Several assessment tools are available and recommended to help determine the severity of NOWS (or NAS), including the Finnegan Neonatal Abstinence Scoring System, the Lipsitz Neonatal Drug-Withdrawal Scoring System, the Neonatal Withdrawal Inventory, the Neonatal Narcotic Withdrawal Index, and the Withdrawal Assessment Tool-Version 1 (WAT-1) [13,17,20,26]. The Finnegan Neonatal Abstinence Scoring System is a 31-item scale that will quantify the severity of NAS/NOWS in order to help guide treatment decisions. The tool may be administered every four hours, and if an infant receives a score of 8 or more points, or the total for three consecutive scores is greater than 23, pharmacotherapy is indicated. In response to the complexity of the Finnegan tool, a shorter modified version is available (the Finnegan Neonatal Abstinence Syndrome Scale—Short Form) and is recommended by the American Academy of Pediatrics [24]. The Lipsitz Neonatal Drug-Withdrawal Scoring System consists of 11 items, and a score of 4 or greater is an indication that opioid therapy should be started. The Neonatal Withdrawal Inventory is an 8-point checklist of NAS/NOWS symptoms, with a 4-point behavioral distress scale. The Neonatal Narcotic Withdrawal Index is comprised of six items, for a possible maximum score of 12 points. A score of 5 or more on this index should prompt pharmacologic intervention [13]. Finally, the WAT-1 is administered to infants experiencing NAS/NOWS who have been exposed to opioids and benzodiazepines for an extended period (including throughout a pregnancy) [20]. With this tool, pharmacotherapy is recommended for patients who score 10 or more points. However, the relative efficacy of these scores has not been definitively proven [23].
Specific neonatal assessments for opioid withdrawal continue to be developed and are becoming more specific to NOWS sequelae. One such tool is the Maternal Opioid Treatment: Human Experimental Research (MOTHER) Neonatal Abstinence Measure (based on the Finnegan scoring system), which includes the addition of common central nervous system, gastrointestinal tract, and autonomic clinical signs. Another simplified tool to assist in quick assessment is the Eat, Sleep, Console (ESC) measure, which is guided by the infant’s clinical signs of withdrawal through evaluation of an infant’s ability to eat ≥1 oz or breastfeed well, sleep undisturbed ≥1 hour, and be consoled [13]. More research is required to prove the relative efficacy of these scales in screening for NOWS.
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If indicated, opioid treatment should be initiated and the infant should be reassessed every three hours. Treatment with other sedatives (e.g., benzodiazepines, clonidine) has been effective, but 83% of physicians in the United States use an opioid (morphine or methadone) to treat NOWS [23]. The dose of replacement opioid varies according to the severity of symptoms and degree of exposure; the average initial dose of morphine sulfate is 0.05 mg/kg every three hours [5]. If there is no improvement after three hours, the dose may be increased to 0.08 mg/kg, then again to a maximum of 0.1 mg/kg every four hours if necessary. Stabilization may take up to 48 hours. After 24 to 48 hours of a constant morphine dose, a gradual weaning can begin. Even after morphine is discontinued, the infant should be monitored hourly for 48 hours. If signs of NOWS reappear, the original dose should be restarted and the same procedure followed until successful. After this, discharge plans may be implemented [13,24].
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