Finnegan Scoring

If you or someone that you support is experiencing prolonged opioid use in their pregnancy you may be interested in learning about Finnegan Scoring and alternative models of care.

The Finnegan Neonatal Abstinence Scoring System is a tool that was developed by Dr. Loretta Finnegan in 1975 and was designed to guide screening, assessment and treatment of Neonatal Abstinence Syndrome (NAS). NAS is a group of withdrawal symptoms that can be experienced by opioid exposed newborns following birth as a result of the sudden discontinuation of prolonged opioid exposure in the womb. Not every hospital scores newborns, however, the ones that do will frequently use the Modified Finnegan Score which is done by assigning numerical scores to 21 of the most common signs and symptoms of NAS. Signs and symptoms of NAS can vary in onset appearing as soon as 24-96 hours following birth and can include high-pitched crying, jitteriness, tremors, generalized convulsions, sweating, fever, excessive sucking, poor feeding, vomiting, diarrhea and more.

Often newborn babies exposed to or suspected to be exposed to opioids will be scored by nurses using the Finnegan Score within the first 2 hours of life and in 3-4 hour intervals following the initial baseline score with increasing frequency for babies who score 8 or higher. In the event the baby scores 8 or higher 3 times consecutively, initiation of medication can occur at this time. The frequency of scoring then increases to every 2 hours until the baby scores 7 or less for a period of 24 hours. Then the 3-4 hour scoring frequency resumes until the baby has been off of morphine and scores have been less than 7 for 48-72 hours. If indicated, high Finnegan Scores management can include the introduction and potentially the slow weaning of pharmaceuticals such as morphine, clonidine, and phenobarbital.

Current scoring of NAS is dependent on nursing assessments and challenges in obtaining reliable assessments do exist. Further training of nurses has shown to improve quality of accuracy and consistency of scoring, yet long-term improvements post-training remain to be seen. If a score is suspected to be inaccurate, even due to normal infant behavior (such as sneezing) some options could be requested by the parents. These include requesting for the baby to be re-scored, be scored by a different nurse, be scored while the parent is in the room, scoring after a feeding and diaper change or perhaps even using a different evidence-based scoring system such as the Eat Sleep Console Scoring Tool.

Emerging evidence supports new non-pharmacological models of care such as rooming-in and Eat Sleep Console can actually reduce length of hospital stay and reduce morphine use. Rooming-in has also been associated with higher success with breastfeeding, lowered costs, and higher rates of discharge into familial custody. This is compared to traditionally receiving care in the NICU which raises the question why rooming in isn’t more widely offered to NAS patients.

There is still a lot of work to do in advancing the guidance and management of NAS. I am hopeful it happens sooner than later because prenatal opioid use and the incidence of NAS is on the rise. According to the CDC 7% of pregnant women self-reported using prescription opioid pain relievers in 2019 and 1 in 5 of those also reported misuse. Quadruple the number of women with Opioid Use Disorder (OUD) were in labor and delivery rooms from 1999-2014 and the incidence of NAS has increased by 383% between 2000-2012. Prenatal opioid use can be attributed to a wide range of circumstances. Examples are heroin addiction, poly-substance abuse, prescribed opioid medication including treatment for chronic pain, and Medication Assisted Treatments (MAT) such as Methadone or Buprenorphine which serve to support recovery and improve pregnancy outcomes.

No matter the circumstances, the goal of improving family-centered care should always remain. 

Written by Ann from Mulberry, FL. Ann is a survivor of opioid addiction, a harm reduction advocate and a student doula. If you would like to reach out to her for virtual doula support, support with a patient along this journey or have any questions check her out on IG @matbirth

References & Suggested Reading

[1] Raffaeli G, Cavallaro G, Allegaert K, Wildschut ED, Fumagalli M, Agosti M, Tibboel D, Mosca F. Neonatal Abstinence Syndrome: Update on Diagnostic and Therapeutic Strategies. Pharmacotherapy. 2017 Jul;37(7):814-823. doi: 10.1002/phar.1954. Epub 2017 Jul 2. PMID: 28519244.

