Finnegan NAS

Overview

Neonatal opioid withdrawal syndrome (NOWS) — formerly neonatal abstinence syndrome (NAS) — occurs in infants born to mothers who used opioids during pregnancy. The Finnegan score quantifies withdrawal severity across three domains: central nervous system (CNS), metabolic/vasomotor/respiratory (MVR), and gastrointestinal (GI). Scores are typically performed every 3–4 hours or after each feeding in the first days of life.

CNS Domain

Sign	Points
Cry: no excessive crying	0
Cry: excessive high-pitched crying (< 5 min)	2
Cry: excessive high-pitched crying (≥ 5 min)	3
Sleep after feeding: > 3 h	0
Sleep after feeding: 2–3 h	1
Sleep after feeding: 1–2 h	2
Sleep after feeding: < 1 h	3
Moro reflex: normal	0
Moro reflex: hyperactive	2
Moro reflex: markedly hyperactive	3
Tremors when disturbed: mild	1
Tremors when disturbed: moderate–severe	2
Tremors when undisturbed: mild	3
Tremors when undisturbed: moderate–severe	4
Increased muscle tone	2
Excoriation (e.g. chin, knees)	1
Myoclonic jerks	3
Generalised convulsions	5

Metabolic / Vasomotor / Respiratory (MVR) Domain

Sign	Points
Sweating	1
Fever 37.2–38.3 °C	1
Fever > 38.4 °C	2
Frequent yawning (> 3 times per assessment)	1
Mottling	1
Nasal stuffiness	1
Sneezing (> 3 times per assessment)	1
Nasal flaring	2
Respiratory rate 60–80 /min	1
Respiratory rate > 80 /min or retractions	2

Gastrointestinal (GI) Domain

Sign	Points
Excessive sucking	1
Poor feeding	2
Regurgitation	2
Projectile vomiting	3
Loose stools	2
Watery stools	3

Score Interpretation

Score	Severity	Recommended Action
0–7	Mild / absent withdrawal	Supportive care; reassess at next feed
8–11	Moderate	Non-pharmacological measures; increase assessment frequency
≥ 12 (two consecutive scores)	Severe	Consider pharmacotherapy (morphine or methadone); consult neonatologist

Clinical Notes

• Assess every 3–4 hours after each feeding for at least the first 5 days of life in at-risk neonates.
• Pharmacotherapy threshold is typically two consecutive scores ≥ 8 or three scores ≥ 8, depending on local protocol.
• Breastfeeding (unless contraindicated) and rooming-in are recommended as first-line non-pharmacological measures.
• The Eat Sleep Console (ESC) approach is an emerging functional outcome-based alternative that may reduce pharmacotherapy rates.

Literature

Finnegan LP, Connaughton JF Jr, Kron RE, Emich JP. Neonatal abstinence syndrome: assessment and management. Addict Dis. 1975;2(1-2):141–158.