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Neonatal Abstinence Syndrome

This booklet will provide you with information on Neonatal Abstinence Syndrome (NAS), what it is and how your baby will be cared for at Mater Mothers’ Hospital (MMH).

Our staff will offer you their full support and guidance, as you take on as much care for your baby as you are able to manage. If you have any questions or concerns please speak with your midwife or nurse.

Neonatal Abstinence Syndrome (NAS)

NAS is a condition that includes disturbances to a newborn baby’s central nervous system, gastro-intestinal, respiratory and autonomic systems. It is due to a baby being exposed to medication and other substances taken by their mother during pregnancy. If the substances are taken regularly, particularly in the third trimester, withdrawal symptoms can develop in the baby after birth.

Substances from which babies may withdraw include alcohol, opiates, amphetamine-type drugs, benzodiazepines and some antidepressant medication. NAS most often happens to babies who are exposed to their mother’s regular doses of methadone, buprenorphine, morphine or heroin. However, if you are on methadone or buprenorphine, your doctor will advise you to stay on this medication during your pregnancy, as going through opiate withdrawal symptoms may put you and baby at risk.

Not all babies who are exposed to substances in this way will have withdrawal symptoms. It is not possible to predict which babies will withdraw, as the amount/dose is only one factor that influences whether NAS occurs and when it starts. Other factors include:

  • the drug or medication used
  • how it is taken and how often
  • its timing around the birth
  • other drug use, genetics and environment.

Most babies who withdraw, show signs within 24 to 72 hours after birth, however some symptoms may not appear for seven to eight days. Withdrawal symptoms can vary from mild to severe and can last from one week to three months. Babies behave in their own way, responding to and recovering from NAS symptoms, interventions and medication in their own time.

If you take medications close to the time of your baby’s birth, they could be born intoxicated. If this happens, your baby will need to be observed until the drug’s effect wears off. Reducing or stopping non-prescribed and illicit drugs during pregnancy will help stop any intoxication or withdrawal symptoms experienced by your baby.

Signs of NAS

Babies do not withdraw the same way adults do. So, although you can sympathise with what your baby is experiencing, be aware that their symptoms can become quite severe. The most common symptoms of NAS are:

  • continuous crying
  • irritability
  • tremors and jitters
  • sleeping difficulties
  • stuffy nose and sneezing
  • feeding difficulties due to sucking problems
  • tense arms, legs and back
  • poor weight gain
  • vomiting/diarrhoea
  • increased breathing rate
  • increased temperature or sweating
  • skin irritation
  • seizures.

As some of these signs may be seen in babies with other medical conditions, your baby will be observed and may be tested to exclude other conditions as well.

Finnegan Score

The Finnegan Score measures a baby’s withdrawal symptoms. If a symptom is not present the score is zero. If the baby displays a severe symptom, a higher score is given.

Finnegan Score Score
CNS disturbances High pitch/excessive cry  2
Continuous (high pitched) cry  3
Sleeps < 1 hour after feed  3
Sleeps < 2 hours after feed  2
Sleeps < 3 hours after feed  1
Hyperactive Moro Reflex  2
Markedly hyperactive Moro Reflex  3
Mild tremors disturbed  1
Mod, severe tremors disturbed  2
Mild tremors undisturbed  3
Mod, severe tremors undisturbed  4
Increased muscle tone  2
Excoriation (specify area—not buttocks)  1
Myoclonic jerks  3
Generalised convulsions  5
Respiratory / vasomotor disturbances  Sweating  1
 Fever (37.3°C to 38.3°C)  1
 Fever (38.4°C and above)  2
 Frequent yawning (>3–4 times)  1
 Mottling  1
 Nasal stuffiness  1
 Sneezing (>3–4 times)  1
 Nasal flaring  2
 Respiratory rate >60/min  1
Respiratory rate >60/min with retractions  2
Gastrointestinal Disturbances  Excessive sucking  1
 Poor feeding  2
 Regurgitation  2
 Projectile vomiting  3
 Loose stools  2
 Watery stools  3

Caring for a baby with NAS

A baby exposed to its mother’s opiate use will need to stay in hospital for a minimum of seven days. The baby will be monitored for withdrawal symptoms using the Finnegan Score. If there are no signs of NAS, they will be discharged by day seven. If treatment is required, they will be admitted to the Neonatal Critical Care Unit for a longer stay.

Each baby is treated individually so we do not estimate the length of stay. Sometimes babies need to stay in hospital for the whole of their NAS treatment, while other babies go home on medication. Their individual response to treatment will determine when they will be discharged from hospital.

After your baby’s birth, they may be transferred with you to the postnatal ward. Babies are admitted to the Neonatal Critical Care Unit only when:

  • the mother has not attended CHAMP or another antenatal care
  • when her drug use is unknown or out of control
  • or if the baby requires special care.

Using the Finnegan Score begins about two hours after birth and is done once every eight hours by you and your midwife. If the total Finnegan Score is three or more, it is increased to four to six times every hour. If the total Finnegan Score is eight or more the paediatrician is notified. If the score continues to be eight or more, consideration is given to transferring the baby to the Neonatal Critical Care Unit for closer observation and, possibly, to begin medication.

Medication

Morphine is a synthetic opiate and is used to treat babies with NAS that is the result of exposure to opiate use. Morphine is usually given as an oral medication. It is given four to six times a day because it does not stay in the body for more than a few hours.

Phenobarbitone is a barbiturate medication sometimes used to reduce withdrawal symptoms in newborn babies. It can be given to NAS babies, usually when the mother has used non-opiate substances or has used a mixture of medications. Please remember to inform staff of your recent drug use.

