Clinical Practice Guidelines: Neonatal Abstinence Syndrome (NAS)



Neonatal Abstinence Syndrome (NAS) is a constellation of withdrawal symptoms in neonates exposed to opioids in utero.  While infants exposed to in utero opioids may have withdrawal symptoms, not all will progress to developing NAS.  However, all Opioid Exposed Neonates (OENs) require specialized monitoring and care.  Unfortunately, the incidence of OENs is increasing in the United States and, more specifically, in Tennessee.  Non-pharmacological measures (soothing, swaddling, low stimulation environments, etc.) are the mainstay of therapy and are associated with shorter lengths of hospital stay, decreased severity of symptoms, and decreased pharmacological therapy utilization.  However, despite maximizing non-pharmacological interventions some OENs with NAS will require pharmacological therapy.

This clinical practice guideline was developed with the goal of standardization of care for OENs, both those with and without NAS, based upon current evidence and best practices.  This includes appropriate screening and monitoring, utilization of hospital resources to maximize non-pharmacologic care, guidance on appropriate pharmacological intervention and weaning, and best discharge practices.  By following the standardized practices outlined in this CPG, this target, at-risk population can be best served to ensure optimization of their care during their birth hospitalization as well as creating a safety net for outpatient follow up and resources.

Content Experts:

  • Travis Crook - Hospital Medicine (contact)
  • Stephan Patrick - NICU
  • Alex Agthe - NICU
  • Lauren Presley - General Pediatrics/Nursery
  • Anna Morad - General Pediatrics/Nursery
  • Erin Munn Child Life
  • Alison Grisso, Pharmacy

Selected References:
Hudak ML, Tan RC; COMMITTEE ON DRUGS; COMMITTEE ON FETUS AND NEWBORN; American Academy of Pediatrics. Neonatal drug withdrawal [published correction appears in Pediatrics. 2014 May;133(5):937]. Pediatrics. 2012;129(2):e540-e560.

Kocherlakota P. Neonatal abstinence syndrome. Pediatrics. 2014;134(2):e547-e561. 

Finnegan LP, Kron RE, Connaughton JF, Emich JP. Basic and Therapeutic Aspects of Perinatal Pharmacology. Raven Press; New York, NY: 1975. A scoring system for evaluation and treatment of the neonatal abstinence syndrome: A new clinical and research tool. pp. 139–153

Maguire D, Cline GJ, Parnell L, Tai CY. Validation of the Finnegan neonatal abstinence syndrome tool-short form. Adv Neonatal Care. 2014;14(6):376–80.
Bada HS, Sithisarn T, Gibson J, et al. Morphine versus clonidine for neonatal abstinence syndrome. Pediatrics. 2015;135(2):e383-e391.

Agthe AG, Kim GR, Mathias KB, et al. Clonidine as an adjunct therapy to opioids for neonatal abstinence syndrome: a randomized, controlled trial. Pediatrics. 2009;123(5):e849-e856. 

Crook TW, Munn EK, Scott TA, et al. Improving the Discharge Process for Opioid-Exposed Neonates. Hosp Pediatr. 2019;9(8):643-648.

Parlaman J, Deodhar P, Sanders V, Jerome J, McDaniel C. Improving Care for Infants With Neonatal Abstinence Syndrome: A Multicenter, Community Hospital-Based Study. Hosp Pediatr. 2019;9(8):608-614.

Davis JM, Shenberger J, Terrin N, et al. Comparison of Safety and Efficacy of Methadone vs Morphine for Treatment of Neonatal Abstinence Syndrome: A Randomized Clinical Trial. JAMA Pediatr. 2018;172(8):741-748.

Patrick SW, Kaplan HC, Passarella M, Davis MM, Lorch SA. Variation in treatment of neonatal abstinence syndrome in US children's hospitals, 2004-2011. J Perinatol. 2014;34(11):867-872.

Hall ES, Wexelblatt SL, Crowley M, et al. A multicenter cohort study of treatments and hospital outcomes in neonatal abstinence syndrome. Pediatrics. 2014;134(2):e527-e534.