While making rounds in the newborn nursery, a physician is asked to examine a 2-day-old infant who is not feeding well. A nurse reports that the infant is irritable, is not sleeping well, and has had several episodes of vomiting and loose stools that day. A review of the maternal history reveals that the mother had poor prenatal care and the pregnancy was complicated by intrauterine growth restriction. On examination, the infant is diaphoretic and has a high-pitched cry. The infant is also noted to have occasional sneezing and is mildly tachypneic. No dysmorphic features are noted and the remainder of the examination is unremarkable. This infant's symptoms are most likely caused by prenatal exposure to which of the following?

Question

While making rounds in the newborn nursery, a physician is asked to examine a 2-day-old infant who is not feeding well.  A nurse reports that the infant is irritable, is not sleeping well, and has had several episodes of vomiting and loose stools that day.  A review of the maternal history reveals that the mother had poor prenatal care and the pregnancy was complicated by intrauterine growth restriction.  On examination, the infant is diaphoretic and has a high-pitched cry.  The infant is also noted to have occasional sneezing and is mildly tachypneic.  No dysmorphic features are noted and the remainder of the examination is unremarkable.  This infant's symptoms are most likely caused by prenatal exposure to which of the following?

Quizplus · Accepted Answer

Neonates may be exposed to prenatal opiates via maternal use of prescription opiates, methadone, or heroin. Methadone is frequently prescribed for pregnant women with heroin use disorder to prevent uncontrolled withdrawal in the mother and fetus. Heroin and methadone are not associated with dysmorphic features or congenital anomalies in the fetus, but prenatal exposure can lead to an increased risk of intrauterine growth restriction, sudden infant death syndrome, and neonatal abstinence syndrome (NAS). NAS usually presents in the first few days of life and is characterized by irritability, a high-pitched cry, sleeping and feeding difficulties, tremors, seizures, autonomic dysfunction (eg, sweating, sneezing), tachypnea, vomiting, and diarrhea. Withdrawal usually presents within 48 hours after birth for heroin withdrawal and at 48-72 hours for methadone withdrawal, although it can be delayed up to 4 weeks. Treatment for NAS includes symptomatic care to calm the infant and help the infant sleep, such as swaddling; providing small, frequent feeds; and keeping the infant in a low-stimulation environment. Pharmacologic treatment (eg, morphine, methadone, buprenorphine) should be used when supportive treatment alone does not control the infant's withdrawal symptoms. (Choice A) Fetal alcohol syndrome consists of growth deficiency; presence of a long, smooth philtrum; small palpebral fissures; and a thin upper lip in addition to central nervous system abnormalities such as intellectual disability. Withdrawal symptoms are usually not seen unless the mother was drinking just prior to delivery. (Choice B) Prenatal exposure to cocaine can result in jitteriness, excessive sucking, and a hyperactive Moro reflex (due to the toxic effects of cocaine); by contrast, withdrawal symptoms from cocaine are usually not as severe as with opiates. Long-term effects on behavior, attention level, and intelligence may be seen. (Choice D) Prenatal exposure to phenytoin can result in fetal hydantoin syndrome, which is characterized by nail and digit hypoplasia, dysmorphic facies, and intellectual disability. Growth deficiency can also be seen. fetal hydantoin syndrome (Choice E) Fetal exposure to valproic acid significantly increases the risk of neural tube defects; may result in cardiac anomalies; and can produce dysmorphic facies, including a cleft lip, narrow bifrontal diameter, midface hypoplasia, broad and depressed nasal bridge, and long philtrum. Educational objective: Neonatal abstinence syndrome is caused by infant withdrawal to opiates and usually presents in the first few days of life. It is characterized by irritability, a high-pitched cry, poor sleeping, tremors, seizures, sweating, sneezing, tachypnea, poor feeding, vomiting, and diarrhea. References: Neonatal abstinence syndrome: Historical perspective, current focus, future directions (http://www.ncbi.nlm.nih.gov/pubmed/26232620) Treating women who are pregnant and parenting for opioid use disorder and the concurrent care of their infants and children: Literature review to support national guidance. (http://www.ncbi.nlm.nih.gov/pubmed/28406856)

While Making Rounds in the Newborn Nursery, a Physician Is