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peds.neonatal-abstinence-syndrome.v1

Neonatal Abstinence Syndrome (NAS) / Neonatal Opioid Withdrawal Syndrome (NOWS)

pediatricsacutesubacuteneonatalacuteinpatienttransition
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NEW Phase C dossier — authored 2026-05-15 for shard-5-obped-id. Covers Neonatal Abstinence Syndrome (NAS) / Neonatal Opioid Withdrawal Syndrome (NOWS) — in-utero opioid (or sedative / SSRI / polysubstance) exposure → postnatal withdrawal syndrome in 60-90% of opioid-exposed infants; onset 24-72 h (heroin) to 5-7 d (methadone) per substance pharmacokinetics. Seed manifest authored 2026-05-25 at prisma/seed/manifests/peds.neonatal-abstinence-syndrome.v1.ts (defineBatch23ScaffoldManifest scaffold; specialtyPack "pediatrics"; sourceWorkupIds ["neonatal_abstinence"]; evidenceIds ["ev_neonatal_abstinence_guideline_review_required"]; terminology projected 1:1 from this dossier — no new codes). manifest: pointer now resolves. (.atoms.ts not authored this pass — scaffold manifest does not require it.) _registry.ts NOT modified per refined shard-5 pattern (3-file set only: dossier TS + brief + research bundle). Registry edit deferred to a future shard. Distinct from psych.opioid_use_disorder.core.v1 (MATERNAL OUD parallel engine; exchanges state — MAT regimen, breastfeeding eligibility, CPS notification, perinatal navigator), id.neonatal-sepsis.early-late.v1 (sepsis differential for irritability / hypothermia / poor feeding in NAS phenotype), id.hsv-neonatal.core.v1 (HSV differential for seizure / atypical neurology — forward-looking), peds.status_epilepticus.v1 (seizure management with NAS carryover), peds.febrile-infant.core.v1 (well-appearing 0-90 d with fever). Sibling differentiation explicitly encoded for psych.opioid_use_disorder.core.v1 and id.neonatal-sepsis.early-late.v1. Phenotype matrix (7-axis exposure-substance × onset-timing × ESC-function-status × pharm-treatment-required × maternal-MAT-status × breastfeeding-eligible × CPS-notification-required cross-product — 3,780 cells collapsed to 10 anchor combinations) encoded indirectly via regimen_axes.nas_acute_function_first.steps (Tier-1-non-pharm / Tier-2-pharm / Tier-3-adjunct) + severity_triggers (10 phenotype-specific triggers) + setting playbooks (ed / nicu = icu / newborn-nursery = inpatient / outpatient). First-class TS phenotype field is schema-blocked. Severity triggers (10): severe_nas_requiring_pharmacotherapy_per_esc (severe — AAP 2024 + Young NEJM 2023 PMID 37125831; ESC function impaired after non-pharm trial), polysubstance_withdrawal_opioid_plus_benzo (severe — Hudak AAP 2012 PMID 22291123; phenobarbital adjunct), severe_autonomic_instability_in_nas (severe — clonidine adjunct + rule out hyperthyroidism / sepsis), nas_with_feeding_intolerance_or_dehydration (severe — IV hydration + slower neonatal bolus rate + NICU), nas_seizure_atypical_consider_hsv (life_threatening — HSV / sepsis / metabolic differential; routes to id.hsv-neonatal forward + id.neonatal-sepsis + peds.status_epilepticus), maternal_mat_continuation_postpartum (mild — ACOG 711 + SAMHSA TIP 63; route to psych.opioid_use_disorder.core.v1), cps_notification_per_state_law (moderate — state statute reference; ACOG 711 non-punitive framework), nas_discharge_to_foster_or_kinship_care (moderate — NAS-trained caregiver + early intervention + Q3-mo developmental follow-up × 1 yr then annual × 5 yr per AAP 2024), naloxone_unindicated_in_chronic_nas (mild — Hudak AAP 2012 + AAP 2024; CONTRAINDICATED