Pros And Cons Of The Finnegan Scoring System

Scoring Due to the lack of a standardized treatment protocol, there is variability in infant assessment and treatment in relation to NAS (Sarah Mary Bagley, Elisha M Wachman, Erica Holland and Susan B Brogly). There are multiple tools used for scoring infants with Neonatal Abstinence Syndrome. By far, the most widely used and studied is the Finnegan Scoring System. It is based off of the nurse’s subjective observations. It looks at the infants central nervous system, respiratory system, gastrointestinal system, and items such as yawning, and sneezing frequency. Disadvantages to this system are it is very time consuming, it does not monitor the infant constantly and nurse measurements are extremely subjective (Hayleigh, A., & Sarah, G. (2012).
Other scoring methods in the studies reviewed include the Lipitz score, Neonatal Withdrawal Inventory, and the MOTHER NAS scale. The scales all have inter-rater reliability coefficients >0.77. Variability in clinical practice has lead to insufficient research in this area. Each neonatal unit develops their own plan of care for pharmacological treatment based off of their minimal scores.
Pharmacological Treatment The latest recommendations from the American Academy of Pediatrics (AAP) on Neonatal Drug Withdrawal, indications for pharmacotherapy include signs of withdrawal such as seizure, fever, decreased duration of sleep, and weight loss or dehydration due to vomiting, diarrhea or poor feeding. (AAP) Goals of therapy include reducing clinical manifestations to protect the newborn. Most all neonatal intensive care units use four common drugs in the treatment of NAS. These include morphine, phenobarbital, clonidine, and methadone as a means to help the infant withdraw as safely as possible. Currently the AAP recommends Morphine as the first line choice for opiate addicted infants. With a short half life of 4 hours it allows for a quicker titration regimen. It is titrated at a rate of 0.04mg/kg/dose. Morphine is generally titrated down by 10% each day until scores allow. Methadone on the other hand, has a half life of 25-32 hours. The research on methadone is still out. There are studies which have shown it to be more effective than the morphine simply because it keeps a consistent serum concentration of the drug ( )> Inevitably, there are times when these therapies just aren’t enough. Infant scores continue to rise or there are relapses of symptoms after weaning has taken place. Adjunct therapies are then introduced. Phenobarbital is given 20mg/kg initially as a loading dose, followed by 10mg/kg for subsequent doses. There are no standard protocols for scoring of infants and when to start treatment.Despite clear cut, evidence-based recommendations from the AAP, the management of the newborn with psychomotor behavior consistent with withdrawal varies widely,
Non-pharmacological Treatments
Non-pharmacological techniques are necessary for an infant with NAS.
The increased metabolic demands, GI upset, hyperactivity, and neurological complications caused by NAS require more than pharmacological treatment. Non-pharmacological treatment options include swaddling, rocking, minimal stimulation and breastfeeding. Including these treatments in the infants’ plan of care proves to reduce scores. The central theme in studies involving non-pharmacological treatment was the infant feeding method (Sarah Mary Bagley1*, Elisha M Wachman2, Erica Holland3 and Susan B Brogly? According to (Bio, L. L., Siu, A., & Poon, C. Y. (2011) , infants that were breastfed compared to formula fed infants, had a lower Finnegan score, reduced hospital stay, and a reduction in the amount of pharmacotherapies and treatment time. Methadone transfers minimally into the breast milk and does not pose an issue with dependence in the infant. The controversy lies at the criteria to permit breastfeeding. Providers have no way of knowing if the mother supplying the milk is only taking methadone. One study found breastfed infants had a slower withrawal requiring treatment (10 vs. 3 days) and decreased Finnegan scores in the first 9 days of life (Sarah Mary Bagley1*, Elisha M Wachman2, Erica Holland3 and Susan B
Brogly)
Longterm Health Issues Longterm issues can exist for infants born addicted to opiates.
Again, there are a lack of studies in this area due to the fact that there or so many other confounding variables. Most mothers addicted to opiates are also dealing with environmental and socio-economical issues as well. These mothers are often single mothers, or exposed to abuse, living in inadequate housing. Therefor, having a study with only certain factors in place is very difficult. A study by Logan, Brown and Hayes, assessed infants at 12 & 18 months using the Mental Development Index (MDI) was substantially lower in opiate exposed children at 12 & 18 months. These infants grow into children with deficits such as motor rigidity, which in turn, were associated with less social responsivity and shorter attn spans. Motor delays were more attributed to maternal absinteeism and birth weight. (REWORD) What we do know is the socio-economical background of the infant plays a significant role in the child’s well being. An infant who is addicted to opiates to birth but also has a poor home environment with absent parental involvement will have far worse outcomes than an infant addicted to opiates at birth who then has a nurturing, fulfilled childhood. Thus, acquiring standard data on these children is very difficult as every childhood has different extrinsic
factors.
Increasing Healthcare Costs Mean hospital charges between 2000-2009 increased from $39,400 to $53, 400 for infants diagnosed with NAS ()>. According to TennCare, a baby with NAS cost 5.6 times more than a baby without NAS in 2010 and infants with NAS are 18 times more likely to enter state custody than infants without NAS ()> Most of these infants were covered under Medicaid. The average in hospital length of stay for an infant with NAS is 16 days compared to 3 days for a healthy newborn. Beyond the costs of initial hospitalization and treatment there are follow up visits and appointments. These children often suffer from mental irregularities and attention deficit disorder. These illnesses often require a lifetime of treatment. Although there is not many studies on adults born to opiate addictions, research shows these adults have difficulties with anxiety and attention deficit disorder. NAS isn’t just something that disappears after the initial withdrawal has resolved, it requires evidence based treatment for follow up, not only for the infant but for the mother as well so the cycle can be stopped. Education is key for these mothers.