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South Australian Perinatal Practice Guideline 

Neonatal Abstinence 
Syndrome (NAS)  

  Department for Health and Wellbeing, Government of South Australia. All rights reserved. 

 

INFORMAL COPY WHEN PRINTED  Page 1 of 22 

OFFICIAL 
 
 

 
Note:

This guideline provides advice of a general nature.  This statewide guideline has been prepared to promote and facilitate standardisation 
and consistency of practice, using a multidisciplinary approach.  The guideline is based on a review of published evidence and expert 
opinion.  

Information in this statewide guideline is current at the time of publication.  

SA Health does not accept responsibility for the quality or accuracy of material on websites linked from this site and does not sponsor, 
approve or endorse materials on such links. 

Health practitioners in the South Australian public health sector are expected to review specific details of each patient and professionally 
assess the applicability of the relevant guideline to that clinical situation. 

If for good clinical reasons, a decision is made to depart from the guideline, the responsible clinician must document in the patient s medical 
record, the decision made, by whom, and detailed reasons for the departure from the guideline. 

This statewide guideline does not address all the elements of clinical practice and assumes that the individual clinicians are responsible 
for discussing care with consumers in an environment that is culturally appropriate and which enables respectful confidential discussion. 
This includes: 

                 The use of interpreter services where necessary, 
                 Advising consumers of their choice and ensuring informed consent is obtained, 
  Providing care within scope of practice, meeting all legislative requirements and maintaining standards of 

professional conduct, and  
                 Documenting all care in accordance with mandatory and local requirements 

Note: The words woman/women/mother/she/her have been used throughout this guideline as most pregnant and birthing people identify 
with their birth sex. However, for the purpose of this guideline, these terms include people who do not identify as women or mothers, 
including those with a non-binary identity. All clinicians should ask the pregnant person what their preferred term is and ensure this is 
communicated to the healthcare team. 

 
Explanation of the Aboriginal artwork: 
The Aboriginal artwork used symbolises the connection to country and the circle shape shows the strong relationships amongst families and the Aboriginal culture. The horse shoe shape design shown in 
front of the generic statement symbolises a woman and those enclosing a smaller horse shoe shape depicts a pregnant woman. The smaller horse shoe shape in this instance represents the unborn child. 
The artwork shown before the specific statements within the document symbolises a footprint and demonstrates the need to move forward together in unison. 

 

     

 

 

 

 

 

 

Purpose and Scope of Perinatal Practice Guideline (PPG) 

The purpose of this guideline is to provide clinicians with information for the assessment and 
management of neonatal abstinence syndrome. It includes use of the Modified Finnegan Neonatal 
Abstinence Severity (MFNASS) scoring system, non-pharmacological/supportive measures and 
pharmacological intervention for babies of both opioid and non-opioid dependent mothers.  

Australian Aboriginal Culture is the oldest living culture in the world yet 
Aboriginal people continue to experience the poorest health outcomes when 
compared to non-Aboriginal Australians. In South Australia, Aboriginal women are 
2-5 times more likely to die in childbirth and their babies are 2-3 times more likely to 
be of low birth weight.  The accumulative effects of stress, low socio economic 
status, exposure to violence, historical trauma, culturally unsafe and discriminatory 
health services and health systems are all major contributors to the disparities in 
Aboriginal maternal and birthing outcomes. Despite these unacceptable statistics 
the birth of an Aboriginal baby is a celebration of life and an important cultural 
event bringing family together in celebration, obligation and responsibility. The 
diversity between Aboriginal cultures, language and practices differ greatly and so 
it is imperative that perinatal services prepare to respectfully manage Aboriginal 
protocol and provide a culturally positive health care experience for Aboriginal 
people to ensure the best maternal, neonatal and child health outcomes. 

 



South Australian Perinatal Practice Guideline 

 Neonatal Abstinence Syndrome 
 

 

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Flowchart: Management of babies born to an opioid dependent mother 

 



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Flowchart: Management of babies born to non-opioid dependent mother 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



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 Neonatal Abstinence Syndrome 
 

 

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Flowchart: MFNASS scoring frequency 

  



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Table of Contents 

 

Purpose and Scope of Perinatal Practice Guideline (PPG) .................................................................. 1 

Flowchart: Management of babies born to an opioid dependent mother .............................................. 2 

Flowchart: Management of babies born to non-opioid dependent mother ............................................ 3 

Flowchart: MFNASS scoring frequency ................................................................................................ 4 

Table of Contents .................................................................................................................................. 5 

Summary of Practice Recommendations .............................................................................................. 6 

Definition ................................................................................................................................................ 6 

Abbreviations ......................................................................................................................................... 6 

Introduction ............................................................................................................................................ 7 

Associations with maternal use of drugs ........................................................................................... 7 

Antenatal care planning ..................................................................................................................... 7 

Non-Opioid Agents and Presentation ................................................................................................ 8 

Early management after birth ................................................................................................................ 9 

Diagnosis of NAS ................................................................................................................................ 10 

Non - Pharmacological Intervention .................................................................................................... 10 

Environmental control ...................................................................................................................... 10 

Feeding strategies ........................................................................................................................... 10 

Functioning of the mother-infant dyad: ............................................................................................ 11 

Pharmacological Intervention .............................................................................................................. 11 

Opioid Withdrawal   Morphine treatment ........................................................................................ 11 

Vomiting in association with morphine dosing: ............................................................................ 12 

Regulation of the prescription of morphine syrup ............................................................................ 12 

Non-Opioid Withdrawal   Phenobarbitone Treatment .................................................................... 13 

Discharge Criteria ................................................................................................................................ 14 

Follow up ............................................................................................................................................. 14 

References .......................................................................................................................................... 15 

Appendices .......................................................................................................................................... 17 

