In June 2023, we commenced a project to review and update the Maternity and Neonatal eHandbook guidelines with a view to completion in 2024. Please be aware that pending this review, some of the current guidelines may be out of date. In the meantime, we recommend that you also refer to more contemporaneous evidence.
Substance use in the mother may cause Neonatal Abstinence Syndrome (NAS) in a newborn. NAS is a syndrome of drug withdrawal observed in babies of women who are physically dependent on the drug during pregnancy; manifested by non- specific signs and symptoms including neurological excitability, gastrointestinal dysfunction, autonomic signs, poor weight gain, neuromuscular abnormalities and occasionally seizures.1
These effects have been observed in babies when their mothers are dependent on opioids, stimulants, some sedatives and alcohol. This syndrome has been observed in neonates even if the mother stopped substance use up to four weeks before birth.
NAS is more common in babies born to opioid-dependent women than in babies born to women dependant on other drugs. There is no dose-response relationship between maternal opioid intake and NAS. Onset of symptoms varies depending on the pharmacological properties of the substance used.
Babies of women dependent on alcohol or drugs may be at increased risk of harm and poor developmental outcomes due to complex interplay of psychosocial and environmental adversity. Assessment of risk of harm or neglect to the baby should occur throughout the pregnancy and postnatal period.
All pregnant women should receive comprehensive information about the risks of alcohol and tobacco use in pregnancy.
If a woman is currently using drugs or has a recent history of drug use, she should receive information about the effects of the relevant drugs on the health of the pregnancy and be referred to an appropriate support service.
Women should be asked about substance use at least twice during their pregnancy. More frequent assessments should be made if concerns exist such as women who present:
- after 20 weeks' pregnancy
- with homelessness
- with altered mental state
- with intoxication
- who have current or a history of alcohol or drug use
Health outcomes for mothers and babies can be improved by providing comprehensive, holistic, multidisciplinary care with assertive follow-up. The aim of antenatal care is to engage the woman and family into a therapeutic, professional, emphatic relationship with the health care providers who will deliver care from the initial contact to discharge from the hospital.
Substance dependent women can be difficult to engage. Each presentation of a substance dependent woman must be viewed as an opportunity to engage the woman to improve health outcomes for herself and her baby (NSW guidelines, 2014).
Statewide secondary consultation services are available from the Women's Alcohol and Drug Service (WADS) on (03) 8345 3931. WADS can assist health workers with all areas relating to substance dependent women during pregnancy and in the perinatal period, including breastfeeding and methadone/buprenorphine stabilisation.
Women who are substance dependent and pregnant are at high risk of complications both to mother and baby. The most common problems include:
- obstetric - prematurity, fetal growth restriction (FGR), fetal demise
- medical - asthma, epilepsy, liver disease, coronary valve disease, blood-borne virus infection, nutritional deficiencies, sepsis, general poor maternal health
- neonatal - prematurity, FGR, neonatal withdrawal, sudden infant death, poor feeding and poor weight gain
- other - psychiatric, social, legal, housing, domestic, financial problems and concerns regarding child welfare and neglect.
A child protection report can be made at any time if the clinician has concerns for the child’s welfare.
A pre-birth child protection notification allows a meeting to occur where the clinicians concerns are discussed with the woman, in the presence of child protection, which may include ongoing drug use, poor attendance at clinic appointments, homelessness or family violence.
These meetings can allow services and supports to be put in place to assist the woman and her family prepare for the baby and improve the likelihood of babies remaining in the care of mothers.
Induction of labour
There is no indication for an induction of labour solely because of maternal substance use if the baby is showing normal growth. Assessment for induction should occur as for all other women.
Avoid Naloxone administration to the infant of a known or suspected opioid dependent woman. Its use can precipitate severe, rapid onset of narcotic withdrawal including seizures.
Babies at risk of NAS should be cared for at the mother’s bedside, unless contraindicated by the medical condition of the woman, her baby or social concerns. The mother should be involved in NAS scoring in the postnatal ward. If the baby does need care in the Special Care Nursery (SCN), parental involvement in care should be encouraged by supportive and non-judgmental staff.
