Hyperthyroidism Feeding problems • Oromotor dysfunction • Anomalies (e.g. cleft palate, micrognathia, Pierre Robin sequence, genetic syndromes such as Prader Willi) • Polycythaemia • Immaturity, including late preterm birth • Jaundice • Brain injury • Sepsis Jitteriness • Hypoglycaemia • Hypocalcaemia • Immaturity • Injury of the nervous system Myoclonic jerking • Not uncommon in opioid-exposed infants and can be mistaken for seizure activity Seizures (rare with NAS) • Hypocalcaemia • Hypoglycaemia • Hypoxic-ischemic encephalopathy • Brain haemorrhage/stroke • Meningitis • Inborn errors of metabolism • Seizure disorders Queensland Clinical Guideline: Perinatal substance use: neonatal Refer to online version, destroy printed copies after use Page 11 of 33 3.4 Assessment tools A variety of assessment tools and methods have been reviewed for usefulness in clinical practice, but high quality evidence remains limited.18 Consistent use of a preferred assessment tool at the facility level promotes familiarity, and consistency of decision making and supports quality data collection and outcome reporting. Tools for assessment of NAS aim to provide objective data about: • Requirements for additional monitoring and care • When to commence pharmacological treatment • Whether a medication dose requires alteration • Resolution of signs 3.4.1 Finnegan neonatal abstinence severity score Table 8. Finnegan neonatal abstinence severity score Aspect Consideration Context • Most widely used38,39 and the Australian standard for assessment of opioid withdrawal in term babies • Has been used (but not validated) to assess signs of non-opioid related NAS8 o Benzodiazepines and alcohol o Neonatal stimulant intoxication o SSRI and SNRI40 Benefits and limitations • Common in clinical practice in Australia • Requires initial and repetitive training to obtain inter-rater reliability • Assessment of some criteria (e.g. Moro reflex) requires baby to be disturbed which may inflate FNAS • Focuses on achieving a FNAS of less than eight • Not validated for preterm babies • May prompt earlier or later initiation and greater intensity of pharmacological treatments Elements • Assesses and allocates a FNAS to 21 signs of withdrawal across three main elements (systems) o Central nervous system o Gastrointestinal o Vasomotor and respiratory Assessment protocol41 • Assess elements half to one hour after each feed o FNAS reflects behaviour since the previous assessment averaged over three to four hours • Make allowances for babies who are preterm or beyond the initial newborn period Review indicated • Consider pharmacological treatment and transfer to neonatal unit when o Two consecutive FNAS 12 or more or o Three consecutive FNAS 8 or more • Refer to: o Appendix A: Finnegan Neonatal Abstinence Severity Score o Appendix B: Finnegan Neonatal Abstinence Severity Score Description Queensland Clinical Guideline: Perinatal substance use: neonatal Refer to online version, destroy printed copies after use Page 12 of 33 3.4.2 Eat, sleep, console Table 9. Eat, sleep, console Aspect Consideration Context • Eat, sleep, console (ESC) first described in 2017 as a quality improvement activity42 • Aims to support the baby exposed to substances to achieve developmentally normal eating, sleeping, consoling and weight gain milestones42 Benefits and limitations • Emphasises partnering with parent/carer and use of non-pharmacologic interventions43 • Promotes parent/carer togetherness with parent/carer as the primary provider of responsive baby care43 • Prompts the consideration of reasons other than NAS that may affect how baby is eating, sleeping, consoling and/or gaining weight • Reported to reduce (for babies experiencing NAS)43,44 o Length of stay o Use of pharmacological treatment • Use not reported for non-opioid exposed babies • Not validated for preterm babies Elements • Response to the following questions (as ‘yes’ or ‘no’) o Does the baby have poor eating? o Did the baby sleep less than 1 hour after feeding? o Is the baby unable to be consoled within 10 minutes using nonpharmacological interventions? Assessment protocol • Assess elements after feeds every 3–4 hours • With parent/carer, review ESC elements • Assessment reflects behaviour since previous assessment • Actively consider other non-NAS related factors that may influence assessment Review indicated • If any question is answered ‘YES’ (and is attributed to NAS) o Team huddle: review and optimise supportive care with parent/carer • If despite optimisation of supportive care, any question continues to be answered ‘YES’ (and is attributed to NAS) o Full healthcare team (multidisciplinary as required) review o Consider morphine initiation and transfer to neonatal unit • Refer to: o Appendix C: Eat, Sleep Console assessment o Appendix D: Eat, Sleep Console descriptions Queensland Clinical Guideline: Perinatal substance use: neonatal Refer to online version, destroy printed copies after use Page 13 of 33 3.5 Specific substances and NAS Table 10. Specific substances and NAS In-utero exposure to: Onset/duration of signs Considerations/specific signs Opioid Heroin • Within 24 hours1,28; up to 5–7 days29 • Duration 8–10 days14 • 50–80% opioid exposed babies require pharmacologic treatment4,8,29 • Onset of clinical signs reflect half-life of the opioid involved1 • Opioid