What is the best evidence based management of neonatal abstinence syndrome?

Neonatal abstinence syndrome is a relatively common condition affecting neonates. This can make considerable impact on the limited cot space available in most neonatal units where there is no transitional care facility. Published reports and reviews in the last three decades have described the role of a number of pharmacological agents in the affected infant.1,2,3 Morphine has become the mainstay of treatment. Although there are different scoring systems available, the most commonly used is that by Finnegan et al4 for assessment and treatment of abstinence.

In our unit we recently had considerable difficulty in managing neonatal abstinence syndrome in three infants, which made us review our guidelines. In this process, we decided to survey the current practice in our region (North West region). We surveyed 17 medical neonatal units in the North West region. We requested guidelines from all the units by telephone, and 15 (88%) responses were received. The two units that did not respond were both district general hospitals. There appeared to be two patterns of morphine dosage, seemingly led by the two main regional units: one suggesting a higher dose regimen (80–100 μg/ kg every four hours) and another suggesting a much smaller dose regimen (30–40 μg/kg every four hours). A third of the units, five (33%), were not using any objective scoring system. The rest used the Finnegan scoring system with their own modification.3

The Cochrane review1 did not seem to recommend a preferred regimen. From our own experience and discussions with professionals, a higher dosage start appeared to result in more rapid symptom resolution. However, we could not quantify this. The aim of this letter is mainly to open a debate on this topic and also to point out the need for appropriate trials to decide on the best regimen of management.