APPENDIX 1. Modified Finnegan NAS chart .................................................................................. 17 

Modified Finnegan withdrawal score ............................................................................................ 17 

Neonatal abstinence syndrome (NAS) scoring chart ................................................................... 18 

Instructions for scoring using the MFNASS ................................................................................. 18 

APPENDIX 2. NAS symptoms and suggested techniques ............................................................. 20 

Acknowledgements ............................................................................................................................. 21 

Write Group Lead ............................................................................................................................ 21 

Write Group Members ..................................................................................................................... 21 

Other major contributors .................................................................................................................. 21 

SAPPG Management Group Members ........................................................................................... 21 

Document Ownership &amp; History .......................................................................................................... 22 

 

  



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Summary of Practice Recommendations  

1. Most infants with signs and symptoms of neonatal abstinence syndrome do not require medication 

2. Optimise non-pharmacological intervention first with parental involvement/ support 

3. If medication is to be commenced, consider PRN or  as needed  dosing and re-evaluate. 

4. Wean regular doses as quickly as possible (e.g. consider daily weaning of medication) 

Definition 

Neonatal 
abstinence 
syndrome (NAS) 

A constellation of signs and symptoms of drug withdrawal in infants after 
birth. Other terms include opioid withdrawal syndrome or neonatal 
withdrawal syndrome. 

Abbreviations 

BD 12 hourly 

CPR Cardiopulmonary resuscitation 

CAFHS Child and Family Health Service 

DASSA Drug and Alcohol Services South Australia 

DDU Drugs of dependence unit 

e.g. For example 

GP General practitioner 

HIV Human immunodeficiency virus 

kg Kilogram(s) 

mg Milligram(s) 

MFNASS Modified Finnegan Neonatal Abstinence Severity Score 

NAS Neonatal abstinence syndrome 

NNP Neonatal nurse practitioner 

NHMRC National Health and Medical Research Council 

% Percent 

PPG Perinatal Practice Guideline(s) 

SA South Australia 

SIDS Sudden infant death syndrome 

SNRIs Serotonin and noradrenaline reuptake inhibitors 

SSRIs Selective serotonin reuptake inhibitors 

SUDI Sudden unexpected death in infancy 

 

  



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Introduction 

Signs and symptoms of NAS can involve the central nervous system (irritability, increased muscle 
tone, tremors, high pitched cry, and disturbed sleep), can be autonomic (sneezing, fever, yawning, 
sweating, mottling) and can include the gastrointestinal system (disorganised sucking, vomiting, 
loose/watery stools or hyperphagia). 

Withdrawal symptoms occur as a result of variety of drugs such as opiates, stimulant and 
antidepressant medications. The onset of withdrawal varies and is dependent on the drug, dose, half-
life, gestational age of the infant, and when the drug was last consumed. 

The incidence of NAS in Australia has decreased and is estimated to be 3 per 1000 live births.1 

Not all women will divulge their drug use to health practitioners, partners or relatives. If an infant has 
symptoms consistent with opioid withdrawal, a history should be taken from the mother in a sensitive 
manner and in a private setting.2 

Infants suspected of opioid withdrawal should be examined thoroughly and other possible causes 
excluded. 

Care planning (including screening, treatment and management) should be family centered, 
individualised with frequent evaluation. 

Associations with maternal use of drugs  

More than 50% of maternal drug use have co-existing psychiatric morbidity3; most commonly 
depression 

Whilst there is no documented increase in congenital abnormalities in infants of opiate, marijuana 
using mother, infants born to mothers using illicit drugs are also at risk of adverse neonatal outcomes 
such as growth restriction, birth defects, sudden infant death and preterm birth4,5 

There is no increase in fetal abnormality in mothers who use opioids, amphetamines, or marijuana 

Antenatal care planning 

If a woman is known to be dependent on opioid or non-opioid substances during pregnancy, a 
multidisciplinary team meeting should be arranged for around 32 weeks gestation to undertake an 
assessment of risk to the unborn child and to develop a family support plan. The woman and her 
partner, maternity care providers (obstetrician, GP, midwife, AMIC worker), Drug and Alcohol Services 
South Australia (DASSA) clinician (if relevant), neonatologist/paediatrician, hospital social worker/case 
coordinator and local Department for Child Protection (DCP) case manager (if allocated), should be 
involved in this team meeting. 

 

  



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Non-Opioid Agents and Presentation  

Agent Presentation Management considerations 

Amphetamine/ 

Methamphetamines 

Lethargy, somnolence and poor 
feeding 

 

  

The majority of amphetamine-exposed 
infants require only minimal supportive 
treatment. 

Few require pharmacological treatment  

Avoid early discharge after birth 

Ensure: 

? Early discharge planning and referral 
to relevant community support 
agencies 

? Psychosocial assessment and liaison 
with child safety services prior to 
discharge 

? Provide midwifery support with 
particular emphasis on breastfeeding 
support and parenting skills 

? Family and social supports are in 
place 

? Paediatric team are involved in 
neonate s hospital discharge and 
follow-up 

SSRI/SNRIs 

(antidepressant 
medication) 

Symptoms are usually mild and
 

most develop within 48 hours of 
birth and resolve without 
treatment within two to six days. 
They include: 

? Increased muscle tone 

? Mild or marked tremors 
while undisturbed 

? Exaggerated Moro reflex 
(i.e. startle)  

? Loose or watery stools 

? Poor feeding 

? Poor sleep (less than 1-2 
hours sleep after feeding)  

? Poor feeding 

Avoid early discharge after birth 

Non-pharmacological measures to support 
infant through withdrawal 

Breastfeeding encouraged 

Cocaine Autonomic stability 

Jitteriness 

Irritability/ high pitched cry  

Excessive sucking and agitation 

Avoid early discharge after birth 

Non-pharmacological measures to support 
infant through withdrawal 

 

 

Alcohol ? Jitteriness 

? Irritability 

? Poor feeding 

? At modest risk of 
hypoglycemia 

? Seizure (rare) 

Avoid early discharge after birth 

Non-pharmacological measures to support 
infant through withdrawal 

 



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Early management after birth 

? DO NOT give Naloxone in resuscitation of babies born to opioid dependent mothers as it has 
the potential to cause life-threatening withdrawal symptoms including seizures. 

