Reprinted with permission from Treatment of Opioid Dependence in Pregnancy: Vermont Guidelines.
Assessment & Documentation
- The infant is scored at 2 hours of age and every 3-4 hours prior to a
feeding - The NAS score will be recorded for the 3-4 hour period immediately before the scoring activity
Signs and symptoms are documented on the NAS form and totaled for a score
Sleeping
For every sign except sleeping, a score of 0 = not present
Use the longest single continuous time sleeping since last feeding
Sleeps 3 or more hours continuously (Score = 0)
Sleeps 2-3 hours after feeding (Score = 1)
Sleeps 1-2 hours after feeding (Score = 2)
Sleeps less than 1 hour after feeding (Score = 3)
When repeating a score within 1 hour after a feeding: Use the same sleep score obtained before the feeding.
Moro Reflex
Cup infant’s head in your hand and raise his/her head about 2-3 inches above the mattress, then drop your hand while holding the infant.
- The infant should be quieted if irritability or crying is present. This
will insure that the jitteriness, if present, is due to withdrawal rather
than agitation.
Hyperactive Moro: arms stay up 3-4 sec with our without tremors (Score = 1)
Markedly Hyperactive Moro: arms stay up > 4 sec with or without tremors (Score = 2)
Tremors
- Tremors = jitteriness
Involuntary movements that are rhythmical
If the infant is asleep, it is normal to have a few jerking movements of the extremities
Mild tremors: hands or feet only, last up to 3 seconds (Score = 1)
Moderate-severe tremors: arms or legs, last more than 3 seconds (Score = 2)
Undisturbed: Tremors that occur in the absence of stimulation
Increased Muscle Tone
While the infant is lying supine, extend and release the infant’s arms and legs to observe for recoil
Infant supine, grasp arms by wrists and gently lift infant, looking for head lag
Difficult to straighten arms but is possible; head lag is present (Score =1)
No head lag noted or arms or legs won’t straighten (Score = 2)
Excoriation
Red or broken skin from excessive rubbing (eg: extremities or chin against linens)
Skin red but intact or is healing and no longer broken (Score = 1) Skin breakdown present (Score = 2)
Sweating
Wetness felt on the infant’s forehead, upper lip (Score = 1)
Sweating on the back of the neck may be from overheating such as swaddling
Nasal Stuffiness
Any nasal noise when breathing (Score =1 )
Runny nose may or may not be present
Sneezing
Infant sneezes 4 or more times in the scoring interval of 3-4 hours (Score =1)
Tachypnea
- The infant must be quieted if crying first; count respirations for full minute
Respiratory rate > 60/min (Score = 2)
Nasal Flaring
Outward spreading of the nostrils during breathing (Score = 1)
Poor Feeding
Poor feeding is defined as any 1 of the following (Score = 2)
Infant demonstrates excessive sucking prior to a feeding yet sucks
infrequently while feeding and takes a small amount of formula/breast milk.
Demonstrates an uncoordinated sucking reflex (difficulty sucking and swallowing)
Infant continuously gulps while eating and stops frequently to breathe.
Inability to close mouth around bottle/breast
Feeding takes more than 20 minutes
Regurgitation/Vomiting
Frequent regurgitation (vomits whole feeding or vomits 2 or more times during feed) not associated with burping (Score = 2)
Loose Stools
Infant has a stool that is at least half liquid (Score = 2)
When repeating a score within 1 hour after a feeding: Use the same stool score obtained before the feeding.
Current Weight < 90% of Birth Weight
Infant is weighed once a day and then that score is carried through the rest of the day
- Weight is < 90% of birth weight (Score = 2)
Continue to score until infant gains weight and is > 90% of birth weight Use workspace at top of form
Excessive Irritability
Distinct from, but may occur in conjunction with crying
Marked by frequent grimacing, excessive sensitivity to sound andlight.
Infant becomes fussy or irritable with light, touch, or handling, despite attempt to console
Consoling calms infant in 5 minutes or less (Score = 1)
Consoling calms infant in 6-15 minutes (Score = 2)
Consoling takes more than 15 minutes or no amount of consolingcalms infant (Score = 3)
