NAS Outcome Measures:

The overall aims statement for the NAS initiative was developed by the expert team along with outcome measures to ensure a standardized approach to the care of the NAS infant and family.

nas outcome image 

Outcome Measures

Examples of NAS Management Algorithms

The expert team is using the following examples to create Care Management Algorithms to standardize the treatment of NAS:

Phase I:  To Treat of not to treat algorithm is used to determine whether the patient will be treated with non-pharmacologic methods or whether they will receive pharmacologic treatment

NAS Treatment Algorithm

 Phase I algorithm 

Phase II:  Stabilization on Morphine algorithm is used to begin treatment and to increase dosing if needed.

NAS Stabilization Algorithm

Phase II Stabilization algorith


 Phase III: Weaning

weaning algorithm image

Phase III Weaning Algorithm

Phase III  Backsliding 

backsliding algorithm image

Phase III  Backsliding algorithm


Carolinas Healthcare System:  Management of Pain in the Neonate

Guidelines to ensure the assessment and management of neonatal pain and potential opioid withdrawal

Catawba Valley Medical Center:  Drug Withdrawal

Guidelines on care needed by infants of mothers that used methadone/opiates or other substances while pregnant.  

Forsyth Medical Center:  Neonatal Abstinence Management

Guidelines for the management and cohorting of infants experiencing withdrawal symptoms.  

Forsyth Medical Center:  Best Practice Neonatal Abstinence Syndrome 

Collection of best practices for the treatment of NAS - part 1

Forsyth Medical Center:   Neonatal Abstinence Assessment

Collection of best practices for the treatment of NAS - part 2

UNC:  Urine Toxicology Screening on Labor and Delivery Clinical Guidelines

Guidelines of who should be screened and a description of toxicology testing available at UNC

UNC:  UNC Newborn Nursery Clinical Guidelines

Guidelines for the treatment of Neonatal Abstinence Syndrome

UNC:  Can my baby withdraw?

