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Neonatal abstinence syndrome

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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).


1.Screening and diagnosis

Take into consideration comorbidities, including infectious and neurologic conditions, when considering the diagnosis of neonatal opioid withdrawal syndrome.
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.
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2.Diagnostic investigations

Clinical assessment: 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.

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  • Neonatal testing

3.Medical management

Setting of care, delivery: plan delivery of infants of mothers with substance use disorder in a center capable of providing monitoring for neonatal withdrawal.

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  • Setting of care (admission to NICU)

  • Observation

  • Pharmacotherapy

4.Nonpharmacologic interventions

Supportive care: provide nonpharmacologic interventions in all infants with opioid exposure, tailored to the clinical signs of the infant.

5.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.

6.Preventative measures

Primary prevention: 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.

7.Follow-up and surveillance

Breastfeeding: 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.
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  • Discharge from hospital

8.Quality improvement

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