in chronic withdrawal — precipitates severe withdrawal), eat_sleep_console_first_line_per_aap_2024 (mild — AAP 2024 + Young NEJM 2023 PMID 37125831; ESC function-based first-line supplanting Finnegan). Bayesian linkage (per §5.5.2): pre-test priors documented in _research-bundles/peds.neonatal-abstinence-syndrome.v1.md — NAS in opioid-exposed infants ~ 60-90%; NAS requiring pharmacotherapy ~ 20-30% per Young NEJM 2023 PMID 37125831 (ESC arm 19.5%; Finnegan arm 52%); polysubstance + benzo ~ 30-50% prolonged course; SSRI/SNRI-only adaptation ~ 20-30% mild self-limited. Key LRs: maternal MAT history + symptomatic neonate LR+ > 50 (essentially diagnostic); positive maternal UDS LR+ ~ 10-20 timing-dependent; meconium / cord tissue positive LR+ > 50 (objective last-trimester); tremor + autonomic features in known-exposed neonate LR+ ~ 20 for NAS; seizure in NAS LR+ ~ 0.3 for NAS (directs to HSV / sepsis / metabolic); vesicular skin lesions or maternal HSV LR+ ~ 8 for neonatal HSV. Conditional dependencies modeled: substance × onset coupling, ESC × non-pharm-trial coupling, UDS timing × yield coupling, maternal MAT × neonatal severity (Welle-Strand 2013 methadone vs buprenorphine). Decision thresholds: T_treat (pharm) = ESC function impaired after adequate non-pharm trial; T_test (rule-out) = asymptomatic + 5-d (heroin) to 7-d (methadone) observation negative; T_HSV-rule-out = ANY seizure in NAS infant. Cross-dossier routing: psych.opioid_use_disorder.core.v1 (maternal axis), id.neonatal-sepsis.early-late.v1 (sepsis ddx), id.hsv-neonatal.core.v1 (forward-looking — seizure / atypical), peds.status_epilepticus.v1 (seizure mgmt), peds.febrile-infant.core.v1 (well-appearing fever), forward to (future) peds.post-nas.outpatient.v1. ROS/DDx LR seed data NOT touched (cross-cutting; not in shard scope). Settings (4): ED (rare delivery-room or community-recognised), NICU = "icu" in dossier-setting vocabulary (severe NAS pharm-requiring + polysubstance + seizure / atypical + dehydration + clonidine adjunct), Newborn nursery = "inpatient" (routine ESC monitoring with rooming-in + non-pharm + breastfeeding when eligible), Outpatient peds (post-discharge primary-care + developmental Q3-mo × 1 yr then annual × 5 yr). Prehospital implicit via flow.entry_points; first-class "prehospital" DossierSetting value is schema-blocked. Drug guidance grounded in AAP 2024 NAS/NOWS update + Young NEJM 2023 PMID 37125831 + Hudak AAP 2012 PMID 22291123 + Kraft BBORN NEJM 2017 PMID 28468518 + ACOG 711 2017 + SAMHSA TIP 63 2021. RxCUIs LIVE-VERIFIED via RxNav property.json 2026-05-25 — all CORRECT as-authored: morphine sulfate oral solution (7052), methadone (6813), buprenorphine (1819), clonidine (2599), phenobarbital (8134), naloxone (7242 — CONTRAINDICATED in chronic NAS, encoded as contraindication_substitute role). The 4 PMIDs were FABRICATED at authoring and were corrected 2026-05-25 to live-confirmed counterparts (37125748→37125831 Young, 22291110→22291123 Hudak, 28538121→28468518 Kraft, 24127022→23359576 Kimberlin). Open gaps: (1) Phenotype matrix not first-class TS field — schema-blocked. (2) Bayesian LR seed data not encoded — lives in narrative + research bundle only this pass; ROS/DDx seed edit cross-cutting. (3) Prehospital not a DossierSetting value — schema-blocked. (4) calc.esc_function not yet registered in clinical-tools-registry.ts — pending registry addition. (5) Manifest file not authored this pass — shard precedent for manifest: "" with seed deferred. (6) Co-located test file (peds.neonatal-abstinence-syndrome.test.ts) not