# Limitations of Scope
Iatrogenic opioid withdrawal: Infants recovering from serious illness who received opioids and sedatives in the hospital may experience symptoms of withdrawal once the drug is discontinued or tapered too quickly. While these infants may benefit from the management strategies discussed in this module, the ESC Care Tool is intended for newborns with prenatal substance exposure.

# Language
A note about gender and sexual orientation terminology: In this module, the terms pregnant women and pregnant individual are used. This is to acknowledge and be inclusive of transgender individuals who are pregnant, and to respect those who wish to continue to be identified as pregnant women or mothers. We encourage all providers to not assume the gender identity or sexual orientation of the pregnant person (or their partner) and to respectfully and non-judgmentally ask all pregnant people about their preference for how they wish to be addressed. 

# INTRODUCTION Terminology
Reviewing the literature on substance exposed newborns several terms and/or diagnoses are used such as:
Neonatal Abstinence Syndrome 1,2 Clinical diagnosis of neurologic, gastrointestinal, and musculoskeletal disturbances associated with withdrawal when substance source(s) are interrupted at birth. Withdrawal from opioids and other psychoactive substances. - This is the term that will be used in the manual.
Neonatal Opioid Withdrawal Syndrome 1,3 Clinical features specific to withdrawal from opioids.
Poor Neonatal Adaptation Syndrome 4,5,6 Clinical features specific to prenatal exposure to selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs). Includes features observed in NAS and NOWS, but also characterized by respiratory distress syndrome (RDS). Also called SSRI neonatal behavioural syndrome (SNBS) but restricted to SSRI.
Substance Exposed Newborn 1,7 Newborn exposed to substances during pregnancy that may cause symptoms of withdrawal postnatally.

# Epidemiology Incidence
Canadian incidence of NAS tripled between 2003 -2014. 8 Incidence rates in BC have risen from 2.6 to 4.7/1000 livebirths between 2010 -2018 9 (see Figure 1). Newborns diagnosed with NAS have longer and more costly length of stay in hospital (Figure 2), especially when treated with morphine. 8,9,10 This has imposed an increasing economic burden on the BC health care system, with total NAS-related hospital expenditure in 2014 reported to be 1.7 times higher than in 2010. 8  

# Hospital Beds Occupied Per Day by Newborns with NAS in BC
Trends in incidence of neonatal abstinence syndrome in Canada and associated healthcare resource utilization. Jacqueline Filteaua, Helen Cooa, Kimberly Dowa 

# Hospital beds occupied per day

# NEWBORN CARE GUIDING PRINCIPLES Trauma Informed Age Appropriate Care (TIAAC)
The period following birth is a sensitive period and a critical phase in human development. 11 Trauma suffered during the first few years of life can lead to toxic stress and adversely influence normal development.
Toxic stress is defined as strong, prolonged, and/or frequent adverse experiences that activate the stress response in the newborn in the absence of protective relationships. Potential stressors include:
  maternal separation  
unresponsive and/or inconsistent care   an overwhelming sensory environment  Toxic stress can result in epigenetic modification in which changes occur in DNA transcription affecting the development of major organs, especially the heart, brain, and kidneys, with lifelong health consequences.  Providing appropriate care for the newborn during periods of acute withdrawal should focus on mitigating the effects of toxic stress. This involves providing effective social emotional buffering by adhering to age appropriate, trauma-informed care principles. Social buffering confers protective effects against toxic stress. 15 Quality of parenting where the parent actively engages and responds to the needs of the newborn can have a profound positive influence on the effectiveness of social buffering during stressful situations. 18 Examples of trauma informed age appropriate care include: 

# Modified gene expression can influence the development of major organs

# How Early Experiences Alters Gene Expression and Shape Development
Newborn Responsive and Family-Centered Care Newborn responsive and family-centered care  focus on the newborn and family and:   is optimal, evidence-based, and applies to all care environments;   enhances bonding and attachment and promotes healthy physical and emotional development of the newborn;   requires collaboration between healthcare providers and the mother, recognizing that the mother plays an integral role in the care of her newborn;   needs to be holistic, culturally appropriate, and delivered as close to home as possible;   systems of care must be prioritized to meet the needs of the newborn and the family. Honest consistent communication, and support, will empower the mother to build care capacity that will ensure ongoing competent care;   promotes mother and baby togetherness, skin-to-skin care, breastfeeding (unless contraindicated), and maternal emotional support to manage the stress related to the symptoms of substance withdrawal in her newborn;   promotes an appropriate care environment for the newborn exposed to substances that will allow for the control of light and noise as tolerated;   is sleep protective. The newborn exposed to substances should not be awakened unnecessarily for assessments and/or procedures;
  decreases length of hospital stay;   is neuroprotective;  
allows for better allocation of resources.

