Modified Finnegan scoring system for neonatal abstinence syndrome

Instructions
Scoring starts at birth and continues every 3 to 4 hours throughout the birth hospitalization. The score should reflect observations of the newborn's behavior and clinical signs over the preceding 3 to 4 hours. All substance-exposed newborns should receive nonpharmacologic measures, regardless of the NAS score.^* Opioid-exposed newborns are monitored for a minimum of 96 hours before discharge.
Scoring
Parameter		Points	Score
Crying	Intermittent crying; able to console	0
	Frequent or continuous crying; able to console at times	2
	Frequent or continuous crying; does not console	3
Sleep^¶	Sleeps ≥3 hours after feeding	0
	Sleeps 2 to <3 hours after feeding	1
	Sleeps 1 to <2 hours after feeding	2
	Sleeps <1 hour after feeding	3
Moro reflex	Normal	0
	Hyperactive Moro	1
	Markedly hyperactive Moro	2
Tremors when stimulated or disturbed	None	0
	Mild tremors	1
	Moderate or severe tremors	2
Tremors when undisturbed	None	0
	Mild tremors	1
	Moderate or severe tremors	2
Tone	Normal	0
	Mildly increased tone	1
	Moderately or severely increased tone	2
Skin excoriation	None	0
	Mild skin excoriation	1
	Moderate to severe skin excoriation	2
Seizures	Any generalized seizure	8
Signs of autonomic dysfunction	Fever ≥37.2°C (99°F)	1
	Frequent yawning	1
	Sweating	1
	Nasal stuffiness	1
	Frequent sneezing	1
	Tachypnea (respiratory rate >60 breaths per minute)	2
Feeding and gastrointestinal signs	Poor feeding	2
	Vomiting	2
	Loose stools	2
Poor weight gain	Current weight ≥10% below birth weight	2
Irritability	None	0
	Mild	1
	Moderate	2
	Extreme	3
Total score:
Interpretation
Score	Interpretation	Intervention
≤8	No or mild NAS manifestations	If the newborn is not receiving pharmacologic therapy: Continue nonpharmacologic measures.^* Monitor scores every 3 to 4 hours.
≤8	No or mild NAS manifestations	If the newborn is receiving pharmacologic therapy for NAS: Continue current nonpharmacologic and pharmacologic therapy.*^Δ Monitor scores every 3 to 4 hours. If scores have been ≤8 for >24 to 48 hours, consider weaning NAS medication(s).^◊
9 to 12	Moderate NAS manifestations	If the newborn is not yet receiving pharmacologic therapy: Provide nonpharmacologic measures and rescore in 1 hour.^* If the next score is still >8, start pharmacologic therapy.^Δ
9 to 12	Moderate NAS manifestations	If the newborn is receiving pharmacologic therapy for NAS: Optimize nonpharmacologic measures and rescore in 1 hour.^* If the next scores is still >8, increase pharmacologic therapy.^Δ
>12	Severe NAS manifestations	If the newborn is not yet receiving pharmacologic therapy: Optimize nonpharmacologic measures and start pharmacologic therapy.^*Δ
>12	Severe NAS manifestations	If the newborn is receiving pharmacologic therapy for NAS: Optimize nonpharmacologic measures and increase pharmacologic therapy.^*Δ

This figure summarizes a modified Finnegan approach to assessing for NAS signs in term newborns with prenatal substance exposure. Commonly used tools for assessing NAS severity include the modified Finnegan scoring system (summarized here) and the Eat, Sleep, Console approach. The choice between these approaches is center-dependent; either method is acceptable. Regardless of the assessment tool used, optimal care for the substance-exposed dyad (ie, newborn and mother/caregiver) requires a dedicated, nonjudgmental multidisciplinary team that is well versed in the management of substance use disorder and NAS. An effective program requires coordination and consistency in the care approach throughout pregnancy, during the birth hospitalization, and in the outpatient setting following discharge. During the birth hospitalization, care for the dyad includes regular assessments of newborn and maternal functioning to promote bonding and healthy parent/caregiver-infant interaction. The care environment should be modified to support both maternal and infant self-regulation. Rooming-in (ie, parent/caregiver and newborn in the same room throughout the birth hospitalization) is the preferred model of inpatient care for NAS. The scoring system above is not appropriate for use in preterm newborns since NAS expression differs in preterm compared with term newborns. Standardized scoring protocols for preterm infants are lacking. Refer to UpToDate topics on NAS for additional details, including a discussion of the evidence supporting this approach.

NAS: neonatal abstinence syndrome.

* Examples of nonpharmacologic measures include holding by the parent/caregiver, skin-to-skin contact, frequent small breast or bottle feeds, safe swaddling, non-nutritive sucking, and maintaining a quiet, low-stimulation environment. Optimally, nonpharmacologic measures are tailored to the individual newborn's NAS manifestations.

¶ The expected duration of sleep after feeding depends on the method of feeding (breast milk versus formula). This is true for healthy infants and for those with NAS. The durations included in this scoring system apply to formula-fed infants. Shorter durations should be used when scoring breastfed newborns. For example, a breastfed newborn who sleeps for 2 hours after feeding should be scored as a 0 for the sleep parameter.

Δ Morphine and methadone are the first-line pharmacologic agents for treatment of opioid-induced NAS. Second-line adjunctive agents include clonidine and phenobarbital. Refer to UpToDate topics on NAS for guidance on dosing, titration, and weaning of these medications.

◊ For newborns requiring more than 1 NAS medication, the opioid (morphine or methadone) is weaned off first. Weaning typically starts once the newborn's scores have been ≤8 for 48 hours. Refer to UpToDate topic on management of NAS for additional details.

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Modified Finnegan scoring system for neonatal abstinence syndrome