Neonatal Abstinence Syndrome (NAS)- Scoring Explanation (done @Newborn 2hrs age)

-is a result of the sudden discontinuation of fetal exposure to substances that were used or abused by the mother during
pregnancy.

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

Total Score
*<5 -MILD- ready to wean down on their methadone
*5-8- MODERATE -a breakthrough dose of morphine may not be appropriate; the infant may not be ready to wean
down on their methadone further.
*8-12- SEVERE- not ready
*>12- VERY SEVERE- not ready
Criteria Score
Sleeping  3hrs or more continuous 0
 2-3hrs after feeding 1
 1-2hrs after feeding 2
 1hr after feeding 3
Moro Reflex  Hyperactive Moro: arms stay up 3-4 sec with or without tremors 1
Cup infant’s head in your hand and
raise his/her head about 2-3 inches  Markedly Hyperactive Moro: arms stay up > 4 sec with or without tremors 2
above the mattress, then drop your
hand while holding the infant.
Tremors  Mild tremors: hands or feet only, last up to 3 seconds 1
Involuntary movements that are
rhythmical  Moderate-severe tremors: arms or legs, last more than 3 seconds 2
Increased Muscle Tone  Difficult to straighten arms but is possible; head lag is present 1
While the infant is lying supine,
extend and release the infant’s arms  No head lag noted or arms or legs won’t straighten 2
and legs to observe for recoil. Infant
supine, grasp arms by wrists and
gently lift infant, looking for head lag
Excoriation  Skin red but intact or is healing and no longer broken 1
Red or broken skin from
 Skin breakdown present 2
excessive rubbing
Sweating  Wetness felt on the infant’s forehead, upper lip 1
Nasal Stuffiness  Any nasal noise when breathing 1
Sneezing  Infant sneezes 4 or more times in the scoring interval of 3-4 hours 1
Tachypnea  Respiratory rate > 60/min 2
Nasal Flaring  Outward spreading of the nostrils during breathing 1
Poor Feeding -Infant demonstrates excessive sucking prior to a feeding yet sucks 2
-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 2
feed) not associated with burping
Loose Stools  Infant has a stool that is at least half liquid 2
Current weight <90% of  Weight is < 90% of birth weight 2
Birth Weight
Excessive Irritability  Consoling calms infant in 5 minutes or less 1
 Consoling calms infant in 6-15 minutes 2
 Consoling takes more than 15 minutes or no amount of consoling calms 3
infant