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The Neonatal Withdrawal Assessment Tool (NWAT): pilot inter-rater reliability and content validity



There is no validated tool to assess iatrogenic opioid withdrawal in preterm infants in the newborn intensive care unit (NICU).

Study design

The Neonatal Withdrawal Assessment Tool (NWAT) was developed to address this gap in clinical practice. In this pilot study, the NWAT was assessed for inter-rater reliability (IRR) and content validity.


Fifty-one NICU providers scored two standardized simulated cases, then 20 paired provider assessments were completed on 5 preterm infants. The overall IRR was 95.6% on the simulated cases, and 98.8% on the 5 pilot infants. A provider survey assessed for content validity; all of the provider participants strongly agreed/agreed that the NWAT adequately measures withdrawal in critically ill infants.


The NWAT demonstrated high IRR and content validity for assessment of iatrogenic opioid withdrawal in preterm infants in this pilot study. Further studies in a larger more diverse patient population are needed before wider adoption into clinical practice.

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Fig. 1

Data availability

Given the data collected as part of this study were collected as part of an exempt quality improvement protocol, data is not available for sharing in a public repository. All relevant results from this study have been summarized in the study tables.


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We would like to thank the nursing and physician staff of the Boston Medical Center NICU for their assistance with the NWAT tool development and roll-out, particularly nurse manager Donna Stickney. No funding was provided for the conduct of this study.

Author information

Authors and Affiliations



GB, TS, and EW created the first draft of the manuscript; EW and CS created the NWAT tool and led the roll-outs and survey; TH and MR contributed to NWAT tool development; JA and MW conducted the analysis; GB, TS, CS, and EW collected data; all authors critically reviewed and approved the final version of the manuscript.

Corresponding author

Correspondence to Elisha M. Wachman.

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Competing interests

The authors declare no competing interests.

Ethics approval

This study was approved by the Institutional Review Board of the Boston University Medical Campus as an exempt protocol with waived informed consent.

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Bektas, G., Soderborg, T., Slater, C. et al. The Neonatal Withdrawal Assessment Tool (NWAT): pilot inter-rater reliability and content validity. J Perinatol (2023).

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