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

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

Modified Finnegan Scoring: Weaning Pharmacologic Treatment

General

  • Stabilizing dose is defined as dose that achieves stable Finnegan scores (all scores < 8 in previous 24 hours)
  • Wean stabilizing dose by 10%
  • Wean morphine as often as 2 times daily if symptoms controlled
  • Maintain morphine dosing interval during wean at q3-4 hours interval
  • After discontinuing morphine, continue to perform Finnegan scoring q3-4 hours with feeds
    • If Finnegan score > 8, recheck in 2 hours
    • If Finnegan score still greater > 8, give a rescue dose of morphine (equal to most recent discontinued dose)
    • If several rescue doses needed, consider resuming scheduled morphine at most recent dose
Medications Weaning Recommendations
Morphine Only
  • Initiate Morphine Wean
    • Finnegan score < 8
    • Begin by decreasing stabilizing morphine dose by 10%
  • Wean Frequency
    • Wean every 12 - 24 hours monitoring symptoms
  • Discontinue Morphine
    • If tolerating a dose of 0.12 - 0.16 mg/kg/day (or 0.02 mg/kg/dose) for at least 12 hours
  • Monitor
    • Before discharge observe at least 48 hours after last dose of morphine
Morphine + Phenobarbital
  • Initiate Morphine Wean
    • Finnegan score < 8 for 24 hours
    • Begin by decreasing stabilizing morphine dose by 10%
  • Wean Frequency
    • Wean every 12- 24 hours, as tolerated to 0.3 mg/kg/day
  • Discontinuing Phenobarbital
    • When morphine dose is 0.3 mg/kg/day maintain morphine dose
    • Discontinue phenobarbital
  • Monitor
    • Observe for 48 hours after phenobarbital discontinuation
    • Resume decreasing morphine if infant remains stable
  • Continued Morphine Wean
    • Decrease morphine dose by 10%
    • Wean as often every 12 - 24 hours monitoring symptoms
  • Discontinue Morphine
    • If tolerating a dose of 0.12 - 0.16 mg/kg/day (or 0.02 mg/kg/dose) for at least 12 hours
  • Monitor
    • Before discharge observe at least 48 hours after last dose of morphine
Morphine + Clonidine
  • Initiate Morphine Wean
    • Finnegan score < 8 for 24 hours
    • Begin by decreasing stabilizing morphine dose by 10%
  • Wean Frequency
    • Wean morphine every 12 - 24 hours, as tolerated to 0.3 mg/kg/day
  • Begin Clonidine Wean
    • When morphine dose is 0.3 mg/kg/day maintain morphine dose
    • Begin weaning clonidine
  • Weaning Clonidine
    • Decrease clonidine by 0.25 mcg/kg/dose every 6-12 hours
    • Discontinue clonidine when dose of 1mcg/kg/dose reached
  • Monitor
    • Observe 12 - 24 hours after clonidine discontinuation
  • Continued Morphine Wean
    • Decrease morphine dose by 10%
    • Wean as often as every 12 - 24 hours
  • Discontinue Morphine
    • If tolerating a dose of 0.12 - 0.16 mg/kg/day (or 0.02 mg/kg/dose) for at least 12 hours
  • Monitor
    • Before discharge observe at least 48 hours after last dose of morphine
 
  • Note:
  • Rebound hypertension has been noted with aggressive clonidine weaning at times
  • If SBP is > 95th % for age or increased > 20 mmHg from baseline, increase clonidine to previous dose