Withdrawal Scoring Sheet
In Utero Drug Exposure
CNS Disturbances |
Score |
2 3 |
|
3 2 1 |
|
2 3 |
|
1 2 3 4 |
|
| Increased muscle tone | 2 |
| Excoriation | 1 |
| Myoclonic jerks | 3 |
| Generalized convulsions | 5 |
Metabolic /Motor / Respiratory Disturbances |
Score |
| Sweating | 1 |
Temperature 37.2 - 38.3 C Temperature 38.4 C or higher |
1 2 |
| Frequent Yawning ( > 3 - 4 times per interval) | 1 |
| Moaning | 1 |
| Nasal Stuffiness | 1 |
| Sneezing ( > 3 - 4 times per interval) | 1 |
| Nasal Flaring | 2 |
Respiratory Rate > 60/min Respiratory Rate > 60/min with retractions |
1 2 |
Gastrointestinal Disturbances |
Score |
| Excessive Sucking | 1 |
| Poor feeding | 2 |
Regurgitation Projectile Vomiting |
2 3 |
Loose stools Watery stools |
2 3 |
| Total Score * | |
| Adjusted Score ** |
*TOTAL SCORE: include clinical symptoms that appear continuously
*ADJUSTED SCORE: circle and subtract from total score a symptom that might occur independent of withdrawal due to a pre-existing condition (i.e. high respiratory rate in an infant with BPD)
Scores should be assessed every 4 hours; score every 2 hours if total is 8 or greater.
Definitions
Excessive crying: Unable to use self-consoling measures (finger/fist sucking) or calm with interventions from the caregiver (holding, rocking, pacificier) from 5 seconds up to 5 minutes.
Continuous crying: Continues to cry intermittently or continuously for > 5 minutes despite consoling measures.
Sleep: Scoring based on the longest period of sleep displayed with the entire scoring interval.
Hyperactive Moro: Exhibits pronounced jitteriness of the hands during or at the end of a moro reflex.
Marked hyperactive Moro: Jitteriness and sustained clonus of the hands / arms during or after a Moro reflex.
Mild tremors disturbed: Exhibits tremors of one or both hands / feet while being handled or disturbed.
Moderate tremors disturbed: Exhibits tremors of arms / legs while being handled or disturbed.
Mild tremors undisturbed: Exhibits tremors of one or both hands / feet while NOT being handled.
Moderate - severe tremors undisturbed: Exhibits tremors of arms / legs while NOT being handled.
Increased muscle tone: No head lag when being pulled to sitting position / total body rigidity / tight flexion of arms and legs.
Excoriation: Skin irritation on chin, knees, cheeks, elbows, toes, or nose. (NOT diaper rash).
Myoclonic jerks: Twitching movements of the muscles of the face or extremities.
Sweating: Moisture on the forehead, upper lip, or back of the neck not due to over-wrapping.
Yawning: More than 3 times within the assessment interval.
Excessive sucking: Rooting > 3 times per interval while displaying swiping movements with hand across mouth in attempt to suck on fist, hands, pacifier.
Poor feeding: Infrequent sucking during feeding OR gulping formula or breastmilk and stopping frequently to breathe (unless related to prematurity)
When a newborn is at known risk of neonatal abstinence syndrome, or when the baby's symptoms are suggestive of the diagnosis, a withdrawal scoring system is useful to objectively measure the infant's symptoms.
Because many of the items listed can occur in well infants or those who have a different underlying problem, the diagnosis is based on the overall constellation of symptoms and their persistence rather than on a single event or piece of information. Scores of 8 or greater for at least 2 consecutive intervals are concerning for withdrawal; treatment should be considered for those infants.