# CLINICAL PRESENTATION OF NEONATAL ABSTINENCE SYNDROME Pathophysiology
While the pathophysiology of NAS is unclear, exposure and abrupt discontinuation of substances during pregnancy alters neurotransmitter activity in the brain of the newborn.
Withdrawal symptoms may present similar to drug toxicity syndrome (effect of too much of the substance). However, symptoms of drug toxicity decrease as the drug is eliminated where symptoms of withdrawal increase due to interruption of the drug supply. Prenatal exposure to substances such as cocaine and SSRIs can result in symptoms of withdrawal, drug toxicity, or a combination of both.  Antenatal exposure to habit forming substances Substances with molecular weight < 600da, that is lipid solubilize, non-ionized and not bound to protein, readily crosses the placenta by passive diffusion

# In the fetus drug molecules attach to biochemical receptors in the CNS, blocking the action of neurotransmitters
As gestation increases more substances will cross the placental barrier due to a larger surface area, decreased diffusion distance, and increased placental blood flow

# Cord clamping at birth interrupts drug supply
Newborn continues to metabolize and excrete remaining metabolites of substances until depleted / excreted Absence of substance(s) at chronically stimulated receptors Altered neurotransmitter release (too much or too little) at the synapses

# Onset of withdrawal symptoms
Substance Effects on Neurotransmitters  Cord clamping and cutting at birth interrupts the drug supply. The newborn will continue to metabolize and excrete the remaining metabolites of substances until depleted and once depleted the absence of substances alter neurotransmitter release resulting in signs of substance withdrawal. Presentation of withdrawal signs and symptoms will depend on the type of substance and the type of neurotransmitter that is affected.
TCA = Tricyclic antidepressant SSRI = Selective serotonin reuptake inhibitor SNRI = Serotonin norepinephrine reuptake inhibitor GABA = Gamma aminobutyric acid (naturally occurring amino acid that works as a neurotransmitter in the brain For interactive content, please access module 3: Care of the newborn exposed to substances during pregnancy (lesson 3) via 

# Signs and Symptoms
NAS consists of neurologic, gastrointestinal, and musculoskeletal disturbances associated with withdrawal once the source of the substance(s) is interrupted at birth. However, these disturbances are highly variable and there is currently no reliable way to predict presence or severity of withdrawal symptoms.

# SYSTEM SIGNS AND SYMPTOMS Central Nervous System
Irritability, high pitched cry, tremors, hypertonic, sleep disturbances

# Gastrointestinal System
Loose stools, vomiting, dysrhythmic sucking and swallowing, poor intake with weight loss

# Respiratory System
Excessive secretions, nasal stuffiness, tachypnea

# Autonomic Nervous System
Sweating, sneezing, yawning, hyperthermia

# Variation in Expression and Severity of Withdrawal Symptoms
The incidence, timing of onset, presentation, and severity of NAS varies significantly among the population of newborns exposed to substances. 10,23,33,34 Variation can be attributed to a variety of factors such as:
type of maternal opioid replacement therapy 35,37   maternal polysubstance use and patterns of substance use 38,39   period of substance exposure and total accumulation of substance/s 

# Comorbidities (HIV, HepB)
Not all newborns exposed to substances are at risk of HIV and Hepatitis B transmission. Review the maternal history to determine risk and need for prophylaxis.
Mother to child transmission of HIV can occur during pregnancy, at the time of delivery, or via breastmilk.  For more information on screening for risk factors and management of the newborn visit the BC Women's Hospital and Health Centre HIV/AIDS Resource webpage at .
Mother to child transmission of Hepatitis B can occur during pregnancy. 47 Consult the BC Centre for Disease Control website at for most current information on screening the newborn at risk for Hepatitis B, prophylaxis indications and interventions.

# Diagnostic Testing for Prenatal Drug Exposure
Although neonatal drug testing is often performed to inform treatment planning, the decision to screen a newborn can be stigmatizing. 48 Routine testing for suspected prenatal substance use is not advisable, 49 as it can adversely affect the therapeutic relationship between the mother and health providers and can affect child welfare services. 50 A positive screen does not necessarily indicate the need for child protection nor influence the type of support required. Informed consent must be obtained prior to testing. However, tests may still be ordered by the primary care provider in the absence of maternal consent if deemed medically necessary.

