Definition

Neonatal withdrawal/abstinence syndrome

• Symptoms evident in babies born to opiate-dependent mothers and mothers on other drugs associated with withdrawal symptoms (generally milder with other drugs) 

Timescale of withdrawal

• Signs of withdrawal from opiates (misused drugs, e.g. heroin) can occur <24 hr after birth
• Signs of withdrawal from opioids (prescribed drugs, e.g. methadone) can occur 3–4 days after birth, occasionally up to 2 weeks after birth
• Multiple drug use can delay, confuse and intensify withdrawal signs in the first weeks of life

Minor signs

• Tremors when disturbed 
• Tachypnoea (>60/min) 
• Pyrexia
• Sweating
• Yawning
• Sneezing 
• Nasal stuffiness
• Poor feeding
• Regurgitation
• Loose stools 
• Sleeping <3 hr after feed (usual among breastfed babies)

Major signs

• Convulsions 
• Profuse vomiting or diarrhoea 
• Inability to co-ordinate sucking, necessitating introduction of tube feeding
• Baby inconsolable after 2 consecutive feeds 

• To identify withdrawal symptoms following birth
• To give effective medical treatment where necessary
• To promote bonding and facilitate good parenting skills
• To support and keep baby comfortable during withdrawal period 
• To optimise feeding and growth 
• To identify social issues and refer to appropriate agencies 

• Check maternal hepatitis B, hepatitis C and HIV status and decide on management plan for baby

Management of labour

• Make sure you know:
  • type and amount of drug(s) exposure
  • route of administration
  • when last dose was taken
• Neonatal team are not required to be present at delivery unless clinical situation dictates 

Delivery

• Do not give naloxone (can exacerbate withdrawal symptoms)
• Care of baby is as for any other baby, including encouragement of skin-to-skin contact and initiation of early breastfeeding, if this is mother's choice (see Breastfeeding guideline)

After delivery

• Transfer to postnatal ward/transitional care and commence normal care
• Admit to NNU only if there are clinical indications
• Keep babies who are not withdrawing, feeding well and have no child protection issues with their mothers in postnatal ward/transitional care 
• Babies who are symptomatic enough to require pharmacological treatment usually require admission to NNU 
• Start case notes
• Take a detailed history, including:
  • social history, to facilitate discharge planning
  • maternal hepatitis B, hepatitis C and HIV status 
• Ensure postnatal baby check and daily review by paediatrician

• Aims of managing a baby at risk of neonatal drug withdrawal are to:
  • maintain normal temperature 
  • reduce hyperactivity
  • reduce excessive crying
  • reduce motor instability
  • ensure adequate weight gain and sleep pattern
  • identify significant withdrawal requiring pharmacological treatment
• Ensure baby reviewed daily by neonatal staff
• For babies with minor signs, use non-pharmacological management (e.g. swaddling)
• Start pharmacological treatment (after other causes excluded) if there is:
  • recurrent vomiting 
  • profuse watery diarrhoea
  • poor feeding requiring tube feeds
  • inconsolability after 2 consecutive feeds
  • seizures
• The assessment chart (see below) aims to reduce subjectivity associated with scoring systems
• When mother has been using an opiate or opioid, a morphine derivative is the most effective way to relieve symptoms
• When there has been multiple drug usage, phenobarbital may be more effective

Opioids

• If authorised by experienced doctor/ANNP start morphine 40 microgram/kg oral 4-hrly. In rare cases, and after discussion with consultant, it may be necessary to increase dose by 10 microgram/kg increments 
• If baby feeding well and settling between feeds, consider doubling dose interval and, after 48 hr, reducing dose by 10 microgram/kg every 48 hr. If major signs continue, discuss with experienced doctor/ANNP
• Consider need for other medication (e.g. phenobarbital)

Phenobarbital

• For treatment of seizures and for babies of mothers who are dependent on other drugs in addition to opiates and suffering serious withdrawal symptoms, give phenobarbital 20 mg/kg IV loading dose over 20 min, then maintenance 4 mg/kg oral daily
• Unless ongoing seizures, give a short 4–6 day course 
• For treatment of seizures, see Seizures guideline

Chlorpromazine

• For babies of mothers who use benzodiazepines, give chlorpromazine 1 mg/kg oral 
  8-hrly if showing signs of withdrawal
  • remember chlorpromazine can reduce seizure threshold 

Breastfeeding

• Unless other contraindications co-exist or baby going for adoption, strongly recommend breastfeeding (see Breastfeeding guideline)
• Support mother in her choice of feeding method
• Give mother all information she needs to make an informed choice about breastfeeding 
• Drugs of misuse do not, in general, pass into breast milk in sufficient quantities to have a major effect in newborn baby 
• Breastfeeding will certainly support mother in feeling she is positively comforting her baby, should he/she be harder to settle

Infections

• Follow relevant guidelines for specific situations, such as HIV, hepatitis B or hepatitis C positive mothers [see Human immunodeficiency virus (HIV) guideline and Hepatitis B and C guideline]
• Give BCG immunisation where indicated (see BCG immunisation guideline)

• Chart available for download from West Midlands Neonatal Operational Delivery Network website: https://www.networks.nhs.uk/nhs-networks/west-midlands-neonatal-operational-delivery/neonatal-guidelines/supporting-links-guidelines-book-2019-2021
• Aim of treatment is to reduce distress and control potentially dangerous signs
• Minor signs (e.g. jitters, sweating, yawning) do not require treatment

Has baby been inconsolable with standard comfort measures (cuddling, swaddling, or non-nutritive sucking) since last feed, had profuse vomiting or loose stools, had an unco-ordinated suck requiring tube feeds or had seizures?

Place a tick in yes or no box (do not indicate any other signs in boxes)

Babies who required treatment

• Ensure discharge planning involving: 
  • social worker (may not be needed if prescribed for pain relief and no other concerns)
  • health visitor
  • community neonatal team if treated at home after discharge
  • drug rehabilitation team for mother
• If seizures occurred or treatment was required, arrange follow-up in named consultant's clinic or as per local protocol

Babies who did not require treatment

• If no signs of withdrawal, discharge after 96 hr
• Arrange follow-up by GP and health visitor and advise referral to hospital if there are concerns
• Clarify need for any ongoing social services involvement