authored — coverage via canonical tests/dossiers/dossier-contract.test.ts only. (7) HSV-specific sub-engine id.hsv-neonatal.core.v1 referenced as routing target but not yet authored. (8) _registry.ts NOT modified per refined shard-5 pattern — registry edit deferred to a future shard. (9) AAP 2024 NAS/NOWS update PMID lookup pending at next research:pubmed loop. Status PROMOTED PLANNED → INTEGRATED 2026-05-25 (fix/planned-verify-wave2): seed manifest authored + manifest: pointer resolves, workups[] non-empty with registry-resolving entries, all citations live-verified (4 fabricated PMIDs corrected), all RxCUIs RxNav-confirmed correct. Item (5) ("Manifest file not authored this pass") and item (9) ("AAP 2024 PMID lookup pending") in the Open gaps note above are partially superseded — the manifest is now authored; the AAP 2024 NAS/NOWS Clinical Report itself remains a guideline reference whose specific PMID was not separately anchored (the 4 anchored trial/report PMIDs are now all verified).

Entry points (6)

  • history
    Maternal in-utero opioid exposure (methadone OR buprenorphine MAT, heroin, prescription opioids) — applies to ~ 60-90% of opioid-exposed infants (Hudak AAP 2012 PMID 22291123)
    maternal_opioid_or_mat_exposure
  • history
    Maternal polysubstance: opioid + benzodiazepines OR opioid + SSRI/SNRI OR illicit poly (cocaine, methamphetamine) — drives delayed / prolonged / atypical course (Hudak AAP 2012)
    maternal_polysubstance_exposure_in_utero
  • symptom
    Tremor / hypertonia / hyperreflexia / autonomic instability (tachycardia, sweating, sneezing, yawning) / GI features (poor feeding, loose stools, vomiting) / sleep disturbance / inconsolable cry in opioid-exposed neonate (AAP 2024 NAS/NOWS update)
    neonatal_withdrawal_features_observed
  • lab_abnormality
    Positive maternal urine drug screen at delivery — confirms opioid exposure axis (timing of last use vs delivery affects yield)
    positive_maternal_uds_at_delivery
  • lab_abnormality
    Positive neonatal UDS OR meconium UDS OR umbilical cord tissue — objective documentation of in-utero exposure (meconium / cord tissue cover last-trimester regardless of recent UDS negativity)
    positive_neonatal_uds_or_meconium_or_cord_tissue
  • symptom
    Eat-Sleep-Console (ESC) function impairment in opioid-exposed neonate — unable to eat ≥ 1 oz per feed OR sleep ≥ 1 h after feed OR console within 10 min of non-pharm (AAP 2024; Young NEJM 2023 PMID 37125831)
    esc_function_impaired

Required inputs (23)

  • chronologic_age_in_hoursrequired
    demographic • used at FRAME
    Age × substance-PK coupling defines onset window: heroin 24-72 h, methadone 2-7 d, buprenorphine 36-60 h, SSRI/SNRI 1-3 d (Hudak AAP 2012)
  • gestational_age_weeksrequired
    demographic • used at CONTEXT
    Preterm < 37 wk may have blunted/atypical NAS presentation; impacts ESC interpretation
  • birth_weight_gramsrequired
    demographic • used at CONTEXT
    All neonatal weight-based dosing (mg/kg, mL/kg); morphine, methadone, buprenorphine, clonidine, phenobarbital all weight-based
  • maternal_mat_type_and_doserequired
    history • used at CONTEXT
    Methadone vs buprenorphine maternal MAT impacts NAS severity (methadone-NAS often more severe + prolonged per Welle-Strand 2013); informs pharm choice + LOS expectations + postpartum MAT continuity (ACOG 711 2017; SAMHSA TIP 63)
  • maternal_polysubstance_patternrequired
    history • used at CONTEXT
    Opioid + benzo polysubstance → delayed / prolonged / atypical NAS + phenobarbital adjunct consideration (Hudak AAP 2012)
