A 2-day-old girl is evaluated in the newborn nursery due to tachypnea, sneezing, and diarrhea. The patient was born via spontaneous vaginal delivery and had been feeding well until several hours ago, when she became tachypneic. She has also been persistently crying and difficult to console. The patient's mother did not receive prenatal care during this pregnancy. Respirations are 65/min. All other vital signs are normal for age. On physical examination, the patient is irritable and has mildly increased tone in all extremities with occasional tremors of the arms and legs. Chest radiograph reveals normal lung fields. Serum glucose and complete blood count are within normal limits, and urine toxicology is pending. Nonpharmacologic interventions do not significantly improve the patient's symptoms. Which of the following pharmacotherapies would most likely improve this patient's symptoms?

Question

A 2-day-old girl is evaluated in the newborn nursery due to tachypnea, sneezing, and diarrhea.  The patient was born via spontaneous vaginal delivery and had been feeding well until several hours ago, when she became tachypneic.  She has also been persistently crying and difficult to console.  The patient's mother did not receive prenatal care during this pregnancy.  Respirations are 65/min.  All other vital signs are normal for age.  On physical examination, the patient is irritable and has mildly increased tone in all extremities with occasional tremors of the arms and legs.  Chest radiograph reveals normal lung fields.  Serum glucose and complete blood count are within normal limits, and urine toxicology is pending.  Nonpharmacologic interventions do not significantly improve the patient's symptoms.  Which of the following pharmacotherapies would most likely improve this patient's symptoms?

Quizplus · Accepted Answer

11ec160b_3c48_870d_9249_3d5d68b9e87e_MD0001_00 This newborn has signs of neonatal abstinence syndrome (NAS), or withdrawal from transplacental exposure to maternal substances (primarily opioids). NAS due to opioid withdrawal occurs in the setting of maternal prescription use/misuse, illicit drug use, or treatment for a substance use disorder (eg, methadone). Newborns exposed to opioids with shorter half-lives (eg, heroin) are symptomatic sooner (eg, age 1-2 days) than those exposed to drugs with longer half-lives (eg, methadone). Characteristic symptoms reflect a dysregulated CNS and autonomic dysfunction. Excessive irritability, often caused by hyperresponsiveness to external stimuli (eg, bright lights, loud noise), and short, interrupted sleep cycles are typical. Symptoms of autonomic dysfunction include sweating, sneezing, and yawning. In addition, diarrhea, vomiting, and poor feeding are common. Examination often reveals tachypnea, tremors, and hypertonia, as seen in this patient. The initial treatment for NAS is nonpharmacologic modifications, such as a low-stimuli environment (eg, quiet room) and swaddling to reduce tremors and irritability. Symptoms refractory to nonpharmacologic treatment, as in this case, warrant opioid replacement (eg, morphine, methadone). Once symptoms are controlled, the medication is weaned off over several weeks. (Choice A) Neonatal withdrawal to maternal benzodiazepine use (less common than opioid use) can present similarly to opioid withdrawal and may warrant pharmacotherapy (eg, phenobarbital). However, flumazenil, a GABA receptor antagonist used for benzodiazepine reversal, can worsen benzodiazepine withdrawal. (Choice C) Naloxone is an opioid receptor antagonist used for acute opioid overdose. Administering naloxone for opioid withdrawal can result in more severe withdrawal symptoms and is contraindicated. (Choice D) Sodium bicarbonate can be used to treat toxic ingestions of tricyclic antidepressants and salicylates. However, toxic maternal ingestion of these substances would present with neonatal symptoms at birth, not two days later. (Choice E) Vitamin K prevents and treats vitamin K deficiency bleeding, which can occur in newborns with mothers who take medications that block vitamin K (eg, anticonvulsants). Unlike this case, patients develop bleeding (eg, mucosal surfaces, gastrointestinal tract, CNS). Educational objective: Neonatal abstinence syndrome due to maternal opioid use causes neurologic, gastrointestinal, and autonomic symptoms; irritability, tremors, diarrhea, and sneezing are classic findings. Patients with symptoms refractory to nonpharmacologic therapy warrant opioid replacement (eg, morphine). __________ References: Neonatal opioid withdrawal syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/33106341)

A 2-Day-Old Girl Is Evaluated in the Newborn Nursery Due