Neonatal Abstinence Scoring on the Postnatal Ward

7/28/2019 Neonatal Abstinence Scoring on the Postnatal Ward

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Neonatal Abstinence Scoring on the Postnatal Ward WACSClinProc4.24/09May-11

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SDMS ID: P2010/0394-001WACSClinProc4.24-09WACS

Title: Neonatal Abstinence Scoring on the Postnatal WardReplaces: New GuidelineDescription: Neonatal abstinence scoring for newborns at risk of neonatal

abstinence syndrome on the postnatal wardTarget Audience: Midwives and medical officersKey Words: Neonatal abstinence syndrome, scoring

Policy Supported:

Purpose:Neonatal abstinence syndrome (NAS) is a syndrome of drug withdrawal observed in

infants of mothers physically dependent on drugs. It is manifested by non-specificsymptoms and signs in the infant. NAS is more common in infants born to opioid-dependent women than in infants born to women dependent on other drugs or alcohol.NAS can produce a major disruption to mother-infant attachment. Unnecessaryseparation of mother and infant should be avoided.

Monitoring of NewbornsAll infants born to drug dependent mothers should receive routine postnatal monitoring(using the Neonatal Abstinence Scoring System) commencing two hours after birth andsubsequently every four hours. If the parents demonstrated interest and ability, theyshould be involved in the assessing and managing of NAS.

The scoring interval is the entire period between when you are scoring the infant and whenthe last score was assigned. The NAS scoring system is dynamic rather than static. Thatis the scores should reflect all symptoms observed over the entire scoring interval, ratherthan at one set point in time. If the infant is unsettled at the time of scoring, efforts shouldbe made to settle the infant prior to scoring symptoms observed during the scoringinterval. The infant should not be woken for scoring.

Infants scoring 3 consecutive NAS scores averaging 8 (eg 9 7 9) or 12 for 2 consecutivescores should be reviewed by the paediatric registrar or consultant (refer to attachment 1

for scoring system instructions).

NAS SCORING SCHEDULE

Score at 2 hours of age (to provide a baseline)

Score at 4 hourly intervals

Score < 8

Continue 4 hourly scoring

Score 8

Score 2 hourly until 24 hours of scores < 8(then continue to score 4 hourly until day

4 of life)

Scores remain < 8

Continue scoring until day 4 of life

*If scores average 8 over 3 consecutive

scores or12 for 2 consecutive scores -inform paediatric registrar or consultant


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Support for Mothers/ParentsMothers of infants at risk of NAS should receive appropriate breastfeeding information andsupport, parent support and assessment, and should be taught settling techniques.

Non-pharmacological management is the first line of treatment for all babies born to drug-dependent women. This includes supportive care interventions such as a quiet setting,breastfeeding, cuddling, swaddling, small frequent feeds and close skin contact.Monitoring of weight loss during the period is necessary because feeding disturbances are

common. Where caloric intake appears insufficient with breastfeeding alone,consideration should be given to the use of supplemental expressed breastmilk.

Discharge PlanningInfants at risk of NAS should remain in hospital for at least 5 days. This allows for aminimum time to monitor for signs of NAS, assess parents parenting skills, assess theadequacy of infant feeding and check for excessive weight loss. Prompt referral should bemade to the Child Health and Parenting Service.

Attachments

Attachment 1 Neonatal Abstinence Scoring Sheet

Attachment 2 Neonatal Abstinence Scoring System

Performance Indicators: Evaluation of compliance with guideline to be achieved throughmedical record audit

Review Date: Annually verified for currency or as changes occur, andreviewed every 3 years

Stakeholders: Midwives and medical staff WACS

Developed by: Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director(Nursing & Midwifery) Womens & Childrens Services

Dr A Dennis Sue McBeathCo-Director (Medical) Co-Director (Nursing & Midwifery)Womens & Childrens Services Womens & Childrens Services

Date: 21 October 2009

REFERENCESNew South Wales Department of Health 2006, National clinical guidelines for themanagement of drug use during pregnancy, birth and the early development years of thenewborn, viewed onlinewww.health.nsw.gov.au/pubs/2006/ncg_druguse.html.