# Issues with diagnostic testing for substance exposure  
Pharmacokinetics of drugs through the maternal-placental-fetal unit and in the newborn are not well understood. 48 
Variation in specimen collection methods, storage, and transport of the specimen to the laboratory can influence test accuracy. 51,52 
Poor sensitivity and specificity may generate false positive or negative results. 53,54   Local laboratories may lack the ability to further analyze positive screens required to inform clinical management, or the resources to process them in a timely manner. 55,56 Newborn Drug Testing Information 

# SPECIMEN EASE OF COLLECTION WINDOW OF DETECTION

# SENSITIVITY AND SPECIFICTY

# ASSESSMENT OF WITHDRAWAL SYMPTOMS Tools for Assessment
Several neonatal withdrawal assessment tools have been developed over the years. 67 The Finnegan Neonatal Abstinence Scoring Tool (FNAST) is the most commonly used tool to assess the severity of withdrawal and inform clinical management.  However, with the increased understanding of neonatal substance withdrawal the usefulness of the FNSAT is being questioned.
Limitations of the FNSAT:
Modified and unvalidated versions are often used due to its intimidating length and complexity 67,73,74  
To minimize subjectivity and maximize inter-rater reliability, extensive and continuous training is required   
Assessment of some criteria (e.g., Moro reflex) requires the newborn to be disturbed, which may artificially inflate scores
Validated for use in full term newborns only 72 
Likely to prompt earlier initiation and greater intensity of pharmacological management 48

# The Eat, Sleep and Console (ESC) Care Tool
In 2008, a quality improvement initiative was launched at Yale New Haven Children's Hospital, Connecticut, USA to improve inpatient outcomes for Neonatal Abstinence Syndrome. 78 The objective was to decrease the average length of hospital stay by 50% for newborns exposed to substances in utero. One of the key interventions of the Yale New Haven quality improvement project was the development and implementation of a novel assessment tool; the Eat, Sleep and Console (ESC) Care Tool.  This work was influenced by the innovative work done by Dr Ron Abrahams, Dr Paul Thiessen and Sarah Payne on Fir Square, BC Women's Hospital where mothers and babies were kept together, and functional assessments and weight gain were used to assess withdrawal in the newborn.  The ESC Care Tool, developed in 2017, is a function-based assessment tool that assesses how the newborn eats, sleeps, and consoles.  The ESC Care Tool was adapted by BC with permission from the developers of the original ESC Care Tool and:
Is best practice evidence-based care. 86 
Aligns with trauma informed, culturally safe care and newborn responsive care

# Promotes mother and baby togetherness  
Promotes the use of non-pharmacological strategies to support the newborn during the acute phase of substance withdrawal
Allows for easy adoption and implementation across all care settings in BC.
Is an objective assessment tool with high inter-rater reliability. 84 
Promotes standardized documentation and care.
Is low cost, simple and achievable. 85 

# Principles of the ESC Approach
Aims to support the newborn exposed to substances to achieve developmentally normal eating, sleeping, consoling, and weight gain milestones.
Mother/caregiver is the primary provider of responsive, newborn-centered care and integral to managing NAS.
Encourage the mother and health care professional to consider reasons other than withdrawal that may affect how the baby is eating, sleeping, consoling, and/or gaining weight.

# Recommendations
ESC Care Tool is developed to track the newborns ESC behaviours and interventions over a 24-hour period:
Initiate ESC assessments and non-pharmacological strategies within 4 -6 hours of birth.
Perform ESC assessment every 2 -4 hours after feeding in collaboration with parent/ caregiver. 84 
Continue for at minimum of 4 -7 days for the newborn exposed to long-acting opioids such as methadone, and a minimum of 48 hours for shorter acting opioids (e.g., oxycodone, codeine). 84,87,88  
For newborns that required pharmacological management, ESC assessments should continue for at least 24 hours after administration of the last dose of morphine. 89,90  
Gestational age at birth and actual postnatal age needs to be considered when assessing ESC behaviours. Some of these behaviours may be normal age appropriate behaviour such as cluster feeding and natural fluctuations in sleep-wake patterns.
Assessments include all ESC behaviours that occurred since the newborn's last assessment as well as all non-pharmacological care interventions implemented. Incorporate input from all caregivers who interacted with the newborn during this period. Monitor excessive weight loss and slow weight gain due to higher energy requirements, poor feeding, loose stools, and vomiting.
Weight loss more than 10% requires a full care team huddle regardless of ESC assessment.

