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 judgement to assess and anticipate the need for resuscitation (e.g. recency and type of substance use, limited/no antenatal care) • Communicate with other members of the multidisciplinary team about the impending birth as required (e.g. if resuscitation is anticipated) Resuscitation • All usual resuscitation procedures are indicated o Refer to Queensland Clinical Guideline Neonatal resuscitation25 Opioid antagonist • If maternal opioid or polysubstance exposure o Do not use opioid antagonist agents (naloxone or naltrexone)26 o May precipitate severe rapid onset of seizures related to withdrawal Rooming-in • Support rooming-in unless there are clinical concerns requiring admission to a neonatal unit or a child safety order mandating separationt 27-29 o Associated with less need for pharmacological treatment 30, reduced length of stay20 and improved breastfeeding rates31 Post-birth safety • Consider potential effects of substance use on the parent/carer’s ability to care for the baby32 o Maternal somnolence33 o Lack of adequate maternal sleep-wake cycling33 o Risk of injury to baby including accidental smothering33 o Increased maternal psychopathology including poor judgement, decreased reaction times, less self-control33 2.1 Clinical surveillance Onset and duration of NAS varies by substance. 14 Use clinical judgement to inform decisions related to duration of clinical observations and surveillance. Table 4. Clinical surveillance In-utero exposure Consideration Any substance • Perform routine newborn observations (e.g. using Neonatal Early Warning Tool) o Increase frequency of observations as clinically indicated o Refer to Section 6.3 Timing of discharge • Paediatric review daily (by teleconference with referral centre if required) if baby: o Shows signs of NAS o Commences morphine or phenobarbital o Is on maximum doses of medication and continues to show signs of NAS o Has signs of NAS where exclusion of alternative causes is not possible Opioid substances or polysubstance • Commence formal assessment for signs of NAS within 2 hours of birth using either Finnegan Neonatal Abstinence Score (FNAS) or the Eat, Sleep, Console (ESC) protocol • Refer to: o Appendix A: Finnegan Neonatal Abstinence Severity Score o Appendix C: Eat, Sleep Console assessment Non-opioid substances • Routine formal assessment for signs of NAS is not required unless/until: o Baby shows signs of NAS • Refer to: o Appendix A: Finnegan Neonatal Abstinence Severity Score o Appendix C: Eat, Sleep Console