1) What is meant by assessing the baby for tremors when they are undisturbed?
Assessing the baby for tremors, undisturbed, means that after a period of disturbing or handling the baby you stop touching the baby and observe for the presence of tremors. You need to observe the baby, without touching them, for 15-30 seconds, after being handled to see if tremors are present. Generally, babies who are not experiencing withdrawal will not continue to have tremors while being undisturbed after a period of touching. Babies experiencing tremors undisturbed is an indication that the CNS is highly irritable as a result of the withdrawal process. You will notice that this sign receives a higher score because it is a greater indication of the severity of withdrawal.

2) How do you score the sleeping item when a baby is breast feeding?
Typically, babies who are breast feeding do not sleep greater than 3 hours after a feeding. In this case you would score the longest sleep period the baby has and put a note in the comments section of the scoring tool to identify that the baby is breast feeding. Until the baby is getting an adequate amount of breast milk per feeding they will not sleep greater than 3 hours after a feeding. If the baby is not satisfied after a breast feeding it may be necessary to supplement the breast feeding with formula. This is something you can discuss with the mother.

3) When should the baby be scored? Before or After a Feeding?
Based on my experience it is best to score the baby before the feeding. This is the time when you are doing vital signs and administering medication for treatment. The goal is to have the baby sleep after the feeding. If you wake the baby an hour or so after the feeding to assess for signs and symptoms of withdrawal the baby may not go back to sleep.  This will interfere with the sleep item on the scoring sheet. There is concern that the baby may get a higher score because they are hungry if you score before the feeding. If the baby seems hungry feed the baby a little then continue with the exam. The important thing is to be consistent. Be sure that everyone scores the baby before the feeding.

4) Can the score be used for preterm infants?
My response to this question is if you can complete each item on the exam then you can use it for preterm infants. If you eliminate one or more of the items on the tool the score used to start, decrease or increase pharmacologic management will not be accurate. The tool was designed for full-term babies who only have a diagnosis of neonatal abstinence.  If a baby is NPO or has rapid respirations due to transient tachypnea or if the baby is being mechanically ventilated those items on the tool cannot be scored. Therefore, the score will not reflect the severity of withdrawal present in the baby. In this case it would not be appropriate to use a score of 8 or greater to start or increase pharmacologic management. Further research needs to be done to design a tool that would be appropriate to use for preterm babies as well as infants who continue to have signs and symptoms of withdrawal who are several months old. In this case the scoring is not accurate because the baby is probably sleeping less and is awake more in relation to feedings.

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