# ESC Assessment Eating
Assess eating behaviour.
Poor eating is defined as follows:
  Newborn is unable to coordinate feeding within 10 minutes of showing hunger cues AND/OR   Newborn is unable to sustain feeding for age appropriate duration at breast OR
Newborn is unable to take in age and weight appropriate volume by alternative feeding method
If the newborn is eating well answer NO and move to section that assess sleeping.
If the newborn is eating poorly answer YES and answer the next question to determine if poor eating is due to substance withdrawal or not.
Substance withdrawal symptoms such as fussiness, tremors, uncoordinated suck, and excessive rooting can affect the newborn's ability to eat and gain weight effectively. If poor eating is due to symptoms of substance withdrawal answer YES.
If poor eating is clearly due to reasons other than symptoms of withdrawal such as prematurity, transitional sleepiness, excess mucus in the first 24 hours, and inability to latch due to infant / maternal anatomical factors, answer NO. Implement appropriate management strategies (e.g., NG feeds for preterm infants), optimize nonpharmacological interventions, and monitor closely.
If it is unclear whether substance withdrawal symptoms are responsible for poor eating, answer YES and continue to monitor closely as this may be an indication of escalating withdrawal symptoms.
Review optimal feeding recommendations with the parent/caregiver and continue to optimize nonpharmacological strategies.
If the newborn is eating poorly a Parent/caregiver-RN huddle is recommended to review optimal feeding recommendations with parent/caregiver. If eating has not improved on subsequent assessment, despite interventions, a full care team huddle is indicated.

# Sleeping
Assess sleeping behaviour.
If the newborn sleeps for more than one hour after feeding answer NO and move to the section that assess consoling.
If the newborn is unable to sleep for at least one hour after feeding answer YES for poor sleeping and answer the next question to determine if poor sleeping is due to substance withdrawal or not.
Substance withdrawal symptoms such as fussiness, restlessness, increased startle, and tremors can affect sleeping behaviour. If the newborn is unable to sleep for at least one hour after feeding due to substance withdrawal symptoms answer YES.
If the baby sleep less than 1 hour due to reasons other than substance withdrawal such as physiologic cluster feeding in first few days of life, interruptions in sleep due to external noise and ambient light, and interruption of sleep due to clinical care answer NO.
If it is unclear whether substance withdrawal symptoms are responsible for poor sleeping or not answer YES and continue to monitor.
A Parent/caregiver-RN huddle is recommended to review nonpharmacological strategies to promote sleeping. If, on subsequent assessment, baby is still sleeping less than one hour after feeding due to symptoms of withdrawal, despite interventions, a full care team huddle is indicated.

# Console
Assess consoling behaviour.
If the newborn consoles easily within 10 minutes and remains consoled for longer than 10 minutes answer NO to indicated that the newborn does not experience any difficulty in consoling and move to the section that assess parental/caregiver presence.
If the newborn is unable to console within 10 minutes or remain consoled for longer than 10 minutes answer YES for difficulty in consoling and answer the next question to determine if difficulty in consoling is due to substance withdrawal or not.
Altered neurotransmitter release due to substance withdrawal increase agitation and difficulty in consoling. If the newborn is unable to console easily within 10 minutes and remains consoled for longer than 10 minutes due to substance withdrawal symptoms answer YES.
Answer NO if the newborn's inconsolability is clearly due to other factors such as caregiver non-responsiveness to infant hunger cues.
If it is unclear whether substance withdrawal symptoms are responsible for inconsolability or not answer YES and continue to monitor.
If newborn has difficulty in consoling regardless of reason a Parent/caregiver-RN Huddle is recommended to review appropriate care interventions and Consoling Support Interventions.
Monitor the newborn closely and continue to optimize non-pharmacological strategies. If newborn is still unable to console at subsequent assessment, despite effective implementation of all levels of consoling support, a full care team huddle is indicated.
Document consoling support needed using the numerical codes 1, 2 or 3:
- Newborn is able to self-console 2. Newborn can console (and stay consoled) with caregiver support within 10 min 3. Newborn is unable to console with caregiver support within, or cannot stay consoled for 10 minutes Please note the numbers are NOT intended as a "score" but to indicate an escalation of withdrawal symptoms and identify a need for increased intervention.

