Table 2.

Example of Neonatal Abstinence Syndrome Assessment Tool Based on the Finnegan Scoring System (9)

Signs and SymptomsScore
Mild tremors when disturbed1
Moderate-to-severe tremors when disturbed2
Mild tremors when undisturbed3
Moderate-to-severe tremors when undisturbed4
High-pitched cry <5 min2
High-pitched cry >5 min3
Hyperactive Moro reflex2
Markedly hyperactive Moro reflex3
Sleeps <3 h after feeding1
Sleeps <2 h after feeding2
Sleeps <1 h after feeding3
Yawning >3 to 4 times/scoring interval1
Increased muscle tone1
Myoclonic jerks3
Generalized convulsions5
Temperature 37.2 to 38.3°C1
Temperature >38.4°C2
Sweating1
Excoriation1
Mottling1
Nasal congestion1
Sneezing >3 to 4 times/scoring interval1
Nasal flaring2
Respiratory rate >60 breaths/min1
Respiratory rate >60 breaths/min with retractions2
Excessive sucking1
Poor feeding/suck-swallow incoordination2
Regurgitation ≥2 times/feeding2
Projectile vomiting3
Loose stools2
Watery stools3