Appendix A: Neonatal Abstinence Syndrome (NAS) Scoring Explanation

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
  • 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



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 = 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)



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)



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



Infant sneezes 4 or more times in the scoring interval of 3-4 hours (Score =1)



  • 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



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)