# Parent/Caregiver Section
Parent/Caregiver Presence and Involvement in Care of the Newborn   Document the time, since last assessment, that the parent/s, or another caregiver, spent with the infant.
Caregiver can be a parent, other family member, designated visitor, cuddler, or healthcare worker that can deliver responsive care in a timely manner.
Document the caregiver who provided the most care.
Numbers above are NOT intended as a "score" but used for ease of documentation and to identify parental/caregiver involvement in the care of the baby. A Parent/caregiver-RN huddle is recommended if parent/caregiver is not spending enough time at the bedside, and/or not delivering newborn care in a responsive and timely manner. During the huddle the parent/ bedside RN will review options to assist the parent/caregiver to provide responsive and timely care.

# Plan of Care
Parent/Caregiver and Bedside RN huddle
Parent/caregiver and Bedside RN should meet if infant receives a YES for any ESC item, to determine if non-pharmacological care interventions can be optimized further.
During the huddle, the parent/caregiver and RN review and discuss how to optimize non-pharmacological care interventions to improve feeding, sleeping and consoling behaviour.

# Full Care Team Huddle
Bedside meeting of entire team (parents/caregiver, bedside RN, nurse leadership if applicable, and provider) is indicated if the newborn:
Has more than 10% weight loss
Continued YES for any ESC items despite optimal non-pharmacological care
Is unable to console despite effective implementation of all levels of consoling support
Has any other significant concerns
The full care team will:
Review non-pharmacological strategies and parental presence
If non-pharmacological care interventions are maximized to the fullest and the newborn continues to have poor eating, sleeping, or consoling behaviour (or other significant concerns are present) and symptoms are felt to be due to substance withdrawal, pharmacological management may be indicated.

# Continue to follow the infant closely, optimizing all non-pharmacological interventions regardless of management decision

# Non-Pharmacological Care Interventions
The ESC Care Tool promotes the use of non-pharmacological strategies to support the newborn during the acute phase of substance withdrawal. Use this section to indicate the use of these strategies using the following codes: 

# NON-PHARMACOLOGICAL MANAGEMENT
Withdrawal from substances after birth results in physiological and physical dysregulation. This may impact sensory stimulation integration, state regulation, motor and tone control, and the autonomic nervous system. 91 The objective of non-pharmacological care interventions are to provide the infant with an environment that supports their ability to self-regulate. Although these strategies are commonly used to comfort and support infants, high quality research to determine their effectiveness is lacking. Despite the current shortcomings in research methodology, data suggests that non-pharmacological interventions may decrease the severity of withdrawal, the need for medical intervention, and duration of hospitalization. 34,92 

# Sensory Stimulation Integration
The following strategies may be helpful to support the infant and prevent sensory overload during the active period of withdrawal: approach the bedside using a gentle voice prior to touching the infant 96   slow, gentle handling 91,96   hold infant closely when transferring infant from one space to another to prevent startling 91   swaddling contains and prevents erratic movements and startling 91,95   tactile stimulation should be gentle and firm; avoid stroking 80   apply gentle pressure over the infant's head or body 91,94   bringing arms/hands midline and positioning infants in a fetal position 91,96,97 

# Swaddling
In the newborn exposed to substances swaddling has been shown to:
reduce crying, startles, and physiological stress 98,99   improve sleep, motor organization and self-regulation 98,99 

# Safety
Combination of swaddling with prone position increases the risk of sudden infant death syndrome. Discontinue use of swaddling prior to discharge, as soon as withdrawal symptoms have resolved. See .

# State Regulation
Sleep-wake regulation is an indication of how effectively the infant can regulate his/her internal processes and the influence of external stimulations. Full-term infants will transition between quiet sleep, active sleep, drowsy, quiet awake, and crying.
The infant exposed to substances may: 

# Skin-to-Skin
Encourage skin-to-skin contact as much as possible to help calm the baby, promote neurobehavioural organization, bonding and attachment, and increase breastmilk supply (if breastfeeding). Skin-to-skin care is associated with improved sleep patterns, 102 a reduction in excessive crying and motor agitation associated with NAS, and a decreased need for pharmacological management. 103 Parent/caregiver should sit in a comfortable chair and be fully awake and focused on the infant.
Distractions such as cell phones should be avoided. Infant should be naked except for diaper and placed directly on mother's/parent/caregiver's chest with a blanket placed over both for warmth.
A wrap can also be used to secure infant.

