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How is Infant Withdrawal Assessed?

In the 1970s, Dr. Loretta Finnegan developed the Finnegan Tool as a way to assess opiate withdrawal in infants and guide medication use. There are 31 items that make up a total score. This tool is commonly used in hospitals and other facilities that treat infants experiencing withdrawal. It has been validated by researchers and is well known among neonatal care providers all around the world. It is also complex, somewhat impractical, and requires subjective decisions, causing a problem with consistency among different care givers. For example, are some scores rushed when the baby is hungry, and some completed after feeding? How can a busy nurse count every yawn and sneeze while caring for other patients in different rooms? What is the definition of "excessive" crying? This means that different caregivers can give very different scores.

When using the Finnegan, we recommend consistently promoting non-pharmacological interventions and standardizing the timing and technique of scores across all staff and family members. See below for a step-by-step discussion of how to correctly use the Finnegan Tool.

 

Eat, Sleep, Console (ESC) is an emerging best practice which focuses on non-pharmacological interventions, like cuddling with parents and feeding human milk. Finnegan and ESC are frequently used together, but can also be used separately.

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Caregivers Guide to the Finnegan

Parents are an essential team member when using the Finnegan Tool. Ask your healthcare providers for a copy of the scoring policy so that you can understand and help with the scoring process.

 

Consider starting or increasing medication treatment for:

2 scores in a row over or averaging 12 or more.

3 scores in a row over or averaging 8 or more.

 

(For example: If the last 3 scores were 9, 6, and 10, then you would consider medication because the average is more than 8.)

 

Score should be done when a baby is fed, wearing a clean diaper, and not crying. It can be done while held or in crib, with or without pacifier. If the baby begins crying during the exam, soothe baby and begin again. If baby is unable to stop crying for long enough to perform score, consider medication.

 

Unless otherwise specified, be sure to make note if your baby exhibits one of these signs any time during the scoring interval. Scoring interval refers to the time between scores, usually corresponding with feedings. Be sure that all caregivers are on the same page as to when the interval starts and ends. For example, if the baby regurgitates during the feeding, does it count for the current or next score?

 

When changing caregivers, be sure to pass along whether any interval score items are present such as sleep, yawning, sneezing, etc.

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The Finnegan Tool
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High-Pitched Crying

 

Despite the name of this item, the pitch of the cry does not matter​

 

Do not score if baby is crying during diaper change, while hungry, or any other time when most babies would cry.

 

Score 2:

The baby continues to cry for 5 minutes despite strategies to soothe like holding or pacifier use at any time while fed and in a clean diaper during scoring interval.

This item score should be given whether cry is high-pitched or not, but not if cry is high-pitched and soothed in less than 5 minutes.

Score 3:

The baby continues to cry for more than 5 minutes despite strategies to soothe like holding or pacifier use at any time during scoring interval.

This item score should be given whether cry is high-pitched or not

Sleep

Score based on longest uninterrupted period of sleep within entire scoring interval. 

Do not combine sleep periods for scoring.

If a 3 hour scoring period is used due to a 3 hour feeding or medication schedule, do not score the item “sleeps less than 3 hours” unless infant wakes up on their own after sleeping for at least 2 hours. 

 

         Score 3    if the baby sleeps less than 1 hour
        Score 2    if the baby sleeps less than 2 hours
       Score 1    if the baby sleeps less than 3 hours

 

Moro Reflex

Moro reflex is also known as the "startle" reflex. Babies commonly do this when there is a noise, movement, or sometimes for no reason at all. It is normal and expected from about 28 weeks gestation to 6 months of age. Parents should be taught how to elicit and assess the Moro reflex.

Score 2

If the baby’s hands have jitters for longer than 5 seconds.

If more than 2 spontaneous Moro reflexes are observed during exam.

Score 3

If the baby has jitters and more than 8-10 clonus beats of hands and/or arms.

Clonus is repetitive back and forth motion of a hand or foot.

Tremors

Tremors and jitters are shaky movements of an arm or leg that can be stopped by placing a hand on the limb.

