Inpatient Pathway for the Evaluation/Treatment of Infants with Neonatal Abstinence Syndrome

Pharmacologic Treatment Recommendations for NAS

NON-OPIOID OR UNKNOWN

  Score Initial Dose Route Maintenance Dosing Comments
Phenobarbitol Pharmacologic treatment should be given to infants with combined NAS scores ≥ 24 over 2-3 scores 16-20mg/kg load
May give in 1 or 2 doses
PO 3-4 mg/kg/day
Begin 12-24 hr later.
May give as daily dose or divide q12 hr.
If scores remain high after 24 hours of observation, start morphine

OPIOID

  Score Initial Dose Route Dosing Comments
Daily dose Q3 hr dosing Q4 hr dosing
Morphine (Option 1) Pharmacologic treatment should be given to infants with combined NAS scores ≥ 24 over 2-3 scores 0.4 mg/kg/Day 0.05 mg/kg/dose 0.067 mg/kg/dose PO Increase dose 10-20% for combined scores of ≥ 24 on 2-3 consecutive scores. Dose may be increased as needed, q 12 hrs until symptoms controlled. If symptoms are not controlled on a total daily dose is >1 mg/kg/day consider adding second medication.
Morphine (Option 2) Highest score in the preceding 24 hrs: PO Allow infant to stabilize 12-24 hours after starting initial dose. Increase dose 10-20% for combined scores of ≥ 24 on 2-3 consecutive scores. Dose may be increased as needed, q 12 hrs until symptoms controlled. If symptoms are not controlled on a total daily dose is >1 mg/kg/day consider adding second medication.
8-10 0.4 mg/kg/Day 0.05 mg/kg/dose 0.067 mg/kg/dose
11-13 0.64 mg/kg/Day 0.08 mg/kg/dose 0.1 mg/kg/dose
14-16 0.88 mg/kg/Day 0.11 mg/kg/dose 0.15 mg/kg/dose
> 16 1.04 mg/kg/Day 0.13 mg/kg/dose 0.17 mg/kg/dose

SECOND AND THIRD LINE MEDICATIONS

  Initial Dose Route Maintenance Dosing Comments
Phenobarbitol
Second Line
16-20mg/kg load Given in
1 or 2 doses
PO 3-4 mg/kg/day
Begin 12-24 hr later
Given as daily dose or divide q 12 hr
 
Clonidine
Third Line
0.0005-0.001 mg/kg/dose q 3-6 hrs.
(0.5 – 1 mcg/kg q 3-6 hrs)
PO Max dose 0.001mg/kg/dose q3hr
(1mcg/kg q 3 hrs)
Clonidine suspension concentration is 0.1 mg/mL. For doses too small to draw up (<0.005 mg), consider giving higher dose less frequently. (e.g. 0.002 mg/kg/dose q 6 hrs. )

Clonidine patch is NOT Recommended.