N Nandakumar and V S Sankar

What is the best evidence based management of neonatal abstinence syndrome?
Arch. Dis. Child. Fetal Neonatal Ed. 2006; 91: F463-a [Full text] [PDF]

graham.reynolds{at}anu.edu.au Graham J Reynolds

Nandakumar and Sankar have opended a debate that targets a very interesting conundrum. The aim of medical management in the process of neonatal abstinence seems to me to be centred on ensuring that the infant has a symptom and stress free withdrawal from addictive drugs. By and large the Finnegan score or simple observation requires active demonstration of withdrawal symptoms before intervention. How much demonstration of withdrawal do we require before offering respite to a distressed baby. Most scoring systems demands a score of X for a period of Y. For most of us who work with these infants, management during this period is distressing in itself, let alone the stress caused to the baby. More sensitive ways of minimising stress and distress linked to earlier detection of withdrawal are required. Thresholds for intervention should be lower and medication doses should suppress almost all symptoms sooner rather than later. The notion that a baby should earn the right to adequate medication by demonstration of real symptoms has no place in current practice. The swaddled, well fed baby may well be "manageable" but he is still effectively going "cold turkey" - a situtation that is somewhat unfair. Clonidine in addition to morphine may have significant advantages and less stigma. The withdrawing baby needs compassionate care that recognises the degrees of stress and distress with early treatment rather than a reluctant medication intervention in a baby "hanging out".