A newborn boy is being evaluated in the nursery the day after delivery. The patient was born to a 26-year-old primigravid woman via spontaneous vaginal delivery at 39 weeks gestation. He was poorly arousable at delivery and required manual stimulation and brief oxygen supplementation. Apgar scores were 5, 6, and 8 at 1, 5, and 10 minutes, respectively. Birth weight and length were appropriate for gestational age. Temperature is 37.6 C (99.7 F) and oxygen saturation is 98% on room air. The patient arouses with an exaggerated startle reflex when examined. Cardiopulmonary examination is difficult due to his shrill cry throughout the evaluation but appears unremarkable. All limbs have a mild generalized hypertonicity, and there is rapid shaking of the upper extremities that resolves with passive movement of the limbs. Glucose level is 75 mg/dL. Leukocyte count is normal, and no bands are present. Which of the following is the best next step in management of this patient?

Question

A newborn boy is being evaluated in the nursery the day after delivery.  The patient was born to a 26-year-old primigravid woman via spontaneous vaginal delivery at 39 weeks gestation.  He was poorly arousable at delivery and required manual stimulation and brief oxygen supplementation.  Apgar scores were 5, 6, and 8 at 1, 5, and 10 minutes, respectively.  Birth weight and length were appropriate for gestational age.  Temperature is 37.6 C (99.7 F) and oxygen saturation is 98% on room air.  The patient arouses with an exaggerated startle reflex when examined.  Cardiopulmonary examination is difficult due to his shrill cry throughout the evaluation but appears unremarkable.  All limbs have a mild generalized hypertonicity, and there is rapid shaking of the upper extremities that resolves with passive movement of the limbs.  Glucose level is 75 mg/dL.  Leukocyte count is normal, and no bands are present.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d6fa_56a7_bc81_1166be705d37_MD0003_00 This patient has an exaggerated startle reflex, tremors, and hypertonia, findings concerning for neonatal abstinence syndrome (NAS). NAS is most commonly characterized by signs of withdrawal in a newborn exposed to maternal opioids (eg, heroin, oxycodone, methadone) in utero; this specific substance use disorder can be referred to as neonatal opioid withdrawal syndrome. Depending on the drug half-life and the duration and timing of exposure, NAS onset can occur within hours or days after birth. At birth, affected newborns may be poorly arousable due to the effects of the opioid. Manifestations of NAS develop as withdrawal begins; the presentation varies in severity but often includes irritability (eg, shrill cry, exaggerated startle reflex) and poor sleep (eg, short sleep cycles). Hypertonia, jitteriness, and tremors (shaking that resolves with passive movement) can also occur. Difficulty feeding is common, often leading to vomiting and poor weight gain. NAS is usually identified clinically in a newborn with known prenatal exposure; however, a neonatal urine or meconium drug screen can confirm the diagnosis in a patient with characteristic findings but no known maternal substance use. Treatment involves nonpharmacologic measures to decrease hypersensitivity (eg, gentle rocking, dim lights, swaddling). Opioid therapy (eg, morphine, methadone) is indicated for symptoms that persist despite supportive care. (Choice A) Phenobarbital is administered to control neonatal seizures. In contrast to this patient's tremors, seizures are shaking movements that cannot be suppressed. (Choice B) In addition to lethargy and irritability, neonatal sepsis typically also causes temperature instability, respiratory distress, and hypotonia (rather than hypertonia). This patient's normal temperature and leukocyte count make infection less likely and blood culture unnecessary. (Choice C) Certain inborn errors of metabolism (eg, maple syrup urine disease) are diagnosed based on abnormal plasma amino acid concentrations. Neonatal symptoms can include irritability, poor feeding, and vomiting. However, hypoglycemia and lethargy, rather than exaggerated startle, are typical. (Choice E) Supportive care alone may be sufficient treatment for mild NAS. However, this infant has more severe symptoms (eg, difficulty feeding, tremors) and needs opioid replacement to improve symptoms and prevent additional complications (eg, poor weight gain). Educational objective: Neonatal abstinence syndrome is caused by withdrawal from in utero exposure to substances, most commonly opioids. Presentation can include irritability, tremors, hypertonia, and difficulty feeding. Urine or meconium drug screening can confirm the diagnosis. References: Neonatal abstinence syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/25070299)

A Newborn Boy Is Being Evaluated in the Nursery the Day