NAS/NOWS, Neonatal — Modified Finnegan Scoring: Pharmacologic — Clinical Pathway: Inpatient Care

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

Modified Finnegan Scoring: Pharmacologic Treatment Recommendations

SCHEDULED Pharmacologic Treatment Recommendations

Scores should be verified by two evaluators prior to initiation of medication.

Score Morphine
Initial Dose		 Route Comments
  • 8 - 11
  • 0.05 mg/kg/dose
  • every 3 - 4 hours
  • PO
  • Initial Dose
    • Choose starting dose based on score when medication initiated
  • Frequency
    • Give q 3 - 4 hours with feeds
  • Dose increase to control symptoms
    • Increase dose 10 - 20% for 3 consecutive scores > 8 or 2 consecutive scores > 12
    • Increase dose every 12 hours until symptoms controlled
  • Monitor
    • Allow patient to stabilize for 24 hours before beginning to wean
  • > 12
  • 0.08 mg/kg/dose
  • every 3 - 4 hours
 PO
  • Note:
  • Convert to IV morphine, use a conversion factor of 3 mg enteral morphine to 1 mg IV morphine
  • Continuous morphine infusion may be needed if shortage of morphine injection
  • Example: morphine PO 0.05 mg/kg/dose q 3 hours = morphine IV 0.015 mg/kg/dose q 3 hours

Modified Finnegan: 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 in spite of maximized non-pharmacologic treatment.

Medication Initial Dose Route Maintenance Dose
Phenobarbital
  • 16 - 20 mg/kg load
  • Give in 1 or 2 doses
  • PO
  • Allow stabilization for 24 hours after initial dose
  • After stabilization start:
    • 3 - 4 mg/kg/dose daily
    • or
    • 1.5 - 2 mg/kg/dose every 12 hours
Clonidine
Alternate 2nd line
  • 1 mcg/kg/dose q 6 hours
  • No loading dose
  • Check BP before 1st dose
  • Rare occurrence of hypotension has been reported with clonidine
  • PO
  • Initial Dose
    • 1 mcg/kg/dose q6hours
  • Increase dose to control symptoms
    • Increase by 0.5 mcg/kg/dose q6 hours to a max of 3 mcg/kg/dose q6h
    • Consider increase to 3 mcg/kg/dose q4h if symptoms not controlled