newborn period Review indicated • Consider pharmacological treatment and transfer to neonatal unit when o Two consecutive FNAS 12 or more or o Three consecutive FNAS 8 or more • Refer to: o Appendix A: Finnegan Neonatal Abstinence Severity Score o Appendix B: Finnegan Neonatal Abstinence Severity Score Description Queensland Clinical Guideline: Perinatal substance use: neonatal Refer to online version, destroy printed copies after use Page 12 of 33 3.4.2 Eat, sleep, console Table 9. Eat, sleep, console Aspect Consideration Context • Eat, sleep, console (ESC) first described in 2017 as a quality improvement activity42 • Aims to support the baby exposed to substances to achieve developmentally normal eating, sleeping, consoling and weight gain milestones42 Benefits and limitations • Emphasises partnering with parent/carer and use of non-pharmacologic interventions43 • Promotes parent/carer togetherness with parent/carer as the primary provider of responsive baby care43 • Prompts the consideration of reasons other than NAS that may affect how baby is eating, sleeping, consoling and/or gaining weight • Reported to reduce (for babies experiencing NAS)43,44 o Length of stay o Use of pharmacological treatment • Use not reported for non-opioid exposed babies • Not validated for preterm babies Elements • Response to the following questions (as ‘yes’ or ‘no’) o Does the baby have poor eating? o Did the baby sleep less than 1 hour after feeding? o Is the baby unable to be consoled within 10 minutes using nonpharmacological interventions? Assessment protocol • Assess elements after feeds every 3–4 hours • With parent/carer, review ESC elements • Assessment reflects behaviour since previous assessment • Actively consider other non-NAS related factors that may influence assessment Review indicated • If any question is answered ‘YES’ (and is attributed to NAS) o Team huddle: review and optimise supportive care with parent/carer • If despite optimisation of supportive care, any question continues to be answered ‘YES’ (and is attributed to NAS) o Full healthcare team (multidisciplinary as required) review o Consider morphine initiation and transfer to neonatal unit • Refer to: o Appendix C: Eat, Sleep Console assessment o Appendix D: Eat, Sleep Console descriptions Queensland Clinical Guideline: Perinatal substance use: neonatal Refer to online version, destroy printed copies after use Page 13 of 33 3.5 Specific substances and NAS Table 10. Specific substances and NAS In-utero exposure to: Onset/duration of signs Considerations/specific signs Opioid Heroin • Within 24 hours1,28; up to 5–7 days29 • Duration 8–10 days14 • 50–80% opioid exposed babies require pharmacologic treatment4,8,29 • Onset of clinical signs reflect half-life of the opioid involved1 • Opioid 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