Inpatient Pathway for the Evaluation/Treatment of Infants
with NAS
Pharmacologic Treatment Recommendations for NAS
NON-OPIOID OR UNKNOWN
Score
Initial Dose
Pharmacologic treatment should be given to
Phenobarbitol infants with combined NAS scores ≥ 24 over
2-3 scores
16-20mg/kg
load
May give in 1
or 2 doses
Route
PO
Maintenance Dosing
Comments
3-4 mg/kg/day
Begin 12-24 hr later.
May give as daily dose
or divide q12 hr.
If scores
remain high
after 24
hours of
observation,
start
morphine
OPIOID
Initial Dose
Score
Route
Daily dose
Pharmacologic
treatment should
0.4 mg/kg/Day
Morphine (Option 1) be given to
infants with
combined NAS
Q3 hr dosing
Dosing Comments
Q4 hr dosing
0.05 mg/kg/dose 0.067 mg/kg/dose PO
Increase dose 1020% for combined
scores of ≥ 24 on 2-3
consecutive scores.
Dose may be
scores ≥ 24 over
2-3 scores
increased as needed,
q 12 hrs until
symptoms controlled.
If symptoms are not
controlled on a total
daily dose is >1
mg/kg/day consider
adding second
medication.
Highest score in
the preceding 24
hrs:
Allow infant to
stabilize 12-24 hours
after starting initial
dose. Increase dose
10-20% for
combined scores of ≥
24 on 2-3
consecutive scores.
Dose may be
increased as needed,
q 12 hrs until
symptoms controlled.
If symptoms are not
controlled on a total
daily dose is >1
mg/kg/day consider
adding second
medication.
8-10
0.4 mg/kg/Day
0.05 mg/kg/dose 0.067 mg/kg/dose
11-13
0.64 mg/kg/Day 0.08 mg/kg/dose 0.1 mg/kg/dose
14-16
0.88 mg/kg/Day 0.11 mg/kg/dose 0.15 mg/kg/dose
PO
Morphine (Option 2)
> 16
1.04 mg/kg/Day 0.13 mg/kg/dose 0.17 mg/kg/dose
SECOND AND THIRD LINE MEDICATIONS

If the patient requires more than 1 mg/kg/Day of morphine, add second line medication



May consider adding Phenobarbital earlier if maternal tox screen is positive for poly-substance abuse, esp. benzodiazapines
(e.g. Xanax) or barbiturates.
After starting Phenobarbital, allow infant to stabilize 24 hours. If scores are still high (“24 rule”) continue to gradually increase
morphine.
If the patient requires more than 2 mg/kg/Day of morphine and Phenobarbital, consider adding Clonidine
Initial Dose
Phenobarbitol
Second Line
Clonidine
Third Line
16-20mg/kg load Given in
1 or 2 doses
Route
PO
0.0005-0.001 mg/kg/dose q 36 hrs.
PO
(0.5 – 1 mcg/kg q 3-6 hrs)
Maintenance Dosing
Comments
3-4 mg/kg/day
Begin 12-24 hr later
Given as daily dose or divide q
12 hr
Max dose 0.001mg/kg/dose
q3hr
(1mcg/kg q 3 hrs)
Clonidine
suspension
concentration is 0.1
mg/mL. For doses
too small to draw up
(<0.005 mg),
consider giving
higher dose less
frequently. (e.g.
0.002 mg/kg/dose q
6 hrs. )
Clonidine patch is
NOT
Recommended.
Methadone
Strongly consider starting
treatment with morphine and
transitioning to methadone
when scores and dosing are


Starting methadone
dose 0.3 mg/kg q12
If immediate postinitiation scores
continue >8, consider

PO

Potential starting
methadone dose 0.3
mg/kg q12
If immediate postintitiation scores
Discharge criteria
include: reliable
and comfortable
family, comfortable
PCP, SW
stable

extra dose of 0.3
mg/kg
Wean starts at 48
hours- 10% per day.



continue >8, consider
extra dose of 0.3 mg/kg
Wean starts at 48 hours
10% wean per day
If patient scores < 9 for
24-48 hours on a stable
methadone wean, may
consider discharge
evaluation, PCP
follow-up with 48
hours then weekly,
Neurodevelopmental
follow-up.