# Ensure infant's:
head is turned to one side
head is in the sniffing position and neck straight to maintain airway
  face is visible  
nose and mouth are not covered by the blanket or wrap
legs are flexed and is lying chest to chest with mother/parent

# Vertical Rocking
Vertical rocking has been shown to decrease neurological hyperactivity and promote selfregulation. 191,104,105 The Hold 106 
See .
Infant can be swaddled. If not, fold infant's arms snugly across his/her chest.
Pick up infant and hold in a vertical, flexed position.
Gently but securely hold infant's bottom with the dominant hand.
Maintain airway by supporting infant's chin with the other hand.
Bring infant's head a bit forward to position infant at a 45-degree angle, as it will be easier to control the infant.
Slowly and rhythmically rock infant up and down.

# Rhythmic movement using swings, chairs or beds  
Swings or vibrating bouncy seats can also be used to provide rhythmical rocking.
Adhere to manufacturer's safety recommendations and site-specific protocols when using. 107 

# Motor and Tone Control
The newborn exposed to substances may display: dysmature pattern of swallow-breath interaction 111 These feeding difficulties and the hypermetabolic state due to withdrawal may result in difficulties with weight gain.

# Feeding
Mothers are encouraged to breastfeed unless there is concern related to continued substance use or other medical contraindication is present such as HIV.
Despite the documented benefits of human milk, breastfeeding rates are low in women with substance use disorder.   
The risk-benefits of breastfeeding should be carefully considered, and attempts should be made to minimize barriers and promote breastfeeding.
In the infant exposed to substances, breastfeeding is associated with:
  delayed onset of withdrawal symptoms 96,115   decreased severity of withdrawal symptoms 82,112,115,116   decreased need for pharmacological management 115,11,12   decreased length of pharmacological management 96,112   shorter length of hospital stay 7,13,14 The Following General Strategies May Be Helpful to Support Optimal Feeding   optimal feeding at early hunger cues without any limits placed in duration or volume of feeding If newborn is breastfeeding, ensure the newborn is latching deeply, with a comfortable latch for mother, and with sustained active suckling with only brief pauses noted. If necessary, assist the mother to achieve more optimal latch/position. To organize suck prior to latching, use expressed breastmilk and have the infant suck on an adult finger. Withhold pacifier use if possible.
To organize suck prior to latching, use expressed breastmilk and have the infant suck on an adult finger. Withhold pacifier use if possible.
Consider fortifying breastmilk or supplementation with a high-calorie breast milk substitute for poor weight gain. 15,16,17 Bottle Feeding
If newborn is bottle feeding:
Reduce GI discomfort by using mother's expressed breast milk, donor breast milk or breastmilk substitute with a low osmolality. 117 
Mimic breastfeeding by letting baby pause and rest periodically. 

# Skin Care
Newborns are at risk for skin injuries as adaptation to the extrauterine environment is still ongoing. The functionally immature epidermal barrier and acid-mantle increases the risk of chemical, microbial, or friction skin injuries. 119,120 Due to irritability, uncontrolled movements, and diarrhea related to withdrawal, the newborn exposed to substances is at risk for excoriations and diaper dermatitis. 121

# Types of skin injuries Excoriation/abrasions
Redness of the skin or broken/bleeding skin often found on chin, ankles and face.
Cause: Rubbing of an extremity or face on a linen covered surface/blankets due to excessive and uncontrolled movements of the extremities and/or head. 

# PHARMACOLOGICAL MANAGEMENT Current Status
The current evidence as to when to initiate medication, treatment regimens, dosing, weaning protocols and use of adjunctive management is limited. 124,125,126 Evidence does show that a standardized pharmacological management protocol with clear weaning guidelines decreases the length of pharmacological intervention and hospital stay. 116,124,127,128 While suboxone and methadone can be used to manage substance withdrawal symptoms in the newborn, morphine is the most commonly used drug to manage newborn opioid withdrawal. 10,23,129 Morphine is a full mu-opioid receptor agonist with well-established pharmacokinetic features and a short half-life.

# General Principles  
Rooming-in and implementing non-pharmacological is paramount. Pharmacological intervention should be employed as an adjunct.
Use ESC Care Tool to guide management.
Minimize opiate replacement exposure in the newborn.
The need for pharmacological management alone is not an indication for admission to the NICU. Transfer to the NICU only if there is a medical indication.
Treatment Algorithm for the Newborn Exposed to Substance(s) in Pregnancy 

# APPENDIX: CONSOLING SUPPORT INTERVENTIONS CONSOLING SUPPORT INTERVENTIONS THAT CAN BE USED WHEN BABY IS DIFFICULT TO CONSOLE