NAS/NOWS, Neonatal — Weaning Pharmacologic Treatment — Clinical Pathway: Inpatient Care

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

ESC: Weaning Pharmacologic Treatment

General

  • Morphine should first be administered on an as-needed basis.
  • If infant requires escalation to scheduled dosing, when infant is able to eat, sleep and be easily consoled for 12-24 hours, begin weaning morphine.
  • Wean morphine as often as three times/day if infant continues to do well.
  • Dose should be weaned by 10% of the stabilizing dose using the weaning calculator.
  • Discontinue morphine when infant tolerating a dose of 0.12 - 0.16 mg/kg/day (or 0.02 mg/kg/dose) for at least 12 hours.
  • Do not change morphine dosing interval during wean (maintain at q3-4 hours interval).
Medications Weaning Recommendations
Morphine Only
  • Initiate Morphine Wean
    • When infant able to eat, sleep and be consoled for 24 hours,
    • Begin by decreasing stabilizing morphine dose by 10%, use weaning calculator
  • Wean Frequency
    • Up to 3 times per 24 hours, as tolerated
  • 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
    • When infant able to eat, sleep and be consoled for 24 hours,
    • Begin by decreasing stabilizing morphine dose by 10%, use weaning calculator
  • Wean Frequency
    • Up to 3 times per 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
  • Continued Morphine Wean
    • Resume decreasing morphine if infant remains stable
    • Decrease morphine dose by 10%, using the weaning calculator
    • Wean as often 3 times a day
  • 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
    • When infant able to eat, sleep and be consoled for 24 hours
    • Begin by decreasing stabilizing morphine dose by 10%, use weaning calculator
  • Wean Frequency
    • Up to 3 times per 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 is reached
  • Monitor
    • Observe 12 - 24 hours after clonidine discontinuation
  • Continued Morphine Wean
    • Decrease morphine dose by 10%, using the weaning calculator
    • Wean as often 3 times a day.
  • 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 > 20mmHg from baseline, increase clonidine to previous dose.