events reported o Laser acupuncture as an adjunct to pharmacological therapy (compared to pharmacological only) reduced length of stay59 o Baby massage reduces maternal stress and depressive symptoms and improves mothers’ perceptions of baby calmness and comfort60 Queensland Clinical Guideline: Perinatal substance use: neonatal Refer to online version, destroy printed copies after use Page 15 of 33 4.1 Feeding Support the woman’s choice of feeding method and provide routine postnatal guidance and education. 4.1.1 Optimal feeding Table 12. Optimal feeding Aspect Optimal feeding Principles • Feeding is discussed in the antenatal period • Baby feeds when showing early hunger cues and until content • On demand without limiting duration or volume of feed • If required, lactation consultant or feeding specialist is consulted If breastfeeding • Latches deeply and comfortably for mother • Sustained active suckling with only brief pauses noted • If needed, expressed breast milk (EBM) offered on adult finger to organise suck prior to latch o Refer to Queensland Clinical Guideline: Establishing breastfeeding65 If formula feeding • Effectively coordinates suck and swallow without gagging or excessive spitting up • If needed, modify chin support, flow of milk or teat • If needed, more frequent or increased calorie feeds are given 4.1.2 Breastfeeding Table 13. Breastfeeding Aspect Consideration Importance • Well-known and substantial benefits from breastfeeding/human milk32,33 o Reduces the incidence of NAS and duration of pharmacotherapy31 o Analgesic for babies66 o Beneficial for soothing agitated baby67 o Decreased stress response and increased vagal tone in lactating women33 • Offer information to mothers about the specific benefits of breastfeeding babies at risk of NAS • Refer to Queensland Clinical Guideline: Establishing breastfeeding65 Substances in breast milk • Most substances can be found in breast milk with varying degrees of bioavailability32 • Robust pharmacokinetic data on individual substance use and the effect on the baby from breast milk is lacking32 • There is limited data to establish a ‘safe’ interval after substance use when breastfeeding can be re-established32 Risk minimisation strategies • Individualise advice according to circumstances o Seek expert advice from the multidisciplinary team as required o Refer to Appendix H: Breastfeeding recommendations by substance • Strategies may include (according to substance and use frequency/dose) o Limit/decrease substance use o Express breastmilk prior to substance use and store for later feed o Express and discard breastmilk after substance use (duration dependent on substance) o Offer formula feeds during substance use o Smoke substance outside away from baby Recommendation • Encourage and support breastfeeding unless the risks clearly outweigh the benefits o Consider risks associated with maternal functioning and toxicities associated with the substance(s) used o Refer to Appendix H: Breastfeeding recommendations by substance • Advise gradual weaning33 as abrupt cessation of breastfeeding may precipitate NAS31 Queensland Clinical Guideline: Perinatal substance use: neonatal Refer to online version, destroy printed copies after use Page 16 of 33 5 Pharmacological therapy Goals of pharmacologic therapy are to relieve discomfort, allow proper nutrition and development, and to foster parental/family bonding. 57 There is widespread support for the use of an opioid as a base therapy with adjunctive therapy if signs are not fully controlled. Few comparative studies have examined different regimens within a specific drug. Table 14. Pharmacological management Aspect Considerations Indications • Despite optimisation of supportive care, signs of NAS not adequately controlled • Following formal assessment and supportive care as per protocols [refer Appendix A: Finnegan Neonatal Abstinence Severity Score and Appendix C: Eat, Sleep Console assessment] o ESC § Any question answered ‘YES’ § OR consoling score of 3 needed o FNAS29: § Three (3) consecutive FNAS average eight (8) or more (e.g. 9 | 7 | 9) § Two (2) consecutive FNAS of 12 or more Care and monitoring • Consult and discuss need for monitoring with parents/family • Admit baby to neonatal unit for close observation and monitoring (as per local protocols) o If co-location available, support access on an individual basis Morphine • Opioid of choice for treatment of opioid NAS33,68,69 o Less likely to require treatment with second line agent68,69 o Duration of treatment may be less69 but evidence conflicting68 • Titrate doses to clinical condition to control signs of NAS o Refer to Table 15. Morphine hydrochloride schedule Phenobarbital • Initial treatment for non-opioid NAS14,33, including if substance: o Is unknown o Is a sedative such as benzodiazepine o Causes alcohol intoxication at birth o Is a SSRI or other anti-depressant o One of two or more (polysubstance use) • If signs of NAS not adequately suppressed on maximum morphine dose, may be used as adjunct to morphine69 • Titrate doses to clinical condition to control signs of NAS o Refer to Table 16. Phenobarbital dosing and weaning schedule Clonidine • Has been used as monotherapy or as adjunct to morphine in the context of non-opioid NAS70 • As an adjunct to standard opioid