PEM Education of the Week
Dr. Yvonne Giunta, MD
CC: Crying
HPI: 5 day old female, ex 39 week neonate presents to ED for evaluation of excessive crying. Mom is 29 years old with one other child who is 2 years old. Baby was born via NSVD and initially admitted to NICU for observation of grunting and flaring as per mom. Baby was doing well and discharged on day 2 of life. Mom states that since she has been home she is crying and cry seems to be excessive. She is otherwise well, afebrile. She is constantly sucking as per mom but does not seem to be feeding well. She is formula fed and mom states it seems to take her forever to finish a 2 oz bottle. She is not sleeping well. BM several times a day, described as diarrhea. Mom seems frustrated.
Vitals: Temp 98 R HR 190 BP not done RR 40 Sat 100 % RA
PE:
Appearance: Infant noted to be crying throughout exam and not consolable, even by mom. Cry is high pitched. MMM, CR< 2 sec
Skin: no jaundice, + mottled skin
HEENT: APFOF, PERRL, EOMI, no scleral icterus, + nasal congestion
Cardio: normal heart sounds, no murmur appreciated, normal UE/LE pulses palpable
Chest: CTA, no WRC
Abdomen: soft, NT, ND, no guarding
Neuro: hyperactive newborn reflexes
Workup includes evaluation for the irritable/crying newborn (some differential below, not completely inclusive):
sunken/bulging fontanelles - exam nl fontanelles
Sepsis - labs
Hair tourniquet - exam nl
foreign body - exam/history not suggestive
Pharyngitis - exam nl
Otitis - exam nl
SVT - ekg sinus tachy
corneal abrasion - fluorescein staining negative
Fracture - exam/skeletal survey nl
Malrotation - imaging nl
child abuse - skeletal survey nl
Patient was ultimately admitted for observation secondary to persistent crying with normal workup in ED. What is the missing link?
Recap: Ex 39 week female, born NSVD, admitted to NICU for observation of grunting and flaring. Since then with persistent crying, poor sleeping, constant sucking, poor feeding. Physical exam impressive for mottled skin, persistent crying, nasal congestion, hyperactive reflexes.
Diagnosis:
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After further questioning, mom admitted to taking 10 mg Oxycontin tablets BID for back pain throughout her pregnancy.
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Neonatal Abstinence Syndrome
NAS occurs in a newborn who was exposed to opiate drugs while in the womb. If the mother continues to use the drugs within the week or so before delivery, the baby will be dependent on the drug at birth. Because the