Instead of basing pharmacologic initiation and escalation of treatment solely on a total Finnegan score, consider prioritizing measures of functional impairment. A functional impairment-based strategy for managing neonatal abstinence syndrome (NAS) should employ staff who have been trained in engaging mothers with opioid use disorder (OUD) and in using non-pharmacologic interventions for the newborn. The use of a functional impairment-based treatment strategy should be designed and tailored to a specific unit within the context of a formal quality improvement initiative so that safety may be routinely monitored and reviewed.
Why we are recommending this best practice
Subacute symptoms of NAS can continue for weeks or months. Prolonged inpatient management and pharmacotherapy may lead to adverse infant neurodevelopment and poor parental engagement. Focusing on a newborn’s functional impairments to guide pharmacotherapy may reduce length of stay and pharmacotherapy exposure. Studies of this method indicate no increase in readmission rates; however, there are no long-term studies to evaluate benefit versus harm of this method.
Strategies for implementation
- Create a unit protocol for nurse scoring of functional measures, conduct nursing and staff education prior to implementation, and educate health care providers regarding guidelines for use of pharmacotherapy. Monitor acceptability and feasibility of this protocol within the hospital as well as readmission rates for infants.
- Examples of published methods emphasizing functional impairment are:
- Finnegan Symptom Prioritization focuses on certain function-based items in the Finnegan score. Most recent reports include poor feeding, poor sleep, and continuous crying as prioritized functional measures. Other components of the Finnegan score that are sometimes included are emesis, diarrhea, tachypnea, or fever.
- “Eat, Sleep, Console” prioritizes a newborn’s inability to take an age-appropriate volume of food, sleep more than one hour after feeding, or be consoled within ten minutes.
- Functional-based assessment and management of newborns with NAS should be designed for the specific hospital. The formal “Eat, Sleep, Console” (ESC) approach was initially developed by Dr. Matthew Grossman at Yale New Haven Children’s Hospital. Similar quality improvement programs are being successfully implemented at both academic centers and community hospitals as part of a non-pharmacologic approach.
- These are emerging (best) practices with encouraging short-term outcomes, and about which further study is needed to confirm long term outcomes.
- Alternative strategies employ the use of a modified Finnegan checklist with the mother scoring subjective functional items (e.g., quality of cry, stool consistency, tremulousness, etc.).
The total Finnegan score describes NAS symptoms, but it does not reflect how NAS severity affects the infant’s ability to function. Several of the symptoms included in the Finnegan scoring system can be attributed to cluster feeding or other normal newborn behaviors. This symptom-based score may lead to unnecessary opioid treatment of infants without functional impairment. Studies show that opioid pharmacotherapy and length of stay decrease significantly with use of a function-based assessment compared to use of the total Finnegan score alone. Use of a function-based assessment can avoid initiation of opioid treatment, separation of the dyad, and a newborn’s transfer to the high-stimulation NICU environment.
- Wachman EM, Grossman M, Schiff DM, et al. Quality improvement initiative to improve inpatient outcomes for Neonatal Abstinence Syndrome. J Perinatol. 2018;38(8):1114-1122. doi: 10.1038/s41372-018-0109-8.
- Grossman MR, Berkwitt AK, Osborn RR, et al. An initiative to improve the quality of care of infants with Neonatal Abstinence Syndrome. Pediatrics. 2017;139(6): e20163360. doi: 10.1542/peds.2016-3360.
- Grossman MR, Lipshaw MJ, Osborn RR, Berkwitt AK. A novel approach to assessing infants with neonatal abstinence syndrome. Hosp Pediatr. 2018;8(1):1-6. doi: 10.1542/hpeds.2017-0128.
- Holmes AV, Atwood EC, Whalen B, et al. Rooming-in to treat neonatal abstinence syndrome: improved family-centered care at lower cost. Pediatrics. 2016;137(6): e20152929. doi: 10.1542/peds.2015-2929.
- Blount T, Painter A, Freeman E, et al. Reduction in length of stay and morphine use for NAS with the “eat, sleep, console” method. Hosp Pediatr. 2019;9(8):615-623. doi: 10.1542/hpeds.2018-0238.
- Kocherlakota P, Qian EC, Patel VC, et al. A new scoring system for the assessment of Neonatal Abstinence Syndrome. Am J Perinatol. 2020;37(3):333-340. doi: 10.1055/s-0039-3400310.