The Paediatric medical team should be involved in the day-to-day care of these babies. In a health service without Paediatric cover, Paediatric advice should be sought and transfer to a higher level of Neonatal capability considered.
The practice of mother and baby sleeping in the same bed is extremely dangerous when women are consuming any sedating substances and should be actively discouraged. Women taking sedating drugs, whether prescribed or illicit, may sleep more deeply and may result in the woman not being appropriately alert to the baby's needs and has been associated with babies being accidentally asphyxiated. Premature babies and small for gestational age babies are particularly at risk of SUDI. SUDI prevention with safe sleeping practices should be modelled in hospital and discussed extensively with parents.
Due to the frequency of maternal mental health comorbidities the possible impact on the baby of medications prescribed for those conditions requires consideration in relation to SIDS.
There are few contraindications to breastfeeding; however where a woman is using drugs and alcohol during pregnancy, the situation requires careful and thoughtful assessment. Where women are stable on methadone or buprenorphine and not using any other drugs, breastfeeding is encouraged even when doses are high. Small amounts of methadone and buprenorphine are transmitted to the baby in breast milk, but not in sufficient quantities to affect the baby clinically . However, a woman should be advised not to suddenly cease breastfeeding, particularly if she is on high doses, as this may precipitate withdrawal in the infant. There is some evidence this small amount of methadone/buprenorphine in the breast milk may ease NAS symptoms.
Where women are dependent on heroin, methamphetamine, alcohol and most other illicit drugs, breastfeeding is actively discouraged due to the transfer of substances into breast milk, including possible contaminants,. Parenting ability may be negatively impacted by substance use.
The risk of transmission of hepatitis C via breast milk is very low. The risk is greatly enhanced when a woman is breastfeeding with cracked or bleeding nipples. In this instance, the woman should be advised to express and discard milk and provide infant formula until the nipples have healed and stopped bleeding (NSW guideline, 2014).
Contraindications to breastfeeding include:
- intoxication with alcohol or other drugs
- HIV positive mother
- hepatitis C positive mother who has cracked and/or bleeding nipples
- breastfeeding may be contraindicated for intermittent periods, including after drug or alcohol use
All women who breastfeed should be advised how and when to express and store or discard breast milk and to develop a safety plan for feeding the baby.
Stimulant use and breastfeeding
Breastfeeding women who use stimulants (amphetamines, methamphetamines, ecstasy or cocaine) should be:
- Informed of the risks
- Advised not to breastfeed for 48 hours after occasional use
Women dependent on stimulants including amphetamines and methamphetamines are advised not to breastfeed.
Tobacco use and breastfeeding
Breastfeeding women who smoke tobacco should be advised to:
- Breastfeed prior to smoking
- Smoke outside and away from the baby to minimise secondary exposure to the baby
- Wear clothes while smoking which can be removed after smoking. Carers who smoke should also wash their hands and clean their teeth prior to handling the baby.
- Be aware that babies exposed to tobacco smoke in utero and after birth are more at risk of SUDI and respiratory difficulties
- Never co-sleep
Cannabis and breastfeeding
- Expert opinion may vary about safety; abstinence is the safest option.
- Passes into breastmilk
- Limited data on the safety of cannabis use and breastfeeding, but breastfeeding not discouraged. (Lactmed)
- Effects on the infant may include sedation, growth delay, poor muscle tone and poor sucking (Liston, 1998)
- Breasfeed prior to use
- May reduce milk supply
- Half-life 20-57 hours
Babies of women solely dependent on cannabis may have delayed onset of withdrawal (after 10 days)and should be referred for weekly assessment until one month of age with a suitably qualified clinician, GP or Paediatrician.
