Neonatal Abstinence Syndrome (NAS) /Neonatal Opioid Withdrawal Syndrome (NOWS) Clinical Pathway, Inpatient – Second Line Medications

Neonatal Abstinence Syndrome (NAS) /Neonatal Opioid Withdrawal Syndrome (NOWS), Clinical Pathway, Inpatient

Second Line Medications

  • Consider adding if > 1 mg/kg/day of morphine is required for symptom control
  • Consider starting phenobarbital earlier if significant neurologic symptoms (tremors, poor sleep patterns), or unable to wean morphine despite maximized non-pharmacologic treatment.
  Initial Dose Route Comments
Phenobarbital
  • 16-20 mg/kg load
  • Give in 1 or 2 doses
  • PO
  • Maintenance:
    • Allow stabilization for 24 hrs after initial dose
    • Give 3-4 mg/kg/dose daily or
      1.5-2 mg/kg/dose every 12 hrs
    • Maintenance dose to start 12-24 hrs after loading dose
Clonidine
Alternate 2nd Line
  • 1 mcg/kg/dose every
    6 hours
  • No loading dose
  • Check BP before 1st dose
  • PO
  • Rare occurrence of hypotension has been reported with clonidine
  • Dose escalation
    • Increase by 0.5 mcg/kg/dose every 6 hours to a max of 3 mcg/kg/dose every 6 hours
    • Consider increase to 3 mcg/kg/dose every
      4 hours if symptoms not controlled