Inpatient Clinical Pathway for Evaluation and Treatment of Infants with Neonatal Abstinence Syndrome (NAS) /Neonatal Opioid Withdrawal Syndrome (NOWS)

Goals and Metrics
Patient Education
Provider Resources
Indications for Infant Screening to Assess Risk for NAS/NOWS
  • Review Maternal factors, Urine Tox Screen
  • Infant Tox Screen
  • Consent Considerations
  • Admission
Infants at Risk for NAS/NOWS
Maximize Non-Pharmacologic Interventions
Provide Family Support, Communication
Evaluation and Scoring Systems
Finnegan Scoring
Eat Sleep Console (ESC) Score
ESC: Scoring Evaluation and Treatment Guidelines
  • Assess infant’s ability to do the following 3 elements:
    • Eat: Breastfeed or take adequate volumes
    • Sleep: At least 1hr undisturbed
    • Be Consoled: Within 10 minutes
  • Infant can do ALL elements:
    • Continue non-pharmacologic care
    • Continue observation
  • Infant can do 1-2 of the elements:
    • Maximize non-pharmacologic care
    • Continue observation until improvement
  • Infant can do NONE of the elements:
    • Maximize non-pharmacologic care
    • Continue observation until improvement
  • Infant continues/becomes able to do ALL
    elements (at least most times):
    • Observe infant at least 3-5 days after birth
      (depending upon substance half-life)
    • OR
    • Observe at least 48 hours after last PRN Morphine
  • If infant continues to do NONE or ONE of the elements:
    • Continue providing non-pharmacologic care
    • Consider PRN Morphine (0.05mg/kg/dose)
  • Morphine PRN
  • Administer morphine PRN (0.05mg/kg/dose) q 3-4 hrs as needed, up to 4 PRN doses in a 24 hour period
  • Scheduled Morphine
  • Consider if > 4 PRN doses in 24 hours. Start at 0.05mg/kg/dose q 3hr
  • Continue evaluation with the ESC tool
  • Discharge Recommendations
  • Ensure that a follow-up appointment is scheduled with the PCP by parent prior to discharge
  • Notify PCP prior to infant’s discharge
  • Refer to Early Intervention
  • If mother is Hepatitis C positive, recommend ID follow up and testing
  • Encourage postnatal support for mother/family
Posted: April 2013
Revised: September 2021
Authors: C. Migone, MD; A. Bustin, PharmD; N. Brutus, DO; S. Ghavam, MD; G. Jani, MD; A. Lembeck, DO;
A. Sosnovsky, MD and with approval of CHOP Newborn Network Pathway Committee