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 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