Western Australian Centre for Evidence Based Nursing & Midwifery 2007, Perinatal careof substance using mothers and their infants, viewed online

http://speciosum.curtin.edu.au/nas/nasIndex.html
http://www.health.nsw.gov.au/pubs/2006/ncg_druguse.htmlhttp://www.health.nsw.gov.au/pubs/2006/ncg_druguse.htmlhttp://www.health.nsw.gov.au/pubs/2006/ncg_druguse.htmlhttp://speciosum.curtin.edu.au/nas/nasIndex.htmlhttp://speciosum.curtin.edu.au/nas/nasIndex.htmlhttp://speciosum.curtin.edu.au/nas/nasIndex.htmlhttp://www.health.nsw.gov.au/pubs/2006/ncg_druguse.html


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ATTACHMENT 1 Neonatal Abstinence Score Sheet

1. Finnegan, L Neonatal abstinence syndrome: assessment and pharmacotherapy. In Nelson N, editor. Current therapy in neonatal- perinatal medicine. 2 ed. Ontario: BC Decker:1990.

Western Australian Centre for Evidence Based Nursing & Midwifery, January 2007 (RHSET 01660A)Online:http://speciosum.curtin.edu.au/nas/nasIndex.html
http://speciosum.curtin.edu.au/nas/nasIndex.htmlhttp://speciosum.curtin.edu.au/nas/nasIndex.htmlhttp://speciosum.curtin.edu.au/nas/nasIndex.htmlhttp://speciosum.curtin.edu.au/nas/nasIndex.html


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ATTACHMENT 2: Neonatal Abstinence Scoring System

The NAS score sheet lists 21 symptoms that are most frequently observed in opiate-exposedinfants. Each symptom and its associated degree of severity are assigned a score and the totalabstinence score is determined by totalling the score assigned to each symptom over the scoringperiod.

Key points

The first abstinence score should be recorded approximately two hours after birth oradmission to the nursery (baseline score). This score reflects all infant behaviour up tothe first scoring interval time point.

Following the baseline score all infants should be scored at 4 hourly intervals, exceptwhen high scores indicate more frequent scoring.

The score sheet allows for 2 hourly scoring over the 24 hour period.

A new sheet should be started at the beginning of each day.

Scoring is dynamic. All signs and symptoms observed during the scoring interval areincluded in the point-total for that period.

If the infants score at any scoring interval is 8, scoring is increased to 2 hourly andcontinued for 24 hours from the last total score of 8 or higher.

If the scores average 8 over 3 consecutive scores or 12 over 2 consecutive scores,then paediatric registrar or consultant must be informed.

If the 2 hourly score is 7 for 24 hours then 4 hourly scoring intervals may be resumed.

Guide to assessment and scoring2,3The neonatal abstinence syndrome scoring system was designed for term babies on four hourlyfeeds and may therefore need modification for preterm infants. In a term infant scoring should beperformed 30 minutes to one hour after a feed, before the baby falls asleep.

High-pitched cry Score 2 if high-pitched at its peak, 3 if high-pitched throughout. Infant

scored if crying is prolonged, even if it is not high-pitched.2Sleep This a scale of increasing severity and a term infant should receive

only one score from the three levels of severity. A premature infant on3 hourly feeds can sleep for 2 hours at most. Scoring should thusbe 1 if the baby sleeps less than 2 hours, 2 if less than 1 hour and 3 ifthe baby does not sleep between feeds.2

Moro reflex The Moro or startle reflex is a normal reflex of young infants andoccurs when a sudden loud noise causes the child to stretch out thearms and flex the legs. Score if the infant exhibits pronouncedjitteriness (rhythmic tremors that are symmetrical and involuntary) ofthe hands during or at the end of a Moro reflex. Score 3 if jitterinessand clonus (repetitive involuntary jerks) of the hands and/or arms arepresent during or after the initiation of the reflex.

