Clinical bedside scoring tool for neonatal drug withdrawal severity based on observed signs during a defined assessment interval.
INSTRUCTIONS
Use this tool to score the highest severity observed in each category during the assessment interval. The bedside version scores every 3 hours for the first 72 hours in infants exposed to narcotics or opiates, or for the first 96 hours in infants exposed to methadone or buprenorphine-containing therapy.
Tremors (muscle activity of limbs)*
Normalscore_0
Minimally increased when hungry or disturbedscore_1
Moderate or marked increase when undisturbed; settles when fed or cuddledscore_2
Marked increase or continuous when undisturbed, including seizure-like movementsscore_3
Irritability (excessive crying)*
Nonescore_0
Slightly increasedscore_1
Moderate to severe irritability when disturbed or hungryscore_2
Marked irritability even when undisturbedscore_3
Reflexes*
Normalscore_0
Increasedscore_1
Markedly increasedscore_2
Stools*
Normalscore_0
Explosive, but frequency 8/day or lessscore_1
Explosive, more than 8 per dayscore_2
Muscle tone*
Normalscore_0
Increasedscore_1
Rigidityscore_2
Skin abrasions*
Noscore_0
Redness of elbows, heels, or pressure points when supinescore_1