Alcohol use and breastfeeding
Breastfeeding women should be informed that:
- NHMRC guidelines state abstinence is the safest option
- Alcohol passes into breast milk (Hale, 2017)
- There is no known safe level of alcohol consumption (NHMRC)
It is advisable to breastfeed before drinking alcohol (or express and store breast milk if planning to consume more than 2 standard drinks in a session), then wait 2 hours for every standard drink consumed at which time the breast milk will be alcohol free (Lactmed)
- Breastfeeding women are advised not to drink everyday even at low levels
- Women are advised to eat before and during drinking (ABA)
- Heavy drinkers should not breastfeed (Hale, 2017)
- Alcohol consumption may affect milk supply, may cause early cessation of breastfeeding, and may be associated with disrupted infant-wake behavioral problems (NHMRC).
If women or babies are experiencing breastfeeding problems or have complex needs, consider a referral to a lactation consultant.
Some women may choose to feed their baby with infant formula. This may be the primary source of nutrition for the infant or provided in conjunction with breastfeeding. Women who choose to formula feed their infants will require information and education including:
- Preparation, transport and storage of (reconstituted/powdered) infant formula
- Appropriate heating and reheating of prepared formula in an appropriate manner
- cleaning and sterilisinge of feeding equipment
Non-pharmacological supportive care is the first line of treatment for babies experiencing symptoms of NAS. Supportive therapy is an important adjunct to medical therapy. This includes interventions such as:
- a quiet setting
- use of a dummy (if parents give consent)
- small frequent feeds
- close skin contact
Pain relief for procedures should be provided based on need as for any baby.
Clinical signs similar to those of NAS may be caused by concurrent illness, such as sepsis and hypoglycaemia. This should be considered when assessing a baby at risk of NAS and investigations performed as required.
Neonatal Abstinence Syndrome - scoring
Infants at risk of developing NAS are evaluated for signs of withdrawal using the modified Finnegan scoring system starting two hours after birth or sooner if signs of withdrawal are evident, and subsequently at four-hourly intervals. The period scored is the 3 hours preceding the scoring time.
Scoring should be performed close to half to one hour after the baby has been fed. The infant will be more settled at this time and an accurate assessment can be obtained. Temperature, respiratory rate and assessment of muscle tone should be carried out prior to feeding when the baby is awake. Do not wake the baby to assess for NAS. Parents are usually very distressed to witness their baby suffering withdrawal and are usually fully supportive of accurate scoring and medication where indicated.
NAS score chart
The NAS score chart lists 21 signs most commonly seen in the passively narcotic addicted neonate. Each sign and its associated degree of severity are assigned a score. The total abstinence score is determined by summation of scores assigned to each sign observed throughout.
Involve the mother in scoring
The baby's mother should assist with the scoring and discuss each sign as it is assessed - it is usually the mother who has been with the baby during the scoring interval. Further, it appears to be important in the mother's acceptance of her baby's condition that she be actively involved in the scoring process.
Neonates with an abstinence score averaging 8 or more for three consecutive scores should be transferred to the special care nursery for evaluation for pharmacotherapy. If there are inconsistencies in the scores, the baby may be observed for a period of time to ensure pharmacotherapy is truly indicated.
All babies exposed to substances in pregnancy should be followed up by a suitably qualified clinician, GP or paediatrician but do not all require assessment with the modified Finnegan NAS.
Guidelines for neonatal abstinence syndrome scoring
Neonatal abstinence syndrome scoring was designed for term babies fed four-hourly.
Modifications necessary for premature babies:
- Mainly necessary in the sections on sleeping and feeding.
- A baby on three-hourly feeds can sleep at most two hours. Scoring should be one if a baby sleeps less than two hours, two if sleeps less than one hour, and three if it does not sleep between feeds.
- Many premature babies require tube feeding. Babies should not be scored for poor feeding if tube feeding is expected at their gestation.
Signs for NAS scoring
|Score 2 if high-pitched at its peak, 3 if high-pitched throughout.
|This is a scale of increasing severity and a baby should only receive one score from the four levels of severity. Undisturbed refers to the baby being asleep or at rest in the cot.
|Increased muscle tone
|Score if the baby has generalised muscle tone greater than the upper limit of normal.
|Score only when excoriations first appear, increase or appear in a new area.
|Yawning and sneezing
|Score if occurs more than 3 to 4 times in 30 minutes.
|Nasal flaring/respiratory rate
|Score only if present without other evidence of lung or airways disease.
|Score if more than that of an average hungry baby.
|Score if baby is very slow to feed or takes inadequate amounts.
|Score only if occurring more frequently than would be expected in a newborn baby.