Do not score startle or jerking movements, particularly of jerking legs normally seen during sleep.

Score 1 

If the baby’s hand or foot has tremors while the baby is being handled.

Score 2

If the baby has tremors of one or both arms or legs while the baby is being handled.


Score 3

If the baby’s hand or foot has tremors 30 seconds after handling.

Score 4 

If the baby has tremors of one or both arms or legs 30 seconds after handling.

Myoclonic Jerks

These are different from jitters and tremors because they do not stop when you lay a hand on the arm or leg. This item should only be scored by a nurse or provider.

Score 3 if the baby has repetitive twitching or jerking movements in their face, arm, or leg.

Convulsions (Seizures) 

This item should only be scored by a nurse or provider.

Score 5

  • If the baby tightens and then relaxes all of their muscles repeatedly.

  • If the baby’s eyes twitch repeatedly in the same way.

Increased Muscle Tone 

Muscle tone is increased if the muscle is flexing and decreased if the muscle is floppy.

There are many ways to check muscle tone. The baby will receive only one score regardless of which method/s you use.

Testing Method - Pull-to-sit: 

This method is preferred for scoring unless there is a contraindication, like arm or shoulder injury.

With the baby on their back, pull them up to sitting position by the hands or arms.

Score 2 if the baby comes up with tightly bent arms and without their head drooping.

 

Testing Method - Upright suspension 

Hold the baby upright with your hands on their chest just under arms.

Score 2 if the baby remains rigid with bent legs and without their head drooping.

 Testing Method - Flexion and extension

With the baby on their back, straighten and release the legs one at a time.

Score 2 if you are unable to gently straighten the leg because the baby is flexing too strongly.

Excoriation

This is a skin injury caused by rubbing and should be scored until it is healed.

Score 1 if the baby has marks on their chin, knees, cheeks, elbows, toes, nose, or armpit (not including diaper area).

Sweating

Do not score if the baby is overdressed or being warmed by an isolette or radiant warmer.

Score 1 if the baby is sweaty on their face, chest, or armpits.

Fever

Do not score if the baby is overdressed or being warmed by an isolette or radiant warmer.

Be sure that all caregivers are using the same equipment and method to check temperature. Do not use the rectal method.

 Score 1 for temperature of 37.3-38 C or 99.2-100.4 F.   

 Score 2 for temperature more than 38 C or 100.4 F.

Frequent Yawning

Score 1 if the baby yawns more than 3 times in the scoring interval

Mottling

Mottling is a marbled appearance of the skin.

Score 1 if the baby has mottling on their chest, trunk, arms or legs

Nasal Stuffiness

Score 1 if the baby has a stuffy nose that you can hear as they breathe.

Sneezing

Score 1 if the baby sneezes more than 3 times within the scoring interval.

Nasal Flaring

Score 2 if the baby flares their nostrils for more than 3 breaths in a row while calm at any time during the scoring interval.

Respiratory Rate

Retractions are extra muscle movements in the chest while breathing. Parents should be taught how to identify and assess retractions.

Score 1 If the baby is breathing faster than 60 times a minute while calm.
Score 2 If the baby is breathing faster than 60 times a minute and is having retractions while calm.

Excessive Sucking

This item is very subjective. It should be scored if the baby is rooting and sucking for more than 5 minutes when they are not hungry.

Score 1

Poor Feeding

This item can be scored for the interval before or after the feeding in question. All caregivers should use the same method.

Score 2:

  • If the baby is unable to eat for at least 15 minutes at the breast/chest or is unable to eat the recommended volume from a bottle.

  • If the baby makes a lot of choking or slurping noises.

  • If the baby spills too much from a bottle.

  • If the baby takes longer than 30 minutes to finish a bottle.

Regurgitation

Do not score if the spit up happens while burping or otherwise stimulating the baby.

Score 2 if the baby spits up more than 2 times during the feeding.

Projectile vomiting

Score 3 if the baby’s vomit travels more than 3 feet.

Stools

Score 2 if the baby has poop with more liquid than a normal baby poop. 

Score 3 If the baby has poop with a water ring on diaper.