? Ineffective breathing or apnoea in the newborn is managed by positive pressure ventilation in 
accordance to Australian Resuscitation Council guidelines 

? The mother s hepatitis B, C and HIV status should be checked if not already done. (See 
Hepatitis B in Pregnancy perinatal practice guideline and Hepatitis B immunoglobulin neonatal 
medication guideline available at www.sahealth.sa.gov.au/perinatal)  

? Urine toxicology screening is useful to determine which drugs the infant has been recently 
exposed to in utero where this is unclear from maternal history. Verbal consent for the urine 
toxicology screen is required and consent should be documented in the Medical Record. The 
test should not be taken if parental consent is not obtained, unless there is a legal directive to 
do so 

? If the infant is otherwise well with no child safety issues are identified, he/she should room in 
and be observed with mother on the postnatal ward 

? NAS is likely to be more severe in infants that have been exposed to opioid derivatives and 
multiple substances during antenatal period. The infant should be reviewed daily by a medical 
officer or neonatal nurse practitioner 

? DO NOT ROUTINELY score infants born to maternal opioid dependence using a Neonatal 
Abstinence Score chart (modified Finnegan chart) unless they are symptomatic 

? The NAS scoring system is a guide and not a precise measure of the infant s clinical course 
? Parents are to be educated with the scoring tool and be encouraged to participate in scoring  

? Encourage breastfeeding or expression of breast milk.  

? Daily assessment for withdrawal signs and symptoms, adequacy of feeds and weight gain will 
enable early recognition and appropriate intervention for the infant 

? Liaise with medical team, social work services and involvement of Department of Child 
Protection should there be any indication of child-at risk  

Benzodiazepines ? May be floppy and lethargic  

? May be jittery with 
increased tone 

? Irritability 

? Poor feeding 

 

? Extended stay with observation for 
signs of withdrawal  

? Should have outpatient review in first 
weeks of life 

? Educate parents to observe for signs 
of withdrawal after hospital discharge 
may be helpful, with instructions to 
present earlier if indicated by the 
infant s behaviour 

? Non-pharmacological measures to 
support infant through withdrawal 

? Phenobarbitone may be required 

Cannabis Mild withdrawal signs: 

? Tremors 

? Exaggerated startle 

? Lethargy  

? Poor sleep 

? Avoid early discharge after birth 

? Non-pharmacological measures to 
support infant through withdrawal 

? Breast feeding encouraged 




South Australian Perinatal Practice Guideline 

 Neonatal Abstinence Syndrome 
 

 

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Diagnosis of NAS 

? Evaluation of signs of neonatal withdrawal should commence using the Modified Finnegan 
Neonatal Abstinence Severity Score (MFNASS); the Australian standard designed for 
assessment of opioid withdrawal in term infants6-11 

? Scoring should occur if signs of withdrawal are evident and then subsequently every 4 hours 
(see flowchart) 

? The Neonatologist or Paediatrician should consider and exclude where appropriate other 
differential diagnoses (e.g. hypoglycaemia, sepsis, intracranial haemorrhage and hypoxic-
ischaemic encephalopathy) 

? Urine toxicology may be clinically helpful to determine the source of substance exposure and 
risk of abstinence (with documented maternal informed consent or a legal directive)  

? The MFNASS has only been validated for opioid NAS yet can still be helpful in assessing non-
opioid NAS6,7  

? The MFNASS has limited use in the premature infant who may display less signs of withdrawal 

? Evaluation and scoring occur every 4 hours. Scoring is based on the infant s behaviour and 
symptoms exhibited over the previous 4 hours (see Instructions for scoring using the 
MFNASS - Appendix 1). This can also be scored in the EMR. 

? The clinician should be well educated on the use of the MFNASS and had directly cared for 
the infant over the previous 4 hours 

? Scoring is performed 30 minutes to 1 hour after the infant has been fed by experienced medical 
staff/midwives/nurses 

? Infants with an abstinence score of 8 or more for three consecutive scores or ?12 at any 
time should be discussed with a Neonatologist or Paediatrician and the infant transferred to a 
Level 4, 5 or 6 Special Care Unit for continuous monitoring 

? If there are inconsistencies in the scores, the infant may be observed for a period in a level 4, 
5 or 6 Special Care Unit to ensure morphine treatment is justified 

? It is important that the mother is actively involved in the scoring process to facilitate family 
participation in care. Staff should discuss each sign as it is assessed with the mother 

Non - Pharmacological Intervention 

? Most infants with signs and symptoms of abstinence DO NOT REQUIRE medication but 
respond well with non- pharmacological intervention.  

