1. Verklan, M. Terese PhD, CCNS, RNC, FAAN

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As you are well aware, the use of opioids, including fentanyl and heroin, has skyrocketed over the last 20 years. Along with the increase in deaths from overdoses, there has been a 7-fold increase in the number of neonates diagnosed with neonatal abstinence syndrome (NAS).1 Neonatal nurses have been caring for affected infants long before the country recognized the opioid epidemic. Throughout the first half of the 20th century, neonates exhibiting symptoms of withdrawal were diagnosed as having congenital morphinism because they were primarily exposed to morphine prenatally.2 Currently, there is a wide range of prescription and nonprescription opioids ingested by the mother that can result in NAS. It is estimated that the incidence of NAS increased from 1.3/1000 births in 2000 to 5.8/1000 births in 2012.2


In the 1970s, Dr Finnegan and colleagues tested and published the Finnegan Neonatal Abstinence Scoring System (FNASS) to have a systematic approach to evaluating neonates born in the heroin epidemic in Philadelphia. At the same time the Lipsitz Tool, an 11-item easier-to-use scale, was recommended by the American Academy of Pediatrics Policy Statement for the care of babies experiencing withdrawal symptoms.3,4 Despite the recommendation, the FNASS was widely adopted for clinical use in the neonatal community, and is the most commonly used model of care for babies demonstrating symptoms of withdrawal.5 Periodic assessments using standardized instruments, including the modified FNASS, are considered the standard of care today.1


There are several significant limitations associated with the FNASS. First, the instrument was designed for use by researchers as a standardized scoring system, not as a tool for clinical use. Assessments of the autonomic nervous system, neurologic, and gastrointestinal signs are inseparably linked to the pharmacologic management of NAS.6 The neonate is evaluated every 2 to 6 hours on the signs of withdrawal, and once a score of 8 or greater has been documented 3 consecutive times, pharmacologic therapy can be initiated. Decreasing medication doses is also dependent on the neonate receiving a score of less than 8. To date, research has not really evaluated the effectiveness of a cutoff score of 8.6 Dr Finnegan and colleagues chose the "8" threshold based on their clinical experiences.5 I am not aware of any research that has critically evaluated a threshold of "7" or "9" to begin pharmacologic management. Thus, the optimal scores to begin pharmacologic treatment, adjust the medications, and discontinue treatment are unknown.


When used in research, the interrater reliability is quite robust.5 Frequently, the Finnegan Neonatal Abstinence Scoring Tool (FNAST) is used in the absence of a standardized training program in the neonatal care areas. The neonatal nurse may interpret symptoms differently from her/his colleagues such that inconsistent scores result. The tool can be lengthy and complex, especially if the nurse is rushed, lacks familiarity with the instrument, or is not well trained to use it properly. In addition, the psychometric properties of the FNAST have been labeled "poor."5


Use of the FNAST also delays treatment for the neonate displaying symptoms of withdrawal. Because the guidelines are to assess the infant every 2 to 6 hours, there can be considerable distress to an inconsolable neonate who must demonstrate the symptoms over a period before treatment is begun. To properly perform an assessment, the neonate is disturbed and stimulated. The nonpharmacologic interventions call for swaddling, low stimulation, and skin-to-skin care. Frequent assessments involving unwrapping the baby to determine whether there are tremors or an exaggerated Moro could prompt more symptoms of withdrawal to be shown.


The original FNAST identified 21 symptoms of withdrawal and attempted to organize the severity of clinical findings. There has been no research to validate the classification of severity or the items that were included. Many of the clinical findings, such as stuffiness and frequent yawning, would not generate a treatment plan including medications in another clinical scenario. Jones and colleagues7 evaluated 19 clinical items in a modified FNAST and found that a combination of an exaggerated Moro reflex, mild tremors when disturbed, and increased muscle tone was exclusive to those neonates demonstrating withdrawal. They also determined that a 5-item instrument differentiated between the infants who did and did not receive pharmacologic treatment.8 Perhaps a shorter, more specific tool can better identify the opioid-exposed neonate who requires treatment.


For those neonates who are started on pharmacologic treatment, weaning from the medication is a very slow, methodical process. The original work by Finnegan did not discuss the weaning process. The typical protocol weans an infant with a stable score by 10% or less per day. Thus, the neonate is exposed to more doses than may be necessary before the medication is completely weaned.


Another limitation is that there is no data regarding long-term outcomes of the neonate who was managed with pharmacologic treatment.5 There are findings for short-term outcomes related to the period of hospitalization. There is also a lack of data on the variety of approaches to care that are seen in clinical practice.


The increasing number of opioid-exposed neonates demands that we find a reliable, valid, and simple instrument that can accurately evaluate symptoms of withdrawal without actually disturbing the baby. Since the 1970s, patterns of drug abuse have substantially changed. Many of substance abusers abuse more than 1 drug, as for example, fentanyl, nicotine, benzodiazepines, to name a few. There needs to be an assessment tool that takes into consideration much more than opioid exposure. The tool needs to be focused on helping neonatal nurses and physicians identify neonates with symptoms of withdrawal as well as the best approach for their management, rather than relying so heavily on pharmacologic treatment. Better long-term outcomes, such as physiologic markers of infant stress, and long-term developmental outcomes also need to be developed and studied.


-M. Terese Verklan, PhD, CCNS, RNC, FAAN


Professor and Neonatal Clinical Nurse Specialist


University of Texas Medical Branch


School of Nursing Galveston


Graduate School of Biological Sciences


Galveston, Texas




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