Newborn presents with jitters and tremors after
delivery:
ure A: Acetaminophen 325 mg/oxycodone hydrochloride
Figure B: Percocet
The interpretation of neonatal toxicology results can be challenging for physicians who must integrate multiple patient results (mother and newborn) and multiple specimen types (urine, meconium, umbilical cord, hair) while evaluating prenatal prescription medication lists, intrapartum medications, and mother’s self-reported history.
In this case, the clinical presentation of the infant, in combination with the mother’s later claim that she self-medicated with Percocet for up to 1 month prior to delivery, led the clinicians to treat the infant with morphine for presumed NAS secondary to opiate withdrawal. Confounding the diagnosis was the clinicians’ inability to detect opiates in both the mother’s and infant’s drug screens. Clinicians need to know the limitations of drug screening in their practice.
Firstly, the type of assay used is important, as immunoassay urine drug screen often is not able to detect synthetic and semisynthetic opiates well. Secondly, in this case, inconsistencies in the mother’s history made it hard / to know exactly what she was taking, and testing for “designer drugs” (eg, synthetic cathinones and cannabinoids) is challenging due to continual changes in synthetic compounds and increasing numbers of novel substances. These substances are being used with little known about their effects in pregnancy and on the neonate, and significant difficulty in detecting them with routine laboratory tests.
Third, urine drug specimens can be tampered with to produce a false-negative result, and although this infant’s specimens were collected in the nursery and therefore were not subjected to abuse, that may not be the case for collection of maternal samples. Lastly, detection of drug use depends on the pattern and frequency of drug(s) used by the mother. When she last used and duration of detectability all play a role. It was likely she had stopped using a few days prior to delivery as the infant was essentially exhibiting withdrawal symptoms almost immediately after birth, so it was not unexpected that the drug could already have been cleared from both the mother’s and infant’s systems.
Summary In this case, the infant was weaned off morphine based on his Finnegan scoring and discharged home to his mother after Child Protective Services’ evaluation was completed. The infant was scheduled for follow-up with his pediatrician, and a recommendation was provided for referral to early intervention services and possibly to a developmental pediatrician (based on the infant’s attainment of milestones) as an outpatient. Jitteriness is a common condition in the newborn that typically presents after the first few hours of life. In this case, jitteriness was noted immediately in the delivery room to an infant born to a mother whose risk factor was recent “prescription” opioid use. As his symptomatology worsened, the history became increasingly inconsistent, making it difficult to elucidate exactly what drug was used by the mother and whether it had been prescribed. Confounding the knowledge of what drug was implicated in clinical signs of NAS were the accompanying negative drug screens on both the mother and neonate. There are many variables that impact how, why, and when an infant will experience neonatal abstinence symptoms. These include the timing and frequency of the mother’s recent intake of a drug, maternal and placental metabolism, and the presence of poly-substance use including cigarettes, methadone, SSRIs, and benzodiazepines. For the infant, withdrawal symptoms will vary depending on gender, gestational age, and genetic factors that influence the infant’s metabolism and excretion of the drug. Additionally, drug testing is becoming increasingly complex with newer modalities in use that require the general pediatrician to be aware of both test- and laboratory-specific variations and limitations. With multiple synthetic and semisynthetic prescription opioids, as well as an expanding category of socalled “designer” recreational synthetic drugs that are flooding the market, there can be an overwhelming clinical presentation of NAS despite lack of laboratory evidence. In such cases the pediatrician should remain on high alert. A referral still needs to be made to social work and Child Protective Services especially if the results of the toxicology screens are unexpected or incongruent with the overall clinical picture. 15 / Acknowledgements: The author thanks Dr. Inez Reeves and Dr. Michal Young for their review and editing of the manuscript. « first ‹ previous 1 2 3 4 References: 1. Huntsman RJ, Lo
ure A: Acetaminophen 325 mg/oxycodone hydrochloride
Figure B: Percocet
The interpretation of neonatal toxicology results can be challenging for physicians who must integrate multiple patient results (mother and newborn) and multiple specimen types (urine, meconium, umbilical cord, hair) while evaluating prenatal prescription medication lists, intrapartum medications, and mother’s self-reported history.
In this case, the clinical presentation of the infant, in combination with the mother’s later claim that she self-medicated with Percocet for up to 1 month prior to delivery, led the clinicians to treat the infant with morphine for presumed NAS secondary to opiate withdrawal. Confounding the diagnosis was the clinicians’ inability to detect opiates in both the mother’s and infant’s drug screens. Clinicians need to know the limitations of drug screening in their practice.
Firstly, the type of assay used is important, as immunoassay urine drug screen often is not able to detect synthetic and semisynthetic opiates well. Secondly, in this case, inconsistencies in the mother’s history made it hard / to know exactly what she was taking, and testing for “designer drugs” (eg, synthetic cathinones and cannabinoids) is challenging due to continual changes in synthetic compounds and increasing numbers of novel substances. These substances are being used with little known about their effects in pregnancy and on the neonate, and significant difficulty in detecting them with routine laboratory tests.
Third, urine drug specimens can be tampered with to produce a false-negative result, and although this infant’s specimens were collected in the nursery and therefore were not subjected to abuse, that may not be the case for collection of maternal samples. Lastly, detection of drug use depends on the pattern and frequency of drug(s) used by the mother. When she last used and duration of detectability all play a role. It was likely she had stopped using a few days prior to delivery as the infant was essentially exhibiting withdrawal symptoms almost immediately after birth, so it was not unexpected that the drug could already have been cleared from both the mother’s and infant’s systems.
Summary In this case, the infant was weaned off morphine based on his Finnegan scoring and discharged home to his mother after Child Protective Services’ evaluation was completed. The infant was scheduled for follow-up with his pediatrician, and a recommendation was provided for referral to early intervention services and possibly to a developmental pediatrician (based on the infant’s attainment of milestones) as an outpatient. Jitteriness is a common condition in the newborn that typically presents after the first few hours of life. In this case, jitteriness was noted immediately in the delivery room to an infant born to a mother whose risk factor was recent “prescription” opioid use. As his symptomatology worsened, the history became increasingly inconsistent, making it difficult to elucidate exactly what drug was used by the mother and whether it had been prescribed. Confounding the knowledge of what drug was implicated in clinical signs of NAS were the accompanying negative drug screens on both the mother and neonate. There are many variables that impact how, why, and when an infant will experience neonatal abstinence symptoms. These include the timing and frequency of the mother’s recent intake of a drug, maternal and placental metabolism, and the presence of poly-substance use including cigarettes, methadone, SSRIs, and benzodiazepines. For the infant, withdrawal symptoms will vary depending on gender, gestational age, and genetic factors that influence the infant’s metabolism and excretion of the drug. Additionally, drug testing is becoming increasingly complex with newer modalities in use that require the general pediatrician to be aware of both test- and laboratory-specific variations and limitations. With multiple synthetic and semisynthetic prescription opioids, as well as an expanding category of socalled “designer” recreational synthetic drugs that are flooding the market, there can be an overwhelming clinical presentation of NAS despite lack of laboratory evidence. In such cases the pediatrician should remain on high alert. A referral still needs to be made to social work and Child Protective Services especially if the results of the toxicology screens are unexpected or incongruent with the overall clinical picture. 15 / Acknowledgements: The author thanks Dr. Inez Reeves and Dr. Michal Young for their review and editing of the manuscript. « first ‹ previous 1 2 3 4 References: 1. Huntsman RJ, Lo
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