  • maternal_hiv_statusrequired
    history • used at CONTEXT
    Maternal HIV → breastfeeding contraindicated in developed countries; AAP Red Book 2024 + WHO infant feeding guidance
  • breastfeeding_intent_and_eligibilityrequired
    history • used at CONTEXT
    MAT (methadone or buprenorphine) compatible with breastfeeding (low milk transfer); HIV / illicit poly / codeine / oxycodone / tramadol contraindicate (ACOG 711 2017; FDA boxed warnings)
  • state_cps_notification_rulerequired
    history • used at DISPOSITION
    State-specific statute: automatic notification of in-utero substance exposure (MN, MA, KY, ND, SD, UT, VA, WI) vs discretionary; document + social work + perinatal navigator
  • temperaturerequired
    vital • used at RED_FLAGS
    Hypothermia or fever in NAS infant → sepsis differential; NAS itself can cause low-grade temperature instability (Hudak AAP 2012)
  • hr_neonaterequired
    vital • used at CONTEXT
    Tachycardia in NAS autonomic axis; severe tachycardia + tremor + sweating → severe_autonomic_instability_in_nas trigger (clonidine consideration)
  • rr_neonaterequired
    vital • used at CONTEXT
    Tachypnea in NAS; severe tachypnea → sepsis differential / cardiac differential
  • spo2_neonate
    vital • used at CONTEXT
    Hypoxaemia not typical of NAS — directs to sepsis / cardiac / pulmonary differential
  • maternal_uds_at_deliveryrequired
    lab • used at INITIAL_WORKUP
    Objective documentation of recent maternal exposure (timing-dependent yield)
  • neonatal_uds_meconium_or_cord_tissuerequired
    lab • used at INITIAL_WORKUP
    Objective documentation of in-utero exposure: heroin metabolites 2-4 d, methadone 3-7 d in UDS; meconium / cord tissue cover last-trimester regardless of recent UDS negativity
  • glucose_neonaterequired
    lab • used at INITIAL_WORKUP
    Hypoglycaemia < 47 mg/dL can mimic NAS (irritability); D10W 2-3 mL/kg bolus if < 47; rule out as primary
  • calcium_magnesium_neonate
    lab • used at INITIAL_WORKUP
    Hypocalcaemia + hypomagnesaemia can mimic NAS (tremor, irritability); rule out as primary
  • cbc_with_diff_neonate
    lab • used at INITIAL_WORKUP
    Baseline + sepsis differential; thrombocytopenia raises Candida / NEC concern not NAS
  • tsh_free_t4_neonate
    lab • used at BRANCHING_WORKUP
    Hyperthyroidism (Graves baby) can mimic severe NAS autonomic instability; check if features atypical
  • bilirubin_neonate
    lab • used at INITIAL_WORKUP
    Bilirubin baseline; severe NAS feeding intolerance can prolong jaundice
  • cranial_us_if_seizure_or_iv_h_risk
    imaging • used at BRANCHING_WORKUP
    Cranial US if seizure in NAS (atypical — IVH / structural CNS rule-out) or preterm baseline
  • hsv_pcr_csf_blood_surface_if_seizure_or_atypical
    lab • used at BRANCHING_WORKUP
    HSV PCR + acyclovir empiric if seizure / vesicles / encephalopathy / maternal HSV — do not attribute to NAS alone (AAP Red Book 2024; Kimberlin 2013 PMID 23359576)
  • ecg_baseline_if_clonidine_considered
    lab • used at TREATMENT
    Baseline QTc before clonidine; clonidine + bradycardia / QT-prolongation monitoring
  • foster_or_kinship_placement_planrequired
    history • used at DISPOSITION
    Discharge planning: NAS-trained foster / kinship care + early intervention referral + developmental Q3 mo × 1 yr then annual × 5 yr (AAP 2024)

12-phase flow (12)

  1. 1FRAME
