Neonatal Abstinence Syndrome (NAS)
Description Diagnostic criteria General and supportive measures Medicine treatment Referral ICD-10 code: P96.1 DESCRIPTION Postnatal opioid (or non-opioid illicit drug) withdrawal syndrome occurring in 55–94% of newborns whose mothers were addicted to or treated with opioids or other nonopioid illicit drugs, during pregnancy. Can result in: foetal malformation, intrauterine death, preterm d
Description
Diagnostic criteria
General and supportive measures
Medicine treatment
Referral
ICD-10 code: P96.1
DESCRIPTION
Postnatal opioid (or non-opioid illicit drug) withdrawal syndrome occurring in 55–94% of newborns whose mothers were addicted to or treated with opioids or other nonopioid illicit drugs, during pregnancy.
Can result in:
- foetal malformation,
- intrauterine death,
- preterm delivery,
- growth restriction, and
- an increased risk of antepartum haemorrhage (APH).
After birth, withdrawal symptoms are most commonly associated with opiate exposure, but can occur with a wide range of substances, including SSRIs, which have a separate guideline. Babies developing Neonatal Abstinence Syndrome (NAS) risk subsequent morbidity and SIDS mortality. A multi-disciplinary approach is needed to optimise care for often, complex social, psychological and support issues.
DIAGNOSTIC CRITERIA
Mother:
- Assess the mother's drug use – especially during pregnancy.
- The mother's urine may be screened for drugs as well.
Newborn:
- Neonatal abstinence syndrome scoring system (Modified Finnegan can be used http://www.lkpz.nl/docs/lkpz_pdf_1310485469.pdf), which assigns points based on each symptom and its severity. The infant's score can help determine treatment.
- Toxicology (drug) screen of urine and of first bowel movements (meconium).
GENERAL AND SUPPORTIVE MEASURES
- At birth, record maternal past and current drug use, dosage and route, including time of last use. Inquire about partner’s drug use – consider adding it to the Roadto-Health Chart.
- Record relatives’ awareness of maternal drug use.
- Check and document mother’s viral status and offer Hepatitis B vaccine.
- (Cross reference: Local Hepatitis B, C, HIV management guidelines).
- Record mother’s choice of feeding method, noting prior discussions and decisions.
- Breastfeeding is not contra-indicated. Mother and baby need to be monitored closely.
- Collect a urine sample from baby within 48 hours to check drug exposure – maternal consent, check antenatal record.
- Commence withdrawal observations 4 hourly/1-hour post feed times for at least 72 hours and record severity level. See the table below for guidance.
Table for timing of symptoms onset.
| Typical timing of symptom onset | Substance |
| 3–72 hours | Alcohol, heroin, morphine, buprenorphine, codeine, diazepam, SSRIs. |
| 24 hours–21 days | Methadone, benzodiazepines, barbiturates. |
MEDICINE TREATMENT
Withdrawal symptoms are reduced when drugs from the same group are reintroduced. Heroin is the most commonly abused illicit opioid in South Africa and is referred to as ‘unga’ or ‘Thai white’. ‘Sugars’ is a mixture of cheap heroin and cocaine that can be cut with a variety of other substances that may even include rat poison or other household detergents. ‘Nyaope’ is a mixture of cheap heroin and cannabis that is commonly used is Gauteng. This mixture is also referred to as ‘Pinch’ in other some areas. There is debate about the exact content of the street drug, ‘Woonga’. It is thought to consist of a number of different substances, that may include heroin, crystal methamphetamine as well as rat poison and antiretroviral medications, specifically efavirenz.
Medicine treatment of NAS
| Problem Drug | Treatment Options |
| Opiate withdrawal |
- Morphine sulphate (Addition of phenobarbitone may reduce symptom severity.) |
| Non-opiate withdrawal | - Phenobarbitone - 20 mg/kg, orally, loading dose. - Maintenance dose 24 hours later. - 4 mg/kg daily in 2 divided doses. |
| Seizure management |
Any seizures should be fully investigated: see: Seizures, neonatal. - Phenobarbitone For opioid withdrawal: If on maintenance morphine sulphate, consider increasing dose. |
Weaning Process
- Decrease dose, NOT dose interval time.
- Discuss weaning difficulties with a specialist.
Weaning regimen
| Drug | Weaning Regimen |
| Morphine sulphate | After 24–48 hours of symptom control, reduce dose by 10– 20% each 24–48 hours as tolerated until dose of 20 mcg/kg reached. Discontinue morphine once dose is 10 mcg/kg/day and observe for 48 hours. |
| Phenobarbitone | After 24–48 hours of stability, reduce dose by 2 mg/kg/dose 48 hourly as tolerated. |
Note:
- Continue NAS assessments for 48 hours after discontinuing medication.
- Ensure Hepatitis B immunisation is given when due.
REFERRAL
- All neonates with repeated seizures.
Standard Treatment Guidelines And Essential Medicines List For South Africa, Hospital Level, Paediatrics, 2023 Edition
Chapter 19: Prematurity And Neonatal Conditions, 19.10 Neonatal Abstinence Syndrome (NAS)