? Non-pharmacological measures are the first-line treatment of NAS and should then be 
continued as an adjunct to pharmacological treatment. Parents and staff should be educated 
on these interventions12-19 (Appendix 2) 

Environmental control  

? Dimmed room lighting, quiet setting, position and comfort measures (e.g. swaying and rocking, 
swaddling, non-nutritive sucking, clustered care, bathing, music therapy, massage 

Feeding strategies  

? Small, frequent feeds, infant-led feeding, breast milk20 

? Encourage establishment and continuation of breastfeeding if the mother is HIV negative and 
no other contraindications for breastfeeding exit 

? Breastfeeding has been demonstrated to significantly reduce NAS symptoms, the need for 
treatment, treatment duration and length of hospital stay19 

? Provide education to the mother around these benefits of breastfeeding or providing 
expressed breast milk 

  



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Functioning of the mother-infant dyad:  

? Fostering parental presence, rooming in, skin to skin contact, direct parental support from 
clinicians   

? Infants should room in with their mothers if it is safe and feasible. Evidence suggests that 
rooming-in is associated with a decreased need for pharmacological treatment and length 
of hospital stay14  

? Non-judgmental care based on trauma-informed care principles should be provided to 
mothers to foster maternal involvement and parental well-being21  

 

*New family-centred model of care for treatment of Neonatal abstinence syndrome (Eat, Sleep, 
Console Approach) been developed and practiced22-26. This method focuses on maximising non  
pharmacological intervention, with encouragement of family involvement and morphine use only 
as needed.  
*There is growing evidence that this model of care for infants with NAS reduces the length of stay, 
reduces medication use and is cost effective.22 However, the research evidence is still evolving 
and the efficacy of this novel model has not been rigorously researched.  

Pharmacological Intervention 

Opioid Withdrawal   Morphine treatment 

Only commence after reassessing and maximising non-pharmacological management8-11, 26-30 

Commence cardiorespiratory monitoring when morphine is prescribed. 

 

MFNASS Score 
 

Morphine dosage (oral) 

? 8 Non-pharmacological treatment and medical review 

? 8 for three consecutive scores 
OR ? 12 for one score 

Prescribe stat doses of morphine 0.1mg/kg/dose as needed 
(minimum interval of 4 hourly, up to 3 doses in 24 
hours).Continue non-pharmacological intervention (observe 
in the nursery for 24 hours) 

Score ? 8 despite three stat doses 
in 24 hours 

Commence Morphine 0.1mg/kg/dose 6 hourly orally 

Score ? 8 despite 0.1mg/kg/dose 
6 hourly  

Commence Morphine 0.125mg/kg/dose 6 hourly orally 

Score ? 8 despite 
0.125mg/kg/dose 6 hourly 

Commence Morphine 0.175mg/kg/dose 6 hourly orally 

Score ? 8 despite 
0.175mg/kg/dose 6 hourly 

Morphine 0.225mg/kg/dose 6 hourly orally 

(Calculate to nearest 0.05mg/dose) 

? Where control is difficult give the total daily dose in 6 divided doses e.g. 4 hourly (step-down 
doses may then need to be &lt;0.05mg)8-10 

? Consider adding adjunct treatment of phenobarbitone if morphine dose is &gt;0.225mg/kg/dose 
or if there is maternal poly-drug use8-11,31 

? Please note: All doses for the entire period of withdrawal management are calculated on the 
basis of birth weight and not on current weight 

? Once symptoms has been controlled (three consecutive scores of &lt;8), using this   

? Dosage regimen, implement the following: 
o Maintain control for 24- 48 hours 
o Initiate the weaning process by decreasing each dose by 0.05mg every 24-48 hours 

4 hourly dose may be reduced to 6 hourly 

? When dosage levels reach 0.2 mg/dose   maintain this dose for 48 hours. At this dose, 
consideration can be given to home management 

? Discontinue morphine when dose 0.1mg/dose  

 



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When oral morphine treatment is discontinued, the NAS scoring should continue for a further 48-72 
hours if an inpatient 

Vomiting in association with morphine dosing: 

? Ensure infant is not being overfed 

? Ensure infant is appropriately postured during and after feeding 

? Give morphine before the feed 

If infant has a large vomit after being given morphine: 

? Re-dose if infant vomits within 10 minutes after a dose 

? Give   dose if infant vomits 10 -20 minutes after a dose 

? If infant vomits &gt;20 minutes after feed, do not give further morphine  

Regulation of the prescription of morphine syrup 

? The Drugs of Dependence Unit regulates the prescription of morphine for treatment of 
neonatal abstinence in the context of maternal opioid dependence. The following points should 
be noted: 

? Authority for prescription of morphine syrup for NAS is restricted to qualified consultants/ 
registrars / NNP 

? Authority to prescribe requires written application to the Drugs of Dependence Unit (DDU) 
from the treating paediatrician in the following circumstances: 

o where inpatient therapy exceeds 14 days 
o pre-discharge, where treatment is to be continued in the community for longer than 

14 days and inpatient treatment is less than14 days 
o where treatment is commenced in a private hospital 
o where treatment is continued in a private hospital by a paediatrician other than the 

authorised paediatrician who commenced treatment in the public hospital 

? Authority is given for the period that the treating specialist requests on the application form. 
An individual authority with a unique number is required for each new patient 

? Authority is given subject to the use of morphine syrup in accordance with this Perinatal 
Practice Guideline or a hospital approved guideline for abstinence treatment 

? Authority can be obtained irrespective of parental consent, although consent is desirable 

? Exemptions to the requirement for authority are as follows: 
o where inpatient treatment is less than 14 days AND where treatment on discharge 

following inpatient treatment does not exceed 14 days 
o where morphine is prescribed as an inpatient or outpatient as part of a pain or 

palliative care treatment plan, in which circumstances authority is not required for a 
period of up to 2 months 

? Under the legislation, other paediatricians employed at the same or another public hospital, or 
a community general practitioner where a paediatrician considers this appropriate, may be a 
locum prescriber for the authorised prescriber provided this locum: 

o undertakes due care in assessing the infant s treatment including practicing within 
approved guidelines and consulting appropriately with a paediatrician 

o complies with the conditions of the authority 
o refers to a paediatrician if three or more consecutive doses of morphine are missed 

? Application forms are available from SA Health website 

? Once an application is received an authority can be issued (if approved) to the paediatrician/ 
consultant and a copy forwarded to the hospital pharmacist  




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Non-Opioid Withdrawal   Phenobarbitone Treatment 

