Withdrawal Scoring Sheet

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 below 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.

*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.

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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.

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Sleep: Scoring based on the longest period of sleep displayed with the entire scoring interval.

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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.

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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.

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Increased muscle tone: No head lag when being pulled to sitting position / total body rigidity / tight flexion of arms and legs.

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Excoriation: Skin irritation on chin, knees, cheeks, elbows, toes, or nose. (NOT diaper rash).

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Myoclonic jerks: Twitching movements of the muscles of the face or extremities.

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Sweating: Moisture on the forehead, upper lip, or back of the neck not due to over-wrapping.

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Yawning: More than 3 times within the assessment interval.

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Excessive sucking: Rooting > 3 times per interval while displaying swiping movements with hand across mouth in attempt to suck on fist, hands, pacifier.

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Poor feeding: Infrequent sucking during feeding OR gulping formula or breastmilk and stopping frequently to breathe (unless related to prematurity)

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