Medication doses prescribed for your baby will depend on the Finnegan Score and your baby’s weight. The dose may need to be adjusted depending on their response to previous doses. Once your baby is settled, the medication will be reduced gradually—usually every second day. The Finnegan Score continues at this time as it provides a measure of how well your baby copes with dose reductions.

The decision to discharge a baby and send them home on medication is made by the care team and is based on the condition and progress of the baby. Your baby’s withdrawal symptoms should be well under control, they should be coping with the dose reductions, feeding well and gaining weight. Parents must also be able to dose their baby and be willing to have twice-weekly contact with the hospital until their baby is off the medication. Careful thought should be given before requesting NAS home treatment as it requires a big commitment from parents.

If a baby is discharged from the Neonatal Critical Care Unit, you and your partner will be able to room-in with your baby prior to discharge.

NAS Carepath

Babies who are admitted for NAS monitoring are nursed using a clinical pathway which guides their care. MMH staff know how to give supportive care in response to early withdrawal symptoms. They can also document the information that they give you, via a Parent Education Map.

Outcomes

Medical evidence shows that while some babies of opioid dependent mothers may experience developmental delays, they usually catch up by 12 months of age. A child’s ongoing development and learning will depend on the nurturing received at home and school.

Parents’ experiences

Having a baby in hospital for a long time and being away from your partner or other children is not easy and you will need to plan your time accordingly. It can be an emotional time with feelings of joy for a new baby while at the same time you may feel anxiety, anger, sadness, grief and disappointment at what is happening to your baby. Some parents may wonder if others judge their ability to be a good parent but be assured that you have done the best you could possibly do.

Staff are keen for you to provide most of your baby’s care and will treat you with respect, but will be mindful that you may be feeling anxious. Our goal is to provide you with the information and support you need to be able to:

  • respond well to your baby
  • help you and your baby through the hospital stay
  • get your baby home as soon as possible.

Breastfeeding and expressing

Breastfeeding is recommended for all babies. It is especially important for babies with NAS as it is thought to help with withdrawal symptoms. It provides an opportunity for close contact and skin to skin care. Breastfeeding will require some commitment from you, but the benefits to your baby will be well worth your efforts. Talk to staff about expressing and ask for some tips on how to make breastfeeding a little easier. For further information, please ask for the Mater Mothers’ Hospitals booklet: A Guide to Breastfeeding, if you don’t already have one.

Responding to your baby

Midwives will teach you ways to comfort and settle your baby. Learning how and when to use the techniques that best suit your baby will help you feel confident to care for them at home. These techniques reflect current safe sleeping guidelines and may be helpful for settling or comforting your baby.

Prolonged crying—hold them close to your body, perhaps wrapped in a blanket or sheet. Reduce loud noises, bright lights and excessive handling.

Sleeplessness—reduce loud noises, bright lights and patting or touching your baby too much. Soft, gentle music or rocking may help, as will a clean nappy and a dry bottom. Feed your baby if they seem hungry.

Excessive sucking of fists—cover your baby’s hands with gloves or mittens if their skin becomes damaged. Keep areas of damaged skin clean with baby soap and water. Avoid lotions and creams as your baby may suck them. Use a dummy when necessary.

Difficult or poor feeding—feed in quiet, calm surroundings with minimal noise and disturbance. Giving smaller feeds more often may help. Keep your baby in a semi-sitting position and well supported. If bottle feeding, use a slow teat. Feed your baby slowly, allowing time for resting between sucking intervals.

Avoid letting your baby sleep on their tummy—always sleep them on their back.

Sneezing, stuffy nose or breathing troubles—keep your baby’s nose and mouth clean and avoid overdressing or wrapping your baby too tightly. If breathing difficulties continue or worsen, contact your GP or hospital.

Regurgitation and/or vomiting—burp your baby each time they stop sucking and after feeding. Support your baby’s cheeks and lower jaw to enhance sucking and swallowing efforts. Safe sleeping guidelines recommend "back to sleep", that is, only sleep your baby on their back. Babies will turn their heads to the side when vomiting if their heads are free of covers. Keep your baby clean and their bedding free of vomit.

Hyperactivity—use soft flannel blankets for comfort. Speak softly to your baby and play soft, soothing music.

Trembling—keep your baby in a warm quiet room. Avoid excessive handling.

Fever—temperature over 37.2ºC. Keep clothing to a minimum, avoid excessive bedclothes. Place your baby in a cool room with a fan but avoid fan blowing directly on to them. Seek medical advice if your baby’s temperature stays elevated for more than four hours or if other symptoms develop.

Nappy area excoriation—ensure prompt changing of soiled nappies. Clean your baby’s bottom with warm water and apply a barrier cream, for example, zinc or castor oil.

Going home

All babies who are admitted for NAS monitoring are followed up by a hospital paediatrician at Mater Children’s Hospital Short Term Follow-up Clinic (STFC) in the week following discharge. This is a very important appointment and must not be missed. During your first week at home together, you will be contacted by MMH nurses and later by Community Child Health nurses.

Source: Adapted with permission from the King Edward Memorial Hospital’s NAS Information booklet (Perth, WA).

An initiative of the Mater Mothers’ Hospital’s NIDS Project funded by the Commonwealth Department of Health and Ageing.

Mater Mothers’ Hospital
Raymond Terrace,
South Brisbane Qld 4101
Phone: 07 3163 2417
Email: champ@mater.org.au

© 2013 Mater Misericordiae Ltd. ACN 096 708 922.

Mater acknowledges consumer consultation in the development of this patient information.
Mater Doc Num: HOSP-002-01093
Last modified 19/11/2015.
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