Eat, Sleep, Console approach to assessing and managing neonatal withdrawal

This figure summarizes the Eat, Sleep, Console approach to assessing for NAS signs and managing newborns with prenatal substance exposure. The choice between this approach versus other approaches (eg, the Finnegan scoring system) is center-dependent; either method is acceptable. Regardless of the assessment tool used, optimal care for the substance-exposed dyad (ie, newborn and mother/caregiver) requires a dedicated, nonjudgmental multidisciplinary team that is well versed in the management of substance use disorder and NAS. An effective program requires coordination and consistency in the care approach throughout pregnancy, during the birth hospitalization, and in the outpatient setting following discharge. During the birth hospitalization, care for the dyad includes regular assessments of newborn and maternal functioning to promote bonding and healthy parent/caregiver-infant interaction. The care environment should be modified to support both maternal and infant self-regulation. Rooming-in (ie, parent/caregiver and newborn in the same room throughout the birth hospitalization) is the preferred model of inpatient care for NAS. Refer to UpToDate topics on NAS for additional details, including a discussion of the evidence supporting this approach.

NAS: neonatal abstinence syndrome; NOWS: neonatal opioid withdrawal syndrome.

* Nonpharmacologic measures should be provided for all substance-exposed neonates, regardless of whether they are demonstrating signs of withdrawal. Examples of nonpharmacologic measures include holding by the parent/caregiver, skin-to-skin contact, frequent small breast or bottle feeds, safe swaddling, non-nutritive sucking, and maintaining a quiet, low-stimulation environment.

¶ Huddles with parents/caregivers may occur in person, by video call, or over the phone. If the parents/caregivers leave the bedside, the clinical team should obtain a reliable contact number and make a plan for communication in the event that a huddle and/or pharmacologic treatment are needed while the parents/caregivers are off site. The purpose of the nurse/parent huddle is to formally review and reinforce nonpharmacologic measures that can be optimized to help the newborn with difficulties eating, sleeping, and consoling. The purpose of the full-team huddle is to consider all possible causes for the newborn's symptoms, to review and reinforce optimal use of nonpharmacologic measures, and to determine if pharmacologic treatment is needed.

Δ If the response is 'no' for every category, withdrawal symptoms are not significantly impairing the newborn's ability to eat, sleep, and console. Escalation of treatment is not necessary for these newborns.

◊ Morphine and methadone are the first-line pharmacologic agents for treatment of NAS/NOWS. Second-line adjunctive agents include clonidine and phenobarbital. Refer to UpToDate topics on NAS for guidance on dosing, titration, and weaning of these medications.

Graphic 144264 Version 2.0

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Eat, Sleep, Console approach to assessing and managing neonatal withdrawal