department shall accept referrals, calls, and other communications from health-care providers involved in the delivery or care of infants born with and affected by FASD, maternal substance abuse resulting in prenatal drug exposure to an illegal or a legal substance, or withdrawal symptoms resulting from prenatal drug exposure to an illegal or a legal substance. Introduction Neonatal abstinence syndrome (NAS) is a syndrome of substance withdrawal with non-specific signs in the baby following chronic in-utero exposure to a variety of substances including opioids, benzodiazepines, barbiturates, selective serotonin reuptake inhibitors (SSRI), serotonin noradrenaline reuptake inhibitors (SNRI), tricyclic antidepressants (TCA) alcohol and nicotine. 1 NAS is more common in neonates born to opioid dependent women.2 As polysubstance exposure during pregnancy becomes more prevalent3, NAS is becoming an increasingly complex syndrome with less predictable time of onset, severity and response to pharmacologic therapy. 2 Maternal substance use that leads to transient withdrawal or toxicity in the neonatal period may have long term neurodevelopmental effects for the baby.4-6 Signs of withdrawal and/or the ability to adapt ex-utero, depend on the type of substance and the type of neurotransmitter that is affected.7 Signs of NAS may also be due to withdrawal, toxicity or a combination of both.8 In cases of residual toxicity (in contrast to withdrawal), further exposure to the withdrawn substance may have detrimental effects.8 Ideally, engagement with women and their families about NAS begins in the antenatal period. Refer to Queensland Clinical Guideline: Perinatal substance use: maternal9 1.1 Incidence in Queensland Reporting and comparison of NAS is complicated by different definitions, screening, assessment and diagnostic tools used in different countries, and the variety and subtlety of clinical presentation.10,11 At the time of publication, no Queensland Health data was approved for inclusion. 1.2 Modulating factors Factors that influence the likelihood of developing NAS, timing of onset, presentation and severity of signs are not completely understood and vary significantly among babies exposed to substances inutero. 7,12 Table 1. Modulating factors for NAS Aspect Consideration Gestational age and gender • Preterm babies have less severe NAS related to13: o Developmental immaturity of specific opiate receptors and neurotransmitter function o Reduced time exposed to opioids in-utero o Reduced fatty deposits of substances • Risk factors for increased severity o Term gestation/average birth weight14 o Male gender associated with increased risk of NAS15 Epigenetics/ pharmacokinetics • Pharmacogenomics14 o OPRMI 118 AA or COMT 158 AA positive genotype associated with increased length of stay and likelihood of treatment16 o Hypermethylation within the OPRM1 promoter is associated with more severe NAS, consistent with gene silencing17 • Maternal and baby metabolism and excretion18 Maternal factors • NAS more likely and/or more severe if7: o Continuous opioid use for more than 5–7 days before birth o Polysubstance use7 o Combination of opioid with benzodiazepines19 or SSRI7 or tobacco1 o Not breastfeeding14 Environmental influences • Antenatal engagement with healthcare providers • Rooming-in practices decrease effects of NAS20 • Assessment tools used to evaluate signs of NAS may influence treatment decisions • Staff and parent/carer engagement with non-pharmacological interventions • The most efficacious pharmacological treatment regimen is uncertain Queensland Clinical Guideline: Perinatal substance use: neonatal Refer to online version, destroy printed copies after use Page 7 of 33 1.3 Clinical standards Table 2. Clinical standards Aspect Consideration Routine/ standard care • Refer to Queensland Clinical Guideline: Standard care21 • Individualise care for the baby considering o History of maternal substance use (e.g. substance(s) used, dosage) o Severity of NAS and need for pharmacological interventions o Parent/carer circumstances and engagement with healthcare providers Models of care • Facilitate a team based approach across and between disciplines that commences antenatally and which extends beyond inpatient discharge • Support specialised maternity substance use programs that facilitate continuity of carer postpartum • Promote family-centred care by identifying locations where families affected by substance use can remain co-located o Aids mitigation of stressors by enhancing responsive and consistent care, and timely adjustment of care to meet baby’s needs Clinician education • Support education about NAS and use of assessment tools to22,23: o Increase reliability and scoring consistency o Facilitate inter and intra-observer validation of scoring o Reduce variability in clinical decision-making • Support clinician development on non-judgemental communication and interactions with substance using families • Support knowledge acquisition about child protection responsibilities and professional capability requirements24 Queensland Clinical Guideline: Perinatal substance use: neonatal Refer to online version, destroy printed copies after use Page 8 of 33 2 Initial newborn care Table 3. Newborn care Aspect Consideration Preparation for birth • Use clinical