A simplified standard tool with an 8-item scales performs as well as the traditional one

A simplified Finnegan Neonatal Abstinence Scoring Tool (FNAST) may be sufficient to accurately assess whether newborns with neonatal abstinence syndrome should receive pharmacologic therapy, researchers found.

They determined that a modified 8-item FNAST scale performs just as well as the traditional 21-item model in discriminating between those neonates who do need pharmacologic therapy, and those who do not.

Such a tool could help standardize the clinical approach to assessing and treating neonates who have been exposed to opioids, suggested Lori A. Devlin, DO, Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky, and colleagues.

Their study was published in JAMA Network Open.

The onset of the opioid epidemic has also led to an increase in the incidence of opioid use disorder (OUD) during pregnancy. In 2014, the number of cases of OUD during pregnancy stood at 6.5 per 1,000 live births — more than a 4-fold increase over the number of cases in 1999 (1.5 per 1,000 live births). In turn, that increased exposure to opioids has led to a 5-fold increase in the incidence of neonatal abstinence syndrome (NAS) between 2004 and 2014, and that number continues to rise.

While a number of observer-rated scales are used to assess the severity of NAS and guide pharmacologic therapy for those newborns with syndrome, Devlin and colleagues pointed out that studies have shown there are differences in the way that raters assess NAS, leading to “significant differences in initiation and duration of pharmacologic therapy, length of hospital stay, and health care utilization.”

In this study, the authors wanted to see whether they could shorten and simplify the widely-used FNAST by identifying those items in the tool that are independently associated with the decision to initiate pharmacologic therapy.

The retrospective study involved medical record reviews of 424 neonates with opioid exposure. Of the 21 items in the FNAST tool Devlin and colleagues first excluded items that were either not seen frequently or extremely heterogeneous, such as convulsion, high-pitched crying, and hyperactive Moro reflex.

Their analysis ended up identifying 8 items independently associated with receipt of pharmacologic therapy:

  • Sleeps <3 hours after feeding: odds ratio [OR], 3.1; 95% CI, 1.9-5.0.
  • Tremors when disturbed: OR, 2.3; 95% CI, 1.3-3.9; tremors when undisturbed: OR, 3.5; 95% CI, 2.0-6.2.
  • Increased muscle tone: OR, 10.0; 95% CI, 3.9-26.0.
  • Body temperature 37.2 °C: OR, 2.1; 95% CI, 1.3-3.5.
  • Respiratory rate >60/min: OR, 2.6; 95% CI, 1.6-4.1.
  • Excessive sucking: OR, 2.4; 95% CI, 1.5-3.8.
  • Poor feeding: OR, 3.0; 95% CI, 1.7-5.3.
  • Regurgitation: OR, 3.2; 95% CI, 1.7-6.2.

The AUC for the 8-item model was 0.86 (95% CI, 0.82-0.89) compared with 0.90 (95% CI, 0.87-0.94) for the 21-item FNAST. The 8-item model also had an AUC of 0.86 (95% CI, 0.79-0.93) when validated against data from the Maternal Opioid Treatment: Human Experimental Research (MOTHER) study.

“This shorter assessment tool could simplify clinical assessment by focusing on components that are relatively consistent across sites. It is important to prospectively validate this scale, which could be widely used and lead to the standardization of the clinical approach and management of neonates prenatally exposed to opioids,” Devlin and colleagues concluded.

In a commentary accompanying the study, Ju Lee Oei, MD, the Royal Hospital for Women, Randwick, New South Wales, Australia, and Trecia Wouldes, PhD, Department of Psychological Medicine, University of Auckland, Auckland, New Zealand, pointed out that while the idea behind this simplified tool is “attractive,” a number of questions regarding the use of this scale — and others like it — need to be answered.

In particular, Oei and Wouldes suggested that there are knowledge gaps regarding long-term outcomes in newborns with NAS. For example, studies looking at prenatal drug exposure — as well as the assessment and treatment for NAS — and later neurodevelopmental outcomes are lacking.

They further noted that the drugs that cause NAS are neurotoxic, as are drugs used to treat withdrawal. However, without those treatments, severe withdrawal could lead to severe complications, and possibly death.

“Certainly, the work of Devlin et al highlights that much more needs to be known about how an infant responds postnatally to intrauterine drug exposure and the optimum screening, diagnostic, and treatment strategies,” wrote Oei and Wouldes. “Perhaps the ultimate goal should not be to decide whether to treat an infant with medication but to prevent poor outcomes, including neurologic harm and death.”

  1. A simplified Finnegan Neonatal Abstinence Scoring Tool (FNAST) is just as effective as the original tool in assessing whether newborns with neonatal abstinence syndrome should receive pharmacologic therapy.

  2. Such a simplified tool could help standardize the way in which infants who have been exposed to opioids in utero are assessed and treated.

Michael Bassett, Contributing Writer, BreakingMED™

Devlin reported serving on the advisory board of Chiesi Farmaceutici outside the submitted work.

Cat ID: 138

Topic ID: 85,138,730,191,41,138,192,144,925

References

Devlin L, et al “Association of a simplified Finnegan Neonatal Abstinence Scoring Tool with the need for pharmacologic treatment for neonatal abstinence syndrome” JAMA Network Open 2020; DOI:10.1001/jamanetworkopen.2020.2275.

Oei JL, Wouldes T “Will simplifying the Finnegan Neonatal Abstinence Scoring Tool improve outcomes for infants with opioid exposure?” JAMA Network Open 2020; DOI: 10.1001/jamanetworkopen.2020.2271.