Brochure for parents on what to expect with NAS

Vidant: NAS Policy and Procedure

Policy for assessment and care of NAS infant

Vidant: Procedure for management of NAS using Clonidine with Morphine

Details the dosing for pharmacologic treatment of NAS

Vidant: Guide to NAS - What to expect for your baby

Parent education booklet

Presby: NAS Initiation

Initiation order set for NAS

Presby: NAS Symptom-Based Protocol

Protocol for symptom-based morphine administration

Neonatal Abstinence Syndrome: How States Can Help Advance the Knowledge Base for Primary Prevention and Best Practices of Care
This report by the Association of State Health and Territorial Officials discusses prevention and intervention opportunities to avert or ameliorate the outcome of NAS along a continuum of care spanning time frames in the mother’s life and that of her child.
In this article, (from Pediatrics, February 2013), the authors review the data regarding the prevalence of exposure and available technologies for identifying exposure as well as current information regarding short- and long-term outcomes of exposed infants, with the aim of facilitating pediatricians in fulfilling their role in the promotion and maintenance of infant and child health.
This article (from Pediatrics, August 2013) reviews the current literature on prevention, recognition, and management of withdrawal syndromes in infants and children.
This documents details the NAS clinical practice guidelines that provide the framework to inform and support a coordinated strategy to address NAS in Ontario.
This article (from JAMA, May 2013) describes the national incidence of NAS and antepartum maternal opiate use and characterizes trends in national health care expenditures associated with NAS from 2000-2009 (all of which increased substantially during this time).
This document describes the guidelines for management of opioid-exposed newborns at Vermont Children’s Hospital at Fletcher Allen Health Care.  It includes treatment, screening, and breastfeeding guidelines, and the guidelines for special cases such as the management of infants born to Hepatitis C positive women.
These NAS clinical practice guidelines were produced by the Provincial Council for Maternal and Child Health in Canada.  They are primarily organized by tables, listing the recommendation, rationale, quality of evidence and classification of recommendations, and implementation considerations.
This article (from Pediatrics, March 2013) updates information about the clinical presentation of infants exposed to intrauterine drugs and the therapeutic options for treatment of withdrawal.  It also includes evidence-based approaches to the management of the hospitalized infant who requires weaning from analgesics or sedatives.
This brief PowerPoint presentation describes the important of attaining reliability with clinical screening tools, defines the items that make up the Finnegan NAS Scoring Tool, and describes how to determine inter-observer reliability with this tool.
This is a lengthy PowerPoint presentation by the Medical Director of QI Services at Nationwide Children’s Hospital in Ohio that describes a clinical convention for determining when LOS is prolonged in a regional neonatal referral center, describes how local data from VON can be used with the Model of Improvement to reduce LOS in a regional neonatal referral center, and lists three interventions (PDSA) associated with decreased LOS for NAS patients.
This statement (from Pediatrics, March 2013) presents current information about the clinical presentation, differential diagnoses, therapeutic options and outcome for the offspring associated with intrauterine drug exposure.
This article (from Addiction, 2010) assesses the variability of the Finnegan scores in newborns not exposed to opiates, showing that scores increased from days 1-3 to weeks 4-6 and show day-night cycles with 5-6 weeks.
This article (from Advances in Neonatal Care, 2012) describes the development, implementation, and outcomes of a NAS management program and utilization of the Finnegan NAS Scoring Tool.  A non-experimental study evaluated change in nursing knowledge about NAS and the use of the scoring tool after implementation of evidence-based clinical practice guidelines and an educational project.  The authors conclude that all nurses showed some level of improvement in knowledge.
This article (Clinical Obstetrics and Gynecology, March 2013) discusses the short- and long-term developmental outcomes associated with prenatal opiate exposure, maternal and infant risk factors, and the importance of characterizing corollary environmental risk factors.
This article (from Journal of Perinatology, 2006) consists of the results of a questionnaire distributed to the chiefs of neonatology divisions with accredited fellowship programs in Neonatal-perinatal medicine in the US.   The authors conclude that the management of neonatal psychomotor behavior consistent with withdrawal varies widely, with inconsistent policies to determine its presence or treatment.  The authors found that only about half of NICUs had written guidelines for the management of NAS at that time.
This article (from New England Journal of Medicine, 2010) describes the results of a double blind, randomized, controlled, international study comparing buprenorphine and methadone treatment for 175 pregnant women with opioid dependency.  Overall, the results were consistent with the use of buprenorphine as an acceptable treatment for opioid dependence in pregnant women.
This article, by a nurse practitioner with clinical NAS experience, provides an overview of the possible risks, benefits, and outcomes of pharmacologic and complementary therapies in the neonatal population, and illustrates the gaps in knowledge related to their use for neonatal withdrawal.
This is a Cochrane Review of opiate treatment for opiate withdrawal in newborn infants.  Selection criteria for this review included trials enrolling infants with NAS born to mothers with an opiate dependence, with >80% follow up and using random or quasi-random allocation to opiate or control.  Controls could include an opiate, sedative, or non-pharmacological treatment.  Because of methodological limitations, the authors advise to treat the conclusions from this review with caution.

A new online resource from the Agency for Healthcare Research and Quality (AHRQ) will help patients, families, and health professionals work together as partners to promote improvement in care. Research shows that when patients are engaged, it can lead to measurable improvements in safety and quality. The Joint Commission was a member of the project team which developed the Guide to Patient and Family Engagement in Hospital Safety and Quality, which is available at no charge.

 guide cover page

The guide outlines four strategies hospitals can use to connect with patients and families, including: 

·         Encourage patients and family members to participate as advisors.

·         Promote better communication among patients, family members, and health care professionals from the point of admission.

·         Implement safe continuity of care by keeping the patient and family informed through nurse bedside change-of-shift reports.

·         Engage patients and families in discharge planning throughout the hospital stay.