receptors are concentrated in the central nervous system (CNS) and gastrointestinal (GI) tract producing predominantly signs of CNS irritability and GI dysfunction45 • Methadone: o No conclusive evidence of relationship between maternal methadone dose and NAS severity33,46-48 o Associated with prolonged QT interval within first 2 days8 • Buprenorphine: o Usually milder signs and less need for pharmacologic treatment35 Methadone • 24–72 hours45 • Duration up to 30 days or more14 Buprenorphine • 48–72 hours28 • Duration up to 28 days or more7 CNS depressants Alcohol • 3–12 hours14 • Higher incidence of abdominal distention and opisthotonos, increased likelihood of apnoea and convulsions49 Barbiturates • 4–7 days up to 10–14 days45 • Median duration 3 months8 • Compared to opioids: less autonomic or GI distress, less jaundice, better Apgar scores8 Benzodiazepines • First hours up to 1 week • Duration may persist for weeks/months • May result in ‘floppy infant syndrome’ associated with toxicity50 • Late exposure associated with higher risk of respiratory problems50 • If used in conjunction with opioids, risk of severe NAS increased19 • NAS can be mild and transient to severe51 CNS Stimulants SSRIs TCA • First 48 hours14,45 • Duration 2–6 days14 • NAS more likely to be mild than severe40,52 • Timing and intensity of NAS influenced by maternal dose and duration of treatment53 • Conflicting findings about the risk of pulmonary hypertension of the newborn (PPHN) in newborn baby54 Amphetamines Methamphetamines • 24 hours55 • Duration 7–10 days • Severity of NAS may be dose-related55 • Requirement for pharmacological treatment rare55 • Heavy maternal use associated with decreased arousal55 Cocaine • 24–48 hours14 • May have no signs Other Nicotine • First 48 hours • SIDS/SUDI risk persists through infancy • Few studies involving non-combustible nicotine-containing products37 • Some reports of excitability, reactivity and hypertonia with smoking; may be dose related36 Cannabinoids • Usually no clinical signs14,35 • Higher incidence of tremors and altered visual responses14 • May exhibit signs of nicotine toxicity56 Queensland Clinical Guideline: Perinatal substance use: neonatal Refer to online version, destroy printed copies after use Page 14 of 33 4 Supportive care Although there is limited good quality evidence to inform specific interventions18,39, supportive care is considered the first line of treatment.57 Promote and recommend supportive care interventions irrespective of the maternal substance used or the severity of NAS exhibited. Refer to Appendix E: Supportive care, Appendix F: Communicating with and comforting baby and Appendix G: Baby stability and stress signals Table 11. Non-pharmacological supportive care Aspect Consideration Communicating with parent/carer • Where possible, promote establishment of relationship antenatally • Partner with parent/carer in a non-judgmental manner43 • Support and welcome involvement of parent/carer in care • Offer information about assessment of NAS, and recognising and responding to baby cues • Coach and model comfort strategies with parent/carer to: o Build parental/family competence o Nurture a trusting staff-family relationship • Refer to Queensland Clinical Guideline: Standard care21 Social integration • Rooming-in enhances bonding and may reduce stigma58 o Reduced length of treatment, reduced mean FNAS score57 o Improved breastfeeding rates58 • Facilitate early and regular skin to skin contact59 o Reduces infant pain scores and improved sleep patterns o Decreases need for pharmacotherapy • Promote positive parent/carer-baby interactions (e.g. social reciprocity, visual tracking, singing60) Feeding • Impaired feeding behaviours are common with NAS (e.g. excessive sucking, poor feeding, regurgitation and diarrhoea)61 • Breastfeeding reduces need for pharmacotherapy • Small frequent feeds may improve digestion and increase feed tolerance61 • Gavage feeds may be required for the baby with disorganised suck or who fails to engage in sufficient nutritive sucking61 • Supplementary feeds may be required for adequate caloric intake and to support weight gain61 Soothing techniques • Speaking calmly, softly and slowly to baby • Respond to baby cues o Provide position and comfort measures (e.g. swaying and rocking62) o Pacifier or dummy may decrease agitation and increase mother-baby eye contact59 o Support ‘hands to face’ for self-soothing • Side-lying and prone positioning baby can improve containment and decrease irritability but supine positioning is preferred due to increased risk of sudden infant death syndrome(SIDS)/sudden unexplained death of an infant (SUDI) in NAS babies60 • Swaddled bathing may reduce hypertonia and improve neurodevelopmental behaviours60 Environment • Avoid overstimulation57-59 o Limit exposure to lights and sound o Protect sleep and promote clustering of care39 o Provide swaddling and holding • Bed type o Non-oscillating water bed (compared to standard bed) had lower FNAS scores and earlier and more consistent weight gain63 o Mechanical rocking bed (compared to standard bed) had higher FNAS scores64 Complimentary therapies • Limited evidence but no adverse