? If the mother does not use opioid drugs but uses central nervous system stimulants 
(amphetamines, cocaine, SSRIs, SNRIs) or depressants (e.g. benzodiazepines and alcohol) 
the infant is observed for evidence of NAS on the postnatal ward 

? The NAS chart is not validated for the assessment of non-opioid withdrawal but can still be of 
use in clinical decision making 

? Neonatal abstinence syndrome is not routinely scored with NAS score chart, but scoring is 
commenced if the infant exhibits signs consistent with NAS (persistent crying/poor settling 
following feeds, tremors/jerks/seizures, poor feeding, diarrhoea/vomiting, fever &gt;37.5 C per 
axilla, tachypnoea, sleepy behaviour) 

? The assessment procedures using the NAS chart are as described under opioid NAS 

? Babies with NAS score of &gt;8 should be discussed with a neonatologist/paediatrician and 
consideration given to transferring to a Level 4, 5 or 6 nursery for observation and further 
management 

? Phenobarbitone is the drug of choice for significant non-opioid NAS(31-33) 

? If there are inconsistencies in the scores, the infant may be observed for a period of time in a 
level 4,5 or 6 nursery to ensure phenobarbitone treatment is truly indicated 

? It is important that the mother is actively involved in the scoring process to facilitate ongoing 
care for the infant. Staff should discuss each sign as it is assessed 

? Commencement of phenobarbitone should only occur in a level 4, 5 or 6 nursery with 
supervision by paediatrician or neonatologist 

? Cardiorespiratory or oximetry monitoring is routinely required at the commencement of 
phenobarbitone as respiratory depression, including apnoeas, may occur following a loading 
dose 

? Where a mother is on a combination of methadone and benzodiazepines and the infant is not 
settling with morphine treatment alone, the addition of phenobarbitone treatment may be 
helpful in the management of withdrawal symptoms 

 

MFNASS Score Phenobarbitone dosage (oral) 

? 8  
Loading dose: 15 mg/kg oral then 2.5 mg/kg/dose orally BD 
commencing 12 hours after loading dose  as maintenance 

? 8  despite 
2.5mg/kg/dose BD 

Increase to 4 mg/kg/dose orally BD 

? 8 despite 
4mg/kg/dose BD 

Increase to 5 mg / kg / dose orally BD 

 

After scores fall below treatment level for 24- 48 hours, the dose should be reduced by 10%-20% from 
previous dose. 

  



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Discharge Criteria 

? Duration of hospitalisation may be tailored according to the type of substance used and other 
factors such as social circumstances.  Infants at risk of NAS caused by opioid withdrawal 
(including methadone and buprenorphine) and/or benzodiazepine should be monitored in 
hospital for at least 5 days. Most infants will exhibit signs and symptoms by 72 hours; however, 
some infants may have a delayed onset if they have been exposed to long  acting substances 
or prolonged benzodiazepines in utero. 

? Earlier discharge for infants who are well (with short exposure of opioids) and has an 
appropriate safety discharge plans/ follow up could be considered at consultant s discretion. 

? Outpatient management of neonatal abstinence may be considered when morphine doses are 
&lt;0.2mg/dose AND infant s symptoms are well controlled with satisfactory weight gain AND 
families for whom home management is appropriate 

? Parents and caregivers are educated on NAS withdrawal symptoms, routine newborn care, 
basic CPR and instruction regarding administration of medications given to parents. 

? Parents and caregivers are provided with information on safe sleeping practices (as according 
to SA Health - Safe Infant Sleeping Standards) and the risk of SIDS/ SUDI  

? Multi-disciplinary planning for safe care has occurred with social worker or coordinating with 
local Department for Child Protection service as appropriate. 

? Rooming in for 24-48 hours is encouraged to assist with assessment of parenting skills, 
psychological stability and general education and specific instruction regarding administration 
of medications. 

? Follow up plan in place (as below) 

? Safety assessment for staff visiting at home has been performed. 

Follow up 

? General Practitioner review within 2 weeks 

? Weekly Paediatrician outpatient review is required for infants discharged on medications for 
NAS 

? Other follow up plans as per multidisciplinary plan: Maternity outreach, Neonatal outreach and 
Child and Family Health, or Department for Child Protection 

? The parents should be counselled regarding the need for hepatitis C screening of their child 
at 12-18 months where the mother is hepatitis C positive. Referral to paediatric infectious 
disease specialist if appropriate. 

 

 

 

 

 

 

 

 

  




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INFORMAL COPY WHEN PRINTED       Page 15 of 22 
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References 

1. Uebel H, Wright IM, Burns L, Hilder L, Bajuk B, Breen C, et al. Epidemiological Evidence for 
a Decreasing Incidence of Neonatal Abstinence Syndrome, 2000-11. Paediatr Perinat Epidemiol. 
2016;30(3):267-73. 

2. RW L. Substance abuse in pregnancy: the team approach to antenatal care. The Obstetrician 
and Gynaecologist 2000;2:11-5. 

3. Oei JL, Abdel-Latif ME, Craig F, Kee A, Austin MP, Lui K. Short-term outcomes of mothers 
and newborn infants with comorbid psychiatric disorders and drug dependency. Aust N Z J Psychiatry. 
2009;43(4):323-31. 

4. Chang G. Maternal Substance Use: Consequences, Identification, and Interventions. Alcohol 
Res. 2020;40(2):06. 

5. Coyle MG, Brogly SB, Ahmed MS, Patrick SW, Jones HE. Neonatal abstinence syndrome. 
Nat Rev Dis Primers. 2018;4(1):47. 

6. LP F. Neonatal abstinence syndrome: assessment and pharmacotherapy. Toronto, Ontario: 
BC Decker Inc, Nelson NM; 1990. 