[2] Kocherlakota P. Neonatal abstinence syndrome. Pediatrics. 2014 Aug;134(2):e547-61. doi: 10.1542/peds.2013-3524. PMID: 25070299.

[3] Center for Substance Abuse Treatment. Medication-assisted treatment for opioid addiction in opioid treatment programs. Treatment Improvement Protocol (TIP) Series 43. DHHS Publication No. (SMA) 05-4048. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005.

[4] Jones HE, Heil SH, Baewert A, et al. Buprenorphine treatment of opioid-dependent pregnant women: a comprehensive review.

[5] Neonatal Abstinence Syndrome: The Use of Clonidine as a Treatment Option Laura Broome, Tsz-Yin So NeoReviews Oct 2011, 12 (10) e575-e584; DOI: 10.1542/neo.12-10-e575

[6] Raffaeli G, Cavallaro G, Allegaert K, Wildschut ED, Fumagalli M, Agosti M, Tibboel D, Mosca F. Neonatal Abstinence Syndrome: Update on Diagnostic and Therapeutic Strategies. Pharmacotherapy. 2017 Jul;37(7):814-823. doi: 10.1002/phar.1954. Epub 2017 Jul 2. PMID: 28519244.

[7] Timpson, Wendy MD, MEd; Killoran, Cheryl MS, RNC-NIC; Maranda, Louise PhD; Picarillo, Alan MD; Bloch-Salisbury, Elisabeth PhD A Quality Improvement Initiative to Increase Scoring Consistency and Accuracy of the Finnegan Tool, Advances in Neonatal Care: February 2018 – Volume 18 – Issue 1 – p 70-78 doi: 10.1097/ANC.0000000000000441

[8] Blount T, Painter A, Freeman E, Grossman M, Sutton AG. Reduction in Length of Stay and Morphine Use for NAS With the “Eat, Sleep, Console” Method. Hosp Pediatr. 2019 Aug;9(8):615-623. doi: 10.1542/hpeds.2018-0238. Epub 2019 Jul 8. PMID: 31285356.

[9] McKnight S, Coo H, Davies G, Holmes B, Newman A, Newton L, Dow K. Rooming-in for Infants at Risk of Neonatal Abstinence Syndrome. Am J Perinatol. 2016 Apr;33(5):495-501. doi: 10.1055/s-0035-1566295. Epub 2015 Nov 20. PMID: 26588259.

[10] MacMillan KDL, Rendon CP, Verma K, Riblet N, Washer DB, Volpe Holmes A. Association of Rooming-in With Outcomes for Neonatal Abstinence Syndrome: A Systematic Review and Meta-analysis. JAMA Pediatr. 2018 Apr 1;172(4):345-351. doi: 10.1001/jamapediatrics.2017.5195. PMID: 29404599; PMCID: PMC5875350.

[11] Haight SC, Ko JY, Tong VT, Bohm MK, Callaghan WM. Opioid Use Disorder Documented at Delivery Hospitalization — United States, 1999–2014. MMWR Morb Mortal Wkly Rep 2018;67:845–849. DOI: icon.

[12] Ko JY, Patrick SW, Tong VT, Patel R, Lind JN, Barfield WD. Incidence of Neonatal Abstinence Syndrome — 28 States, 1999–2013. MMWR Morb Mortal Wkly Rep 2016;65:799–802.

[13] Ko JY, D’Angelo DV, Haight SC, et al. Vital Signs: Prescription Opioid Pain Reliever Use During Pregnancy — 34 U.S. Jurisdictions, 2019. MMWR Morb Mortal Wkly Rep 2020;69:897–903.

[14] Successful Implementation of the Eat Sleep Console Model of Care for Infants With NAS in a Community Hospital Douglas Dodds, Kayla Koch, Talia Buitrago-Mogollon, Sara Horstmann Hospital Pediatrics Aug 2019, 9 (8) 632-638; DOI: 10.1542/hpeds.2019-0086

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