Tremors This is a scale of increasing severity and an infant should only receiveone score from the four levels of severity. Undisturbed refers to thebaby being asleep or at rest in the cot. 2

Increased muscle tone Score if excessive or above-normal muscle tone or tension is observedmuscles become stiff or rigid and the infant shows markedresistance to passive movements, eg. if the infant does not experienceany head lag when being pulled to the sitting position; or there is tightflexion of the infants arms and legs (unable to slightly extend thesewhen an attempt is made to extend and release the supine infantsarms and legs).4


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Excoriation Excoriations (skin abrasions resulting from constant rubbing against asurfaced that is covered with fabric such as bed linen). Score onlywhen excoriations first appear, increase or appear in a new area. 2

Myoclonic jerks Score if involuntary muscular contractions which are irregular andexceedingly abrupt (usually involving a single group of muscles) areobserved.4

Generalisedconvulsions

In the newborn infant generalised seizures or convulsions are oftenreferred to as tonic seizures. They are most commonly seen as

generalised activity involving tonic extensions of all limbs, but aresometimes limited to one or both limbs on one side. Unusual limbmovements may accompany a seizure. In the upper limbs these oftenresemble swimming or rowing. In the lower limbs, they resemblepedalling or cycling. Other subtle signs may include eye staring,rapid involuntary movements of the eyes, chewing, back arching andfist clenching.4

Sweating Score if sweating is spontaneous and is not due to excessive clothingor high room temperature.4

Hyperthermia Temperature should be taken per axilla. Mild pyrexia (37.2 38.3C) isan early indication of heat produced by increase muscle tone and

tremors.Yawning Score if more than 3 yawns observed within the scoring interval. 2, 4

Mottling Score if mottling (marbled appearance of pink and pale or white areas)is present on the infants chest, trunk, arms or legs.4

Nasal stuffiness Score if the infant sounds congested; mucous may be visible.4

Sneezing Score if more than 3 sneezes observed within the scoring interval. 2, 4

Nasal flaring Score only if repeated dilation of the nostrils is observed without otherevidence of lung or airways disease.4

Respiratory rate Respirations are counted for one full minute. Score only if >60 perminute without other evidence of lung or airway disease.2 Score 2 ifrespiration involves drawing in of the intercostal muscles (retractions).

Excessive sucking Score if hyperactive/disorganised sucking, increased rooting reflex, or

attempts to suck fists or thumbs (more than that of an average hungryinfant) are observed. 2, 4

Poor feeding Score if infant demonstrates excessive sucking prior to feeding, yetsucks infrequently during a feeding taking a small amount of breastmilkor formula, and/or demonstrates an uncoordinated sucking reflex(difficulty sucking and swallowing).3 Premature infants may requiretube feeding and should not be scored for poor feeding if tube feedingis expected at their gestation. 2

Regurgitation Score if at least one episode of regurgitation is observed even if vomitis contained in the mouth.4

Loose/watery stools Score if loose (curds/seedy appearance) or watery stools (water ring onnappy around stool) are observed. Check the nappy after theexamination is complete if not apparent during the examination. 4

References

1. Finnegan LP. Neonatal abstinence syndrome: assessment and pharmacotherapy, In Nelson, M, editor. Curren t therapy in neonatal-perinatal medicine. 2 ed. Ontario: BCDecker, 1990.

2. Royal Womens Hospital Drug Information Centre. Newborn Emergency Transport Service (Victoria). Neonatal handbook. Carlton, Vic: Royal Womens Hospital; 2004.3. Finnegan LP, Kaltenback K. Neonatal abstinence syndrome. In: Hoekelman RA, Friedman SB, Nelson N, Seidel HM, editors. Primary pediatric care. 2 ed. St Louis: CV Mosby;

1992. p. 1367-78.4. Lester BM, Tronick EZ, Brazelton TB. The Neonatal Intensive Care Unit Network Neurobehavioural Scale Procedures. Pediatrics. 2004;113(3 Pt 2):641-647.

Western Australian Centre for Evidence Based Nursing & Midwifery, January 2007 (RHSET 01660A)Online:http://speciosum.curtin.edu.au/nas/nasIndex.html
http://speciosum.curtin.edu.au/nas/nasIndex.htmlhttp://speciosum.curtin.edu.au/nas/nasIndex.htmlhttp://speciosum.curtin.edu.au/nas/nasIndex.htmlhttp://speciosum.curtin.edu.au/nas/nasIndex.html

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Neonatal Abstinence Scoring on the Postnatal Ward