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 therapy reported to: o Decrease length of pharmacological therapy (compared to placebo)71,72 o Decrease length of hospital stay73 o Have a shorter duration of outpatient therapy after discharge compared to phenobarbital74 Methadone • Conflicting evidence about duration of pharmacological treatment required compared with morphine75,76 Buprenorphine • Insufficient data to recommend as standard of care for treating NAS38 o Reported to have significant reduction in length of stay and length of treatment compared to morphine and other medications34,38,77 Queensland Clinical Guideline: Perinatal substance use: neonatal Refer to online version, destroy printed copies after use Page 17 of 33 5.1 Morphine hydrochloride schedule Refer to NeoMedQ morphine hydrochloride78 Table 15. Morphine hydrochloride schedule Total daily dose (oral) Equivalent 6 hourly dose (oral) Equivalent 4 hourly dose (oral) • Commence at 0.5 mg/kg/day in 4 divided doses (6 hourly) 0.125 mg/kg 6 hourly — • If signs not controlled on 0.5 mg/kg/day o Increase total daily dose to 0.7 mg/kg/day 0.175 mg/kg 6 hourly 0.12 mg/kg 4 hourly • If signs not controlled on 0.7 mg/kg/day o Increase total daily dose to 0.9 mg/kg/day 0.225 mg/kg 6 hourly 0.15 mg/kg 4 hourly • If signs not controlled on 0.9 mg/kg/day o Increase total daily dose to 1 mg/kg/day 0.25 mg/kg 6 hourly 0.16 mg/kg 4 hourly • If signs not controlled on 1 mg/kg/day o Consider adding phenobarbital — — 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 dose and still showing signs of NAS • Monitoring o At initiation of morphine, commence cardio-respiratory and/or continuous oxygen saturation monitoring o If morphine dosage 0.7 mg/kg/day or more, commence cardio-respiratory or oxygen saturation o When dose is less than 0.5 mg/kg/day and if nursed in accordance with SIDS guidelines79, respiratory monitoring can be ceased Titration • 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