Morning Report: 4/23/2012

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!