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Neonatal abstinence syndrome

What's new

Added 2023 SOGC, 2020 AAP, and 2017 ACOG guidelines for the diagnosis and management of neonatal abstinence syndrome.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of neonatal abstinence syndrome are prepared by our editorial team based on guidelines from the Society of Obstetricians and Gynaecologists of Canada (SOGC 2023,2017), the American Academy of Pediatrics (AAP 2020), and the American College of Obstetricians and Gynecologists (ACOG 2017). ...
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Screening and diagnosis

Diagnosis
As per AAP 2020 guidelines:
Take into consideration comorbidities, including infectious and neurologic conditions, when considering the diagnosis of neonatal opioid withdrawal syndrome.
E
Establish the diagnosis of neonatal opioid withdrawal syndrome only if no other potential causes of neonatal symptoms have been identified after a full evaluation and no clear in-utero exposure has been identified through maternal history, screening, or testing.
E
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Diagnostic investigations

Clinical assessment: as per AAP 2020 guidelines, obtain a standardized assessment with a commonly used tool (such as the modified Finnegan score) to measure the presence and severity of withdrawal symptoms in all infants at risk for neonatal opioid withdrawal syndrome, as well as to assess the response to treatment.
E
Modified Finnegan Neonatal Abstinence Score (NAS)
Cry
Normal
Excessive high-pitched cry < 5 minutes
Continuous high-pitched cry > 5 minutes
Sleep
Sleeps > 3 hours after feeding
Sleeps < 3 hours after feeding
Sleeps < 2 hours after feeding
Sleeps < 1 hour after feeding
Moro reflex
Normal
Hyperactive
Markedly hyperactive
Tremor
None
Mild tremors when disturbed
Moderate-to-severe tremors when disturbed
Mild tremors when undisturbed
Moderate-to-severe tremors when undisturbed
Increased muscle tone
No
Yes
Excoriations (chin, knees, elbows, toes, nose)
No
Yes
Myoclonic jerks (twitching/jerking of limbs)
No
Yes
Generalized convulsions
No
Yes
Sweating
No
Yes
Hyperthermia
None
37.2-38.3 °C [99.0-100.9 °F]
> 38.3 °C [> 100.9 °F]
Frequent yawning
No
Yes
Mottling
No
Yes
Nasal stuffiness
No
Yes
Sneezing (> 3-4 times per scoring interval)
No
Yes
Nasal flaring
No
Yes
Respiratory rate
Normal
> 60 breaths/minute without retractions
> 60 breaths/minute with retractions
Excessive sucking
No
Yes
Poor feeding
No
Yes
Regurgitation
No
≥ 2 times during/after feeding
Projectile vomiting
No
Yes
Stools
Normal
Loose (curds/seedy)
Watery (water ring on diaper around stool)
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  • Neonatal testing

Medical management

Setting of care, delivery: as per SOGC 2023 guidelines, plan delivery of infants of mothers with substance use disorder in a center capable of providing monitoring for neonatal withdrawal.
A

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  • Setting of care (admission to NICU)

  • Observation

  • Pharmacotherapy

Nonpharmacologic interventions

Supportive care: as per AAP 2020 guidelines, provide nonpharmacologic interventions in all infants with opioid exposure, tailored to the clinical signs of the infant.
E

Patient education

Antenatal counseling: as per AAP 2020 guidelines, provide antenatal counseling with education on the clinical signs of withdrawal and enhancement of maternal understanding of postnatal treatment (such as nonpharmacologic treatment, including breastfeeding, and pharmacotherapy) in pregnant patients with opioid use disorder. Provide maternal antenatal counseling by a pediatric provider when possible.
E

Preventative measures

Primary prevention: as per ACOG 2017 guidelines, obtain early universal screening for opioid use during pregnancy and offer brief intervention (such as engaging the patient in a short conversation, providing feedback and advice) and referral for treatment for opioid use and opioid use disorder to improve maternal and infant outcomes.
E

Follow-up and surveillance

Breastfeeding: as per AAP 2020 guidelines, support breastfeeding if there are no other contraindications in infants of mothers receiving treatment for opioid use disorder with buprenorphine or methadone without a relapse for ≥ 90 days.
E
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  • Discharge from hospital

Quality improvement

Access to treatment: as per AAP 2020 guidelines, ensure that all pregnant females have access to medications for opioid use disorder to reduce the risk of overdose death and improve pregnancy outcomes.
E
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  • Hospital requirements