7. Timpson W, Killoran C, Maranda L, Picarillo A, Bloch-Salisbury E. A Quality Improvement 
Initiative to Increase Scoring Consistency and Accuracy of the Finnegan Tool: Challenges in Obtaining 
Reliable Assessments of Drug Withdrawal in Neonatal Abstinence Syndrome. Adv Neonatal Care. 
2018;18(1):70-8. 

8. Health NDo. Clinical Guidelines: Substance Use During Pregnancy, Birth and the Postnatal 
Period NSW Department of Health. 2014 [ 

9. Service GoWACaAH. Clinical Guidelines: Neonatal Abstinence Syndrome. Government of 
Western Australia Child and Adolescent Health Service. 2020 [ 

10. Guidelines QC. Queensland Clinical Guidelines: Perinatal substance use: 2017 [ 

11. Starship NZ. Drug dependency - infants born to drug dependent mothers 2018 [ 

12. D?Apolito KC. Assessing neonates for neonatal abstinence: are you reliable? J Perinat 
Neonatal Nurs. 2014;28(3):220-31. 

13. Patrick SW, Barfield WD, Poindexter BB. Neonatal Opioid Withdrawal Syndrome. Pediatrics. 
2020;146(5). 

14. Velez M, Jansson LM. The Opioid dependent mother and newborn dyad: non-pharmacologic 
care. J Addict Med. 2008;2(3):113-20. 

15. Jansson LM. ABM clinical protocol #21: Guidelines for breastfeeding and the drug-dependent 
woman. Breastfeed Med. 2009;4(4):225-8. 

16. MacMillan KDL, Rendon CP, Verma K, Riblet N, Washer DB, Volpe Holmes A. Association of 
Rooming-in With Outcomes for Neonatal Abstinence Syndrome: A Systematic Review and Meta-
analysis. JAMA Pediatr. 2018;172(4):345-51. 

17. McQueen K, Taylor C, Murphy-Oikonen J. Systematic Review of Newborn Feeding Method 
and Outcomes Related to Neonatal Abstinence Syndrome. J Obstet Gynecol Neonatal Nurs. 
2019;48(4):398-407. 

18. Mangat AK, Schm lzer GM, Kraft WK. Pharmacological and non-pharmacological treatments 
for the Neonatal Abstinence Syndrome (NAS). Semin Fetal Neonatal Med. 2019;24(2):133-41. 

19. Pahl A, Young L, Buus-Frank ME, Marcellus L, Soll R. Non-pharmacological care for opioid 
withdrawal in newborns. Cochrane Database Syst Rev. 2020;12(12):Cd013217. 

20. Pandey R, Kanike N, Ibrahim M, Swarup N, Super DM, Groh-Wargo S, et al. Lactose-free 
infant formula does not change outcomes of neonatal abstinence syndrome (NAS): a randomized 
clinical trial. J Perinatol. 2021;41(3):598-605. 

21. Salameh TN, Polivka B. Knowledge of and Perceived Competence in Trauma-Informed Care 
and Attitudes of NICU Nurses Toward Mothers of Newborns With Neonatal Abstinence Syndrome. J 
Obstet Gynecol Neonatal Nurs. 2020;49(4):373-87. 

22. Grossman MR, Berkwitt AK, Osborn RR, Xu Y, Esserman DA, Shapiro ED, et al. An Initiative 
to Improve the Quality of Care of Infants With Neonatal Abstinence Syndrome. Pediatrics. 2017;139(6). 

23. Achilles JS, Castaneda-Lovato J. A Quality Improvement Initiative to Improve the Care of 
Infants Born Exposed to Opioids by Implementing the Eat, Sleep, Console Assessment Tool. Hosp 
Pediatr. 2019;9(8):624-31. 



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24. Parlaman J, Deodhar P, Sanders V, Jerome J, McDaniel C. Improving Care for Infants With 
Neonatal Abstinence Syndrome: A Multicenter, Community Hospital-Based Study. Hosp Pediatr. 
2019;9(8):608-14. 

25. Wachman EM, Grossman M, Schiff DM, Philipp BL, Minear S, Hutton E, et al. Quality 
improvement initiative to improve inpatient outcomes for Neonatal Abstinence Syndrome. J Perinatol. 
2018;38(8):1114-22. 

26. Kocherlakota P. Chapter 19 - Pharmacologic Therapy for Neonatal Abstinence Syndrome. In: 
Benitz WE, Smith PB, editors. Infectious Disease and Pharmacology. Philadelphia: Elsevier; 2019. p. 
243-59. 

27. Disher T, Gullickson C, Singh B, Cameron C, Boulos L, Beaubien L, et al. Pharmacological 
Treatments for Neonatal Abstinence Syndrome: A Systematic Review and Network Meta-analysis. 
JAMA Pediatr. 2019;173(3):234-43. 

28. McQueen K, Murphy-Oikonen J. Neonatal Abstinence Syndrome. N Engl J Med. 
2016;375(25):2468-79. 

29. Mian P, Tibboel D, Wildschut ED, van den Anker JN, Allegaert K. Morphine treatment for 
neonatal abstinence syndrome: huge dosing variability underscores the need for a better clinical study 
design. Minerva Pediatr. 2019;71(3):263-86. 

30. Stover MW, Davis JM. Opioids in pregnancy and neonatal abstinence syndrome. Semin 
Perinatol. 2015;39(7):561-5. 

31. Nayeri F, Sheikh M, Kalani M, Niknafs P, Shariat M, Dalili H, et al. Phenobarbital versus 
morphine in the management of neonatal abstinence syndrome, a randomized control trial. BMC 
Pediatr. 2015;15:57. 

32. Raffaeli G, Cavallaro G, Allegaert K, Wildschut ED, Fumagalli M, Agosti M, et al. Neonatal 
Abstinence Syndrome: Update on Diagnostic and Therapeutic Strategies. Pharmacotherapy. 
2017;37(7):814-23. 

33. Zimmermann U, Rudin C, Du  A, Held L, Bucher HU. Treatment of opioid withdrawal in 
neonates with morphine, phenobarbital, or chlorpromazine: a randomized double-blind trial. Eur J 
Pediatr. 2020;179(1):141-9. 

 

 

 

 

 

 

 

 

  



South Australian Perinatal Practice Guideline 

 Neonatal Abstinence Syndrome 
 

 

INFORMAL COPY WHEN PRINTED       Page 17 of 22 
 OFFICIAL 

Appendices 

APPENDIX 1. Modified Finnegan NAS chart 

Modified Finnegan withdrawal score 

WARD UNIT NO: DOB: 
SURNAME, OTHER NAMES: SEX: 
 

SYSTEM SIGNS &amp;SYMPTOMS SC
O

R
E

 

           NE
O

N
A

T
A

L
  W

IT
H

D
R

A
W

A
L

  S
C

O
R

IN
G

  C
H

A
R

T
  (T

E
R

M
  IN

F
A

N
T

S
) 

C
E

N
T

R
A

L
 N

E
R

V
O

U
S

  
S

Y
S

T
E

M
 

D
IS

T
U

R
B

A
N

C
E

S
 

High-Pitched Cry 

Continuous High-Pitched Cry 

2 

3 

           

Sleeps &lt; 1 hour after feeding  

Sleeps &lt; 2 hours after feeding  

Sleeps &lt; 3 hours after feeding 

3 

2 

1 

           

Mild tremors when disturbed 

Mod-severe tremors when disturbed 

Mild tremors undisturbed  

Mod-severe tremors undisturbed 

1 

2 

3 

4 

           

Increased Muscle Tone 2            

Excoriation (specify area) 1            

Myoclonic Jerks 3            

Generalised Convulsions 5            

M
E

T
A

B
O

L
IC

 /
 V

A
S

O
M

O
T

O
R

 /
 

R
E

S
P

IR
A

T
O

R
Y

 

D
IS

T
U

R
B

A
N

C
E

S
 

Fever (37.3?C   38.3?C)  

Fever (38.4?C and higher) 

1 

2 

           

Frequent Yawning (&gt;3-4 times) 1            

Nasal Stuffiness 1            

Sneezing (&gt;3-4 times) 1            

Nasal Flaring 2            

Respiratory Rate &gt; 60 / min 1            

Respiratory Rate &gt; 60 / min with 
retractions 

2 
           

G
A

S
T

R
O

IN
T

E
S

T
IN

A
L

 

D
IS

T
U

R
B

A
N

C
E

S
 

Excessive sucking 1            

Poor Feeding 2            

Regurgitation  

Projectile Vomiting 

2 

3 

           

Loose Stools Watery Stools 
2 

3 

           

 Max Score: 41 
TOTAL SCORE 

            

 SCORER S INITIALS              

Adapted from Finnegan LP. In: Nelson N, editor. Current therapy in neonatal-perinatal medicine. 2ed. Ontario: BC Decker;1990. 

 

  



South Australian Perinatal Practice Guideline 

 Neonatal Abstinence Syndrome 
 

 

INFORMAL COPY WHEN PRINTED       Page 18 of 22 
 OFFICIAL 

Neonatal abstinence syndrome (NAS) scoring chart 

Instructions for scoring using the MFNASS 

? The score should be based on the infant s behaviour/symptoms exhibited over the previous 4 
hours  

? Some scales are of increasing severity and only 1 score should be made for each category 

? Modifications for prematurity are mainly necessary in the sections on sleeping, e.g. an infant 
who needs three-hourly feeds can only sleep at most 2.5 hours between them  

? Scoring should be 1 if the infant sleeps less than two, 2 if sleeps less than one hour, and 3 if 
the infant does not sleep between feeds. Many premature infants require tube feeding  

? Infants should not be scored for poor feeding if tube feeding is routine for their gestation  

 

CNS disturbances 

Cry: If the infant can be consoled and ceases crying within 5 

minutes, the score would be 2 for a high-pitched crying. If the 

infant continues to cry for longer than 5 minutes despite 

consoling measures, the score would be 3 for continuous 

crying 

Sleep: Scored based on the longest time the infant sleeps without being 

disturbed 

Disturbed tremors: Occurs when the infant is handled. Mild tremors of 

the hands or feet should score 1, tremors involving the entire arm/leg 

(moderate/severe) score 2  

Undisturbed tremors: Examined after the infant has been disturbed 

and has 20 to 30 seconds of being undisturbed. If tremors of the hands 

or feet continue score 3. Tremors of the entire extremity 

(moderate/severe) score 4.  

Increased muscle tone: Assessed using the pull-to-sit 

manoeuver when the infant is not crying. Score if the infant 

has increased muscle tone; meaning their arms are straight 

and their body and head are raised without any head lag  

Excoriation: Score if excoriation is present during the scoring period  

Myoclonic jerks: Involuntary spasms or twitching movements 

of a muscles in face or extremities, often stimulation induced  

Generalised convulsions: Tonic seizures are generalised 

activity involving tonic extension of all limbs that continue even 

when the effected limb is touched or flexed 

Metabolic/vasomotor/ 

respiratory disturbances 

Fever: Ensure sweating or fever is not related to overheating 

from being overdressed or overwrapped 

Yawning/sneezing: yawns or sneezes occurring more than 3 

times in the 4-hour scoring interval 

Nasal stuffiness/flaring: Flaring occurring during inspiration  

Respiratory rate: Count for 1 minute when the infant is not 

crying 

Respiratory rate with retractions: The presence of an 

indentation of the chest wall during breathing 



South Australian Perinatal Practice Guideline 

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INFORMAL COPY WHEN PRINTED       Page 19 of 22 
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Gastrointestinal 

disturbances 

Excessive sucking: Score if the infant cannot attach properly onto a 

pacifier or teat whilst turning the head from side to side 

Poor feeding: Infrequent sucking during the feeding, or taking small 

amounts of formula or breast milk, or uncoordinated sucking, or 

prolonged time to complete the feed (&gt;20 minutes) 

Regurgitation and 

projective 

vomiting 

Regurgitation: Effortless return of gastric contents from the mouth. 

Score if frequent (?2 times) and not associated with burping 

Projectile vomiting: Ejection of the stomach contents from the mouth 

under force. Score if 1 or more episodes occur during or after feeding  

Loose stools: May or may not explosive, curdy or seedy stool 

Watery stools: Water circulating the stool in a ring 

 
Adapted from: D'Apolito KC1. Assessing neonates for neonatal abstinence: are you reliable? The Journal of Perinatal 
and Neonatal Nursing 2014; 28(3):220-31  

 

 

 

 

 

 

 

 

 

 

  



South Australian Perinatal Practice Guideline 

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INFORMAL COPY WHEN PRINTED       Page 20 of 22 
 OFFICIAL 

APPENDIX 2. NAS symptoms and suggested techniques 

Symptom Techniques 

Prolonged and/or high-pitched crying  
 

  Holding/containment techniques: Swaddling: 
tightly wrap the infant with a light muslin wrap 
ensuring not to over-heat 
Holding: Hold the infant s hands against their 
chest in a supine position, providing firm but 
gentle pressure to the trunk or head 

  Handle in a soft, slow manner 

  Decrease environmental stimulus e.g. decrease 
loud noises, provide dim lighting 

  Avoid rocking beds which may increase NAS 
symptoms and ensure sleep practices are in 
accordance with safe sleeping guidelines 

  Pacifiers can have a soothing and state-
organising effect  
 

Sleeplessness 

 

  Decrease environmental stimuli  

  Cluster care to avoiding unnecessary tactile 
stimuli 

  Encourage skin to skin contact 

  Demand feed 

Difficult or poor feeding  
 

 

  Provide frequent, small volume, on-demand 
feeding  

  Feed in a quiet, calm environment with minimal 
noise or stimulus 

  Pause the feed if the infant is becoming tired, 
needs to reposition or requires self-organisation  

Regurgitation and/or vomiting  
 

  To wind, rub the back instead of patting (which 
may provoke hyperactive Moro reflex in some 
infants)  

  Some infants may require a pacifier during 
winding if they become distressed when the feed 
is paused 

Excessive sucking of fists  
 

  Cover hands with mittens 

Hyperactivity 

 

  Reduce environmental stimuli including sound 
and light  

  Gentle vertical rocking, swaying, swaddling, and 
containment of hands  

  Avoid unnecessary tactile stimuli by clustering 
care and providing skin to skin  

  Visual stimulation with black and white objects 
may prevent overstimulation 

Trembling  
 

 

  Avoid excessive handling  

  Gentle handling and containment, positioning, 
non-nutritive sucking, and swaddling 

 

Fever (Temperature over 37 C)  
 

  Fold a blanket across the chest to contain the 
arms if they cannot tolerate being wrapped due 
to fever 

  Reduce clothing and blankets 

  Monitor temperature as clinically indicated 



South Australian Perinatal Practice Guideline 

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Acknowledgements 

The South Australian Perinatal Practice Guidelines gratefully acknowledge the contribution of 

clinicians and other stakeholders who participated throughout the guideline development process 

particularly:  

Write Group Lead 

Dr Alvin Tan 

Write Group Members 

Dr Michael Hewson 
Erin Grace 
Kim Gibson 
Dr Gillian Watterson 

Other major contributors 

Emma Marshall 

SAPPG Management Group Members 

Sonia Angus 
Lyn Bastian 
Dr Elizabeth Beare 
Elizabeth Bennett 
Dr Feisal Chenia 
John Coomblas 
Dr Danielle Crosby 
Dr Vanessa Ellison 
Dr Ray Farley 
Allison Waldron 
Dr Kritesh Kumar 
Catherine Leggett 
Dr Anupam Parange 
Rebecca Smith 
A/Prof Chris Wilkinson 

 

  



South Australian Perinatal Practice Guideline 

 Neonatal Abstinence Syndrome 
 

 

INFORMAL COPY WHEN PRINTED       Page 22 of 22 
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Document Ownership &amp; History 

Developed by: SA Maternal, Neonatal &amp; Gynaecology Community of Practice 
Contact: HealthCYWHSPerinatalProtocol@sa.gov.au 
Endorsed by: Domain Custodian, Clinical Governance Safety and Quality 
Next review due:  21/02/2027  
ISBN number:   978-1-76083-485-2 
 
CGSQ reference:  PPG010 
Policy history: Is this a new policy (V1)?  N 
 Does this policy amend or update and existing policy?   Y  
 If so, which version? 
 Does this policy replace another policy with a different title?  Y  
 If so, which policy (title)? Infants of Drug Dependent Women 
 
 

Approval 
Date 

Version 
Who approved New/Revised 
Version 

Reason for Change 

21/02/2022 V4 
Domain Custodian, Clinical 
Governance Safety and Quality 

Formally reviewed.  

23/09/2013 V3 
SA Health Safety &amp; Quality 
Strategic Governance Committee 

Formally reviewed in line with scheduled 
timeline for review 

18/02/2008 V2 
SA Health Maternal and Neonatal 
Clinical Network 

Formally reviewed in line with scheduled 
timeline for review 

17/03/2004 V1 
SA Health Maternal and Neonatal 
Clinical Network 

Original SA Health Maternal and 
Neonatal Clinical Network approved 
version. 

 



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