Once the Finnegan score averages 8 or more for 3 consecutive scores, or averages 11 or more for 2 consecutive scores, transfer baby to SCN for:
- further assessment and scoring by a neonatal RN/RM experienced in using the Finnegan’s scoring tool
- pharmacological treatment as per protocol.
Pharmacological treatment dose changes should be calculated using birth weight not current weight.
Morphine Hydrochloride (1mg/mL) should be administered orally for NAS caused by opioid withdrawal.
Commencing treatment may commit the infant to several weeks in a neonatal unit (or a prolonged period of weaning of treatment in a Home based withdrawal program, if appropriate).
The scores on which the treatment is based should be checked and confirmed in the SCN.
|Table 1: Recommended Morphine Treatment Regime Score
|3 consecutive scores average 8 or more
|125 micrograms/kg/dose 6-hourly or 85 micrograms/kg/dose 4-hourly*
|2 consecutive scores average 12 or more
|125-175 micrograms/kg/dose 6-hourly or 85-120 micrograms/kg/dose 4-hourly*
*If NAS symptoms are not assessed as controlled with 6-hourly medication, change dose frequency to 4-hourly in the first instance before increasing the dose
*The Royal Women's Hospital routinely uses 6-hourly dosing.
*Mercy Hospital for Women and Monash Medical Centre use 4-hourly dosing during initial phases of stabilisation.
Note: Half-life of morphine
Gestation <37 weeks = 28 hours
Term 0-10 days of age = 7 hours
Mothers and their babies should be routinely observed as inpatients for at least five days before being discharged.
Babies receiving morphine should be closely monitored including use of an apnoea monitor while commencing and stabilising on treatment, as morphine is a respiratory depressant (local consensus).
Overdosing may result in:
- respiratory depression
- abdominal distension
- urinary retention (rarely)
Once NAS symptoms are assessed as controlled (three consecutive scores less than 8) the following should be implemented:
Weaning morphine treatment – on 6-hourly dosing:
- Reduce by 10% of the initial dose (based on birth weight) every 72 hours (i.e. 12.5-17.5 micrograms/kg/dose)
- When daily dosage is 30micrograms/kg/dose, morphine may be discontinued
- Continue assessment of NAS for a further 72 hours.
Weaning morphine treatment – on 4-hourly dosing:
- Reduce by 10% of the initial dose (based on birth weight) every 72 hours (i.e. 8.5-12 micrograms/kg/dose)
- When on 35 micrograms/kg/dose, change dose frequency from 4-hourly to 6-hourly (i.e. 35 micrograms/kg/dose 6-hourly)
- Discontinue treatment after 72 hours
- Continue assessment of NAS for a further 72 hours
Supportive therapy (using a dummy, swaddling, close wrapping, small frequent feeds, providing close skin contact) is an important adjunct to medical therapy.
If an infant is vomiting in association with morphine dosing, ensure that the infant is not being overfed and that the infant is being appropriately postured during and after feeding.
Give the morphine before the feed.
If baby has a large vomit after being given morphine:
- Re-dose if vomits within 10 minutes of dose,
- Give a half dose if vomits between 10 and 30 minutes after dose,
- Do not give further morphine if baby vomits more than 30 minutes after feed, (always err on side of caution)
Phenobarbitone may be indicated as an additional therapy where there has been concurrent use of opioid and non-opioid drugs in pregnancy, particularly benzodiazepines, and the symptoms of NAS are not adequately suppressed by morphine treatment alone.
Phenobarbitone should be used as the first-line treatment if babies with signs of NAS reach threshold for treatment and:
- maternal drugs used are unknown
- maternal drugs used are non-opioid drugs
- the mother was intoxicated with alcohol or non-opioid drugs at the time of birth
- if used as a first line treatment, a loading dose is likely to achieve more rapid control of symptoms.