    Confirm in-utero opioid (or sedative / SSRI / polysubstance) exposure; onset-timing window per substance pharmacokinetics (heroin 24-72 h, methadone 2-7 d, buprenorphine 36-60 h, SSRI/SNRI 1-3 d, benzo variable/delayed); differentiate NAS from sepsis / hypoglycemia / hypocalcemia / hyperthyroidism / HSV / IVH / structural CNS; mild-moderate-severe stratification by ESC function impairment (NOT Finnegan score per AAP 2024)
    inputs: chronologic_age_in_hours, maternal_mat_type_and_dose, maternal_polysubstance_pattern
    advance: Exposure axis confirmed + onset window framed + ESC function status assessed
  2. 2ENTRY
    Maternal MAT history (methadone, buprenorphine) OR positive maternal UDS at delivery OR positive neonatal UDS / meconium / umbilical cord tissue OR observed neonatal withdrawal features in known-exposed infant
    inputs: maternal_mat_type_and_dose, maternal_uds_at_delivery, neonatal_uds_meconium_or_cord_tissue
    advance: Exposure documented (subjective + objective) and ESC function status assessed
  3. 3CONTEXT
    Exposure substance(s) + duration / dose / timing of last use, polysubstance pattern, maternal HIV status, illicit-co-substance exposure, breastfeeding intent and eligibility, CPS / social-work status, perinatal navigator engaged, family/foster placement plan
    inputs: gestational_age_weeks, birth_weight_grams, maternal_hiv_status, breastfeeding_intent_and_eligibility, hr_neonate, rr_neonate
    advance: Substance axes + maternal MAT + breastfeeding eligibility + foster plan documented
  4. 4RED_FLAGS
    Seizure in NAS (atypical — rule out HSV / sepsis / metabolic / hypoglycemia / hypocalcemia / IVH / structural CNS; routes to id.hsv-neonatal + id.neonatal-sepsis + peds.status_epilepticus), feeding intolerance / dehydration (weight loss > 10% birth weight; IV hydration + NICU), severe autonomic instability (tachycardia + sweating + tremor severe), polysubstance withdrawal (opioid + benzo) with delayed / prolonged / atypical course
    inputs: temperature, hr_neonate, glucose_neonate
    advance: Red flags actioned; HSV / sepsis / metabolic differential closed; polysubstance flagged
  5. 5INITIAL_WORKUP
    Maternal + neonatal UDS at minimum; meconium or umbilical cord tissue for objective exposure documentation; CBC + BMP + glucose + calcium + magnesium + bilirubin; consider TSH if features (hyperthyroidism mimics); HSV workup if seizure or atypical features; cranial US if seizure; ECG if clonidine considered (QT baseline). Begin Eat-Sleep-Console (ESC) function assessment q3-4 h with feeds per AAP 2024 + Young NEJM 2023
    inputs: maternal_uds_at_delivery, neonatal_uds_meconium_or_cord_tissue, glucose_neonate, calcium_magnesium_neonate, cbc_with_diff_neonate, bilirubin_neonate
    actions: panel.cbc, panel.renal, panel.glucose_a1c
    advance: Exposure documented + metabolic / sepsis primaries ruled out + ESC scoring initiated
  6. 6BRANCHING_WORKUP
    Sepsis workup if febrile / hypothermic / clinical concern (routes to id.neonatal-sepsis.early-late.v1); HSV PCR (CSF / blood / surface) + acyclovir empiric if seizure / vesicles / encephalopathy / maternal HSV (routes to id.hsv-neonatal.core.v1 forward-looking); metabolic workup (ammonia, lactate, urine organic acids) if AMS / seizure; EEG if seizure; cranial US baseline for preterm or if IVH concern
    inputs: hsv_pcr_csf_blood_surface_if_seizure_or_atypical, cranial_us_if_seizure_or_iv_h_risk, tsh_free_t4_neonate
    actions: workup.pediatric_fever
    advance: Branching workup directed by red flags; sepsis / HSV / metabolic differential resolved or empirically covered
  7. 7DIFFERENTIAL
