Oral Morphine Initiation Protocol and Enteral Morphine Protocol for NAS

Protocol should be initiated if an infant has 2 consecutive scores ≥8 or 1 score ≥12 within a 24-h period (just as was done previously with the methadone taper).
 Concentration of Enteral Morphine to Be Used for All Doses: 0.2 mg/mL
Starting dose:
 Enteral: 0.05 mg/kg/dose orally q3h
 IV: 0.02 mg/kg/dose (IV morphine and enteral morphine doses are not equivalent)
 Enteral: Increase by 0.025–0.04 mg/kg every 3 h until controlled (NAS <8)
 IV: Increase by 0.01 mg/kg every 3 h until controlled (NAS <8)
 Rescue Dose: If infant has 1 score of ≥12 double the previous dose given (enteral or IV) × 1 and then adjust accordingly:
  If NAS score now <12: make the scheduled MD the same as the rescue dose that was just administered. The first higher MD should be given at the next scheduled care/feed.
  If NAS score still ≥12: increase next dose by 50%. Continue to do so until score is <12. Once <12, then follow guideline listed above.
  If infant requires and is not stabilized on <0.1 mg/kg/dose every 3 h of morphine, consider adding adjunctive therapy (see Table 3).
  • IV, intravenous; MD, maintenance dose.