- Phenobarbitone may cause respiratory depression, apnoea and hypotension.
- Apnoea monitoring is required
|Phenobarbitone doses to be calculated on birthweight
|All threshold scores
|Loading dose: 10-15 mg/kg orally or parentally if not tolerating oral intake
|Then (maintenance doses)
|Average 8 or more for 3 consecutive scores
|3 mg/kg/ dose 12 hourly
|Average 11 or more for 2 consecutive scores
(consider higher dosage)
|3-4 mg/kg / dose 12 hourly
Phenobarbitone levels should be performed if:
- indicated by clinical condition
Once NAS symptoms have been assessed as controlled (three consecutive scores less than 8) for 48 hours, then phenobarbitone dose should be reduced by 2 mg per dose every fourth day or longer until less than 2 mg/kg/day, depending on Paediatric assessment of clinical condition.
Some infants with NAS symptoms are incompletely responsive to treatment with morphine and/or phenobarbitone.
Consideration should be given to alternative causes of symptoms other than withdrawal.
Other pharmacological treatments that may be useful include:
Clonidine 0.5 -1 microgram/kg orally every 6 hours based on weight at commencement of treatment (may be increased to 1microgram/kg every 4 hours).
Adverse effects may include:
- rebound hypertension if clonidine is not tapered off over more than a week
- Wean dosage by 25% of the initial dose every 5 days
- Chloral hydrate 8 mg/kg/dose orally 8-hourly based on weight at commencement of treatment (one paper reports use of 30-50mg/kg/dose orally with dose frequency increased up to 3 times per day in conjunction with clonidine).
Safety and back-up plans
When women have occasional drug use, a safety or back-up plan should be developed in advance for the times when they are under the influence of substances. This safety plan should be discussed with women prior to their discharge from the acute setting. Safety plans should include:
- the mother's ability/plans to have baby cared for and fed by another appropriate person if she is substance-affected
- preparing infant formula prior to substance use.
- knowing how to express and store breastmilk.
An infant can be considered for discharge when:
- a five-day postnatal observation period is completed and there are no signs of continuing significant withdrawal (there is a significant risk of unsupervised withdrawal occurring at home if infants are discharged earlier than five days, particularly if mother is on methadone or buprenorphine)
- the infant requiring medical therapy for withdrawal has been off all medication for at least 72 hours (this may not apply to phenobarbitone) or has been assessed as appropriate for Infant Home Based Withdrawal (if available)
- any child protection issues and significant parental issues (such as suitable accommodation) have been appropriately addressed
The home sleeping environment should be assessed as per Red Nose safe sleeping guidelines, preferably prior to the babies discharge. This may be done by hospital domiciliary staff, the maternal and child health nurse or the child protection practitioner.
The infant should have early medical follow up (within two weeks of discharge) and have early and regular review by domiciliary or Maternal and Child Health nurses (MCHN). In many cases, families with substance use issues are referred to the Enhanced Home Visiting Maternal and Child Health Nurse and a discussion should occur prior to discharge with the midwife and the community nurse to ensure the family is visited in a timely fashion.
If the baby has been medicated for NAS, has poor weight gain or feeding issues, is Small for gestational age (SGA) or has other health or medical concerns, an early follow up with the MCHN or outreach hospital in the home for review is indicated.
Child Protection services may be involved at any time before and after the birth. If so, they take responsibility for organising community support.
Neonatal Abstinence Syndrome article on nejm.org
Women’s Alcohol & Drug Service (WADS)
The Royal Women’s Hospital Clinical practice guideline Neonatal Abstinence Syndrome, accessed September 2017
NSW Government, Neonatal Abstinence Syndrome Guidelines, September 2013
Drugs and Lactation Database (LactMed) on toxnet.nlm.nih.gov
Breastfeeding and Medications on breastfeedingonline.com
Alcohol use and breastfeeding breastfeeding.asn.au
1. New South Wales Department of Health. National clinical guidelines for the management of drug use during pregnancy, birth and the early development years of the newborn. Sydney, NSW: New South Wales Department of Health. 2006.
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First published: September 2013
Review by: September 2016