result from withdrawal from additional non opiate substances and hence a non opiate sedative may aid symptom control. Infants whose symptoms remain uncontrolled despite 2 increases in morphine dose should therefore be commenced on phenobarbitone as per BNFC at 5mg/kg/dose once daily. Severely affected infants could therefore have second line treatment started within 48 hours. Further increases in morphine may still then be necessary.
    Phenobarbitone can be stopped prior to discharge once symptoms are under control.
  • On infrequent occasions the primary drug of abuse is a non opiate. In such infants withdrawal maybe best treated with the appropriate matched substance. For example in primary maternal benzodiazepine use lorazepam may be the most effective treatment.
  • Dose Changes
  • do not start to decrease
    - after at least 48 hours
    - if symptom control has not been achieved
  • Use Leeds Withdrawal Score sheet to calculate average score for previous 24 hours (omitting highest and lowest scores). Adjust dose depending on average score as follows:
    8+ same dose or increase by 10%
    6-8 decrease dose by 10% 24 hrly
    3-5 decrease dose by 25% 24 hrly
    0-2 decrease dose by 50% 24 hrly
  • Each dose should be given before a feed

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Note: Oral morphine solution can be available in various concentrations. Wherever possible use the dilute 100 microgram/mL strength. Always check the concentration as well as the dose prescribed.

  • If a patient is ventilated and requires opiate treatment, use:
    • Morphine sulphate infusion (see monograph)
      • Conversion factor: 2 mg oral morphine sulphate is equivalent to 1 mg of intravenous morphine sulphate.
      • Doses of up to 1200 micrograms/kg/day have been used
    • Addition of second line drugs must be discussed with the consultant in charge.
    • An observation period of 48 hours should be allowed prior to discharge, to allow for breakthrough withdrawal.
    • The fitting baby
      • Should immediately be started on morphine if not already receiving it
      • The fits should be treated with phenobarbitone (alcohol free) (see protocol)
    • Every baby (regardless of withdrawal) should be referred to the Springfield Neonatal Follow Up Clinic before discharge. Referrals will then be triaged by the team in the Springfield Clinic - not all infants will necessarily require follow up in the clinic but that will be decided by the clinic staff themselves. Liaison with Social Work Department is to be arranged if required only. All follow-up is to be arranged by the transitional care staff / outreach nurse. The mother should be given a follow-up appointment card in her hand before discharge. Please ensure a copy of the discharge letter is sent to the Springfield Neonatal Follow Up Clinic.
    • If a mother is Hep C positive, testing of the baby, as per the current Hep C guideline (hyperlink to: Hepatitis C Virus in infants of infected mothers
      Diagnosis of
      ) will be managed at the Springfield Neonatal Follow Up Clinic. It does not require a separate referral to the Neonatal Infection Clinic.
    • Hepatitis B immunisation will be offered to all these infants, regardless of type of drug use.
      • Use standard schedule (birth, 1 month, 6 months), unless mother is Hep B positive, in which case the accelerated schedule should be used (see separate guideline);
      • If baby does receive Hep B vaccine for environmental risk then a Leeds Withdrawal Score sheet  to arrange 2nd and 3rd doses. For Hep B positive mothers this is arranged automatically by the fetal screening co-ordinator.
    • Cocaine Use: It is no longer necessary to obtain a cranial ultrasound on every baby whose mother has taken cocaine in pregnancy, but this should be undertaken if the baby has a seizure or shows signs of neurological pathology.
    • Breast feeding is generally to be encouraged, even if mother has taken opiates or cocaine.
      • If heavy use or if any concerns, to discuss with pregnancy liaison team
      • Contra-indication: substance using women with positive HIV status

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Provenance

Record: 274
Objective:
Clinical condition:

Neonatal drug withdrawal

Target patient group: newborn infants
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

N/A


Evidence base

Not supplied

Document history

LHP version 1.0

Related information

Not supplied

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