    NAS (opioid) vs SSRI/SNRI-induced neonatal adaptation syndrome (milder, 1-3 d, self-limited) vs benzo withdrawal (variable, delayed) vs polysubstance vs sepsis vs HSV vs hypoglycemia / hypocalcemia / hypomagnesemia vs hyperthyroidism (Graves baby) vs IVH vs metabolic vs structural CNS vs colic (older)
    advance: Working differential refined and exposure axis confirmed
  8. 8RISK_STRATIFICATION
    ESC function score per AAP 2024 update (eating ≥ 1 oz / feed adequate / sleeping ≥ 1 h after feed / consolable within 10 min with non-pharm) — first-line per AAP 2024 + Young NEJM 2023 PMID 37125831; polysubstance status; maternal MAT type; comorbid neonatal illness; foster-placement complexity. Finnegan score retained as legacy only — NOT first-line
    inputs: esc_function_impaired
    advance: ESC function status documented per feed; severity tier (mild / moderate / severe) set
  9. 9TREATMENT
    Tier 1 non-pharm (rooming-in, breastfeeding when eligible, swaddling, low-stimulation environment, kangaroo care, on-demand feeding) — ALWAYS, regardless of severity. Tier 2 pharmacologic (oral morphine 0.04-0.08 mg/kg q3-4h titrated; methadone 0.05-0.1 mg/kg q6-12h alternative; oral buprenorphine 5-10 mcg/kg q8h emerging per Kraft BBORN 2017 PMID 28468518) — ONLY if ESC function impaired AFTER adequate non-pharm trial × ≥ 3 consecutive feed cycles. Tier 3 adjuncts — clonidine 1 mcg/kg q4-6h PO/IV for severe autonomic (BP / HR / QT monitoring); phenobarbital 5 mg/kg load then 2-5 mg/kg/day for polysubstance with benzo coexposure (NOT for opioid-only NAS). Naloxone is CONTRAINDICATED for chronic NAS (precipitates severe withdrawal) — reserve for acute intoxication
    inputs: birth_weight_grams, esc_function_impaired, ecg_baseline_if_clonidine_considered
    advance: Non-pharm trial documented; pharm initiated only if function-impaired; CPS notification + social work engaged
  10. 10DISPOSITION
    Newborn nursery (= inpatient) for routine ESC monitoring of opioid-exposed neonate; NICU (= icu) for severe NAS requiring pharm, polysubstance + phenobarbital, seizure / atypical neurology, feeding intolerance / dehydration, clonidine adjunct with monitoring; do not discharge until tolerating feeds reliably, ESC function recovered, family / foster competence demonstrated, perinatal navigator engaged, CPS notification documented per state law, early intervention referral placed
    inputs: state_cps_notification_rule, foster_or_kinship_placement_plan
    advance: Setting + caregiver plan + CPS status + EI referral documented
  11. 11MONITORING
    ESC function assessment q3-4 h (with feeds) per AAP 2024; vitals q4 h; daily weight + I/O; ECG baseline + during clonidine; phenobarbital level if used > 5 d; HSV / sepsis workup repeat if new features; family / foster bonding observation; wean schedule (morphine 10% q24-48 h; methadone 10-20% q3-7 d; buprenorphine 10-15% q24-48 h) once stable function × 48-72 h
    inputs: esc_function_impaired
    advance: Wean completed; function stable off pharm × 48-72 h
  12. 12FOLLOWUP
    Pediatric primary care within 24-48 h of discharge; perinatal navigator continuity; early intervention referral; developmental surveillance Q3 mo × 1 yr then annually × 5 yr; maternal MAT coordination postpartum (ACOG 711 2017; SAMHSA TIP 63 2021); breastfeeding support if continuing; ophthalmology if perinatal substance + CNS features; audiology if HSV / meningitis differential triggered; mental health for caregiver
    advance: Outpatient plan + EI referral + perinatal navigator + family education documented