Thanks to Dr. Lau for today’s Morning Report (presented on 4/13/2012)!
Here’s the case:
26 day old female brought in by mother for increased crying and fussiness
Vitals normal: T 98.9, RR 44, HR 130, BP normal
PMH:
NICU stay until 6 days ago – ex-35 weeker on methadone taper (Mother was using heroin in first part of pregnancy, then was on Methadone for 6 months)
Meds:
Methadone 0.15 mg BID, taper down to 0.10 mg BID starting today
Exam:
Consolable
Skin pink and dry
Conjunctivae normal
Lung and heart sounds normal
No rash, no hair tourniquets
…normal except
Abnormal physical exam findings:
*Hyperactive Moro reflex
*Tremors when disturbed
*Myoclonic jerks
*?Mild increase in muscle tone
Baby was observed for few hours to be feeding well and consolable – only cries when on exam table (mom states baby was crying much more at home but was consolable)
Also noted to be *sucking on fingers while not feeding
So what’s the diagnosis?
Answer:
Neonatal Abstinence Syndrome
Continue reading for management:
Management:
– Must rule out all causes of crying baby first e.g. sepsis, trauma, hair tourniquet… so observation period of few hours is important
– In many cases, babies will need higher doses or maintain doses as they gain weight
– Use NAS scoring system to gauge baby’s withdrawal symptoms
- 21 symptoms
- >8 means pt needs pharmacotherapy
- * above are all +ves on scoring system
– You can call NICU for help but in my case – “we don’t do consults in the ER but you can just increase the dose 10%-15%”
– Per Neofax dose of methadone is 0.05 -0.2 mg/kg/dose
- We increased dose 12% to 0.18 mg BID
– Lots of social issues
- Consult social work to reassess home situation
- Is anyone else using baby’s methadone – appropriate amount in bottle?
- Is baby well cared for? – in this case mother was still on methadone and the discharge notes from NICU emphasized that father was taking child home. We called father and had him come in to make sure he also understands new dosing
- Withdrawing babies are very fussy, can parents handle the baby at home?
That’s the case, leave any comments below. Thanks for reading!
Jay Khadpe MD
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