• Titrate doses to control signs of NAS • May require reduction in dosing interval to 4 hourly or increase in total daily dose Vomiting baby • Reduce the risk of baby vomiting morphine dose by: o Giving the dose before a feed o Ensuring the baby is not overfed • If large vomit within 15 minutes of receiving the dose, repeat dose once only Weaning • Commence weaning when signs of NAS controlled for 48–72 hours as evidenced by o FNAS consistently less than 8 or o ESC questions consistently answered ‘NO’ • Modify rate of weaning according to clinical response • Do not reduce dose by more than 0.1 mg/kg/day within 48 hours of a prior reduction, unless there are other indications (e.g. over-sedated baby) From 4 hourly dosing • Reduce total daily dose by 0.1–0.2 mg/kg/day no more than every 48 hours until 0.2 mg/kg/day then • Maintain same total daily dose and reduce frequency to every 6 hours From 6 hourly dosing • Reduce total daily dose by 0.1–0.2 mg/kg/day no more than every 48 hours Discontinue • When total daily dose is 0.1–0.12 mg/kg/day based on birth weight or current weight whichever is greater • Continue assessments for 72 hours after ceasing morphine Queensland Clinical Guideline: Perinatal substance use: neonatal Refer to online version, destroy printed copies after use Page 18 of 33 5.2 Phenobarbital schedule Refer to NeoMedQ phenobarbital (phenobarbitone)80 Table 16. Phenobarbital dosing and weaning schedule Total daily dose (mg/kg/day IV or oral) Oral or IV Loading dose 10–15 mg/kg once Maintenance (start 12 hours after loading) Equivalent 12 hourly dose • Commence at 5 mg/kg/day oral or IV in two divided doses 2.5 mg/kg every 12 hours • If signs not controlled on 5 mg/kg/day o Increase to 8 mg/kg/day oral or IV in two divided doses 4 mg/kg every 12 hours • If signs not controlled on 8 mg/kg/day o Increase to 10 mg/kg/day oral or IV in two divided doses 5 mg/kg every 12 hours Clinical surveillance • Assess baby for signs of NAS using a structured assessment tool o FNAS every 4–6 hours after feeds o ESC every 3–4 hours after feeds • Paediatrician/nurse practitioner review o Prior to commencing medication o Daily or more frequently until signs of NAS controlled o On maximum dosage and signs of NAS not controlled • Monitoring o Cardiorespiratory monitor when phenobarbital 10 mg/kg/day or more Titration • Loading dose more likely to achieve rapid control of signs of NAS • Titrate doses to control signs of NAS • IV only if oral feeds not tolerated • If NAS signs not controlled on maximum dose reconsider diagnosis Vomiting baby • Reduce the risk of baby vomiting phenobarbital dose by: o Giving the dose before a feed o Ensuring the baby is not overfed • If large vomit within 15 minutes of receiving the dose, repeat dose once only Weaning • Commence weaning when signs of NAS controlled for 72 hours as evidenced by o FNAS consistently less than 8 or o ESC questions consistently answered ‘NO’ • Do not reduce dose by more than 10 to 20% within 72 hours of a prior reduction (and only following regular clinical review of signs of NAS) Queensland Clinical Guideline: Perinatal substance use: neonatal Refer