Simplified tool could improve treatment decisions for neonatal abstinence syndrome
Simplifying the Finnegan Neonatal Abstinence Scoring Tool, or FNAST, could improve its use in making treatment decisions for neonatal abstinence syndrome, or NAS, study findings showed.
Researchers determined that only eight of the FNAST’s 21 screening items are necessary to properly diagnose an infant with NAS.
“This shorter assessment tool could simplify clinical assessment by focusing on components that are relatively consistent across sites,” Lori A. Devlin, DO, associate professor of pediatrics at the University of Louisville School of Medicine, and colleagues wrote in JAMA Network Open. “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.”
For the study, Devlin and colleagues retrospectively reviewed medical records of neonates with antenatal opioid exposure using three cohorts from University of Louisville, the University of Kentucky and Tufts University. They validated their model using an external cohort of neonates enrolled in the Maternal Opioid Treatment: Human Experimental Research (MOTHER).
Neonates had opioid exposure at a gestational age of at least 36 weeks. Among 424 neonates included in the primary analysis, 238 were treated. The median time to treatment from birth was 3 days.
Devlin and colleagues combined two tremor items from the FNAST tool and removed three items — convulsions, high-pitched cry and hyperactive Moro reflex — from further analysis because they were either not observed or had “extremely different frequencies” in the cohorts. They found that eight of the remaining items were “independently associated with receipt of pharmacologic therapy.”
The eight items were: sleep less than 3 hours after feeding; tremors when disturbed or undisturbed; increased muscle tone; body temperature greater than or equal to 37.2°C; respiratory rate greater than 60 breaths per minute; excessive sucking; poor feeding; and regurgitation.
In a related commentary, Ju Lee Oei, MD, from the University of New South Wales in Australia, and Trecia Wouldes, PhD, from the University of Auckland in New Zealand, characterized the tool as attractively simple, but said several questions need to be addressed, including whether the association between the eight items and NAS remains consistent over time. They said adopting a simplified tool will only be effective if it is accepted by clinicians and parents or caretakers, “which is often not the case.”
“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,” they wrote. “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.” – by Ken Downey Jr.
Disclosures: The authors report no relevant financial disclosures.
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The care of infants with in utero opioid exposure has improved considerably over the past 10 years. Gains have been made primarily by standardization and optimization of nonpharmacologic means. For symptom assessment, this has focused largely on education and reducing interobserver variability at single institutions. Devlin and her colleagues have now focused on examining the value of individual elements within the Finnegan instrument. The overarching goal is removal of items not predictive of outcomes. In this way, we don’t spend time doing things that in the end don’t help practitioners make better clinical decisions. Toward this end, in addition to reducing from 21 to eight elements, they also simplified the proposed scoring to a simple “present” or “absent.”
Strengths of the paper include a high-quality statistical approach. There were a variety of different clinical sites, which helps control for both differences in the patient populations, but also institutional approaches to scoring. External validity is suggested with the high degree of overlap with other published attempts at shortening the Finnegan score. Indeed, our group recently published a shortened nine-item score with overlap of six of their eight elements: sleep, tremor, fever, excessive sucking, feeding and regurgitation. (Editor’s note: See reference below.) Similarly, none of the three other recently proposed shortened scales (Maguire, Gomez-Pomar, Chervoneva) include Moro reflex, sneezing, excoriation, seizure, yawning, mettling, nasal flaring or myoclonic jerks. This suggests these are universally low yield items, and recording these every 4 hours does not add to the quality of NAS care.
Even for centers that do not decide to change from current use of the Finnegan, the trial has some valuable information. High-pitched cry and Moro reflex appear to have large differences between sites, and although not measured in this study, likely between individuals. Site educators still using the Finnegan could focus attention on standardizing the assessment of these two signs in particular through use of videos.
For sites looking at changing from their current use of the Finnegan score to either one of the newer shortened versions or the Eat, Sleep, Console, should consider a few factors. Regardless of the system chosen, attention must be toward systematic teaching and the ongoing process of quality improvement through assessment. The Eat, Sleep, Console approach was not devised using a quantitative approach to assess specific elements or to examine the performance characteristics of the Finnegan. It instead sprang from first principles that these three symptoms are the key factors associated with driving treatment decisions. This implicit assumption is that heterogeneity in expression of other NAS symptoms between infants is not clinically helpful enough to systematically measure. Sites looking to change should also be clear about what the goal is and separate it from other universal tenets of maximizing efficacy of nonpharmacological treatments.
Reference:
Chervoneva I, et al. J Perinatol. 2020;doi:10.1038/s41372-020-0606-4.
Disclosure: Kraft reports no relevant financial disclosures.
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Devlin LA, et al. JAMA Netw Open. 2020; doi:10.1001/jamanetworkopen.2020.2275.
Oei JL, Wouldes T. JAMA Netw Open. 2020;doi:10.1001/jamanetworkopen.2020.2271.
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