Neonatal abstinence syndrome (NAS) is a result of the sudden discontinuation of fetal exposure to substances that were used or abused by the mother during pregnancy. Withdrawal from licit or illicit substances is becoming more common among neonates in both developed and developing countries. NAS continues to be an important clinical entity throughout much of the world. NAS leads to a constellation of signs and symptoms involving multiple systems. The pathophysiology of NAS is not completely understood. Urine or meconium confirmation may assist the diagnosis and management of NAS. The Finnegan scoring system is commonly used to assess the severity of NAS; scoring can be helpful for initiating, monitoring, and terminating treatment in neonates. Nonpharmacological care is the initial treatment option, and pharmacological treatment is required if an improvement is not observed after nonpharmacological measures or if the infant develops severe withdrawal. Morphine is the most commonly used drug in the treatment of NAS secondary to opioids. An algorithmic approach to the management of infants with NAS is suggested. Breastfeeding is not contraindicated in NAS, unless the mother is taking street drugs, is involved in polydrug abuse, or is infected with HIV. Future studies are required to assess the long-term effects of NAS on children after prenatal exposure.
Comments
Erroneous maximum daily morphine dose in NAS: beware of misleading abbreviations
Sir,
We often rely on the AAP guidelines to support our clinical practice. With satisfaction.
We run a small neonatal level II unit that serves a population of 160'000 with about 1700 births/year. We recently reviewed our 2011-2016 cases of neonatal abstinence syndromes (NAS). We cared for 12 NAS (out of 10'653 live births, incidence of 1.1/1000 births). 9/12 were treated with oral morphine with a median maximal daily dose of 1 mg/kg.day (range 0.48 – 7.3) with very few side effects (one infant was constipated).
We realized that 4/9 received (much) more (respectively 1.5, 4.8, 7.0, 7.3 mg/kg.day) than the AAP recommended maximal daily dose of 1.3 mg/kg(1).
To try and understand the discrepancy between our apparently clinically safe practice and the AAP guidelines, we went all the way back to the initial quoted study on maximal daily morphine dose: O'Grady and al's single doses of 1.3 mg/kg (2009) turned into 1.3 mg/kg.d in Kraft and van den Anker's paper (2012) and into 1.3 mg/kg.day in the 2014 AAP guidelines(1-3).
We believe abbreviations can be misleading. We also believe that the 2014 AAP guidelines on maximum daily oral morphine dose to treat NAS are erroneous and based on misread abbreviations.
Could you please comment on our understanding of Kocherlakota's review?
1. Kocherlakota P. Neonatal Absitience Syndrome. Pediatrics 2014;134:e547-e561
2. Kraft WK, van den Anker JN. Pharmacologic Management of the Opioid Neonatal Abstinence Syndrome. Pediatr Clin North Am. 2012 October ; 59(5): 1147–1165.
3. O’Grady MJ, Hopewell J, White MJ. Management of neonatal abstinence syndrome: a national survey and review of practice. Arch Dis Child Fetal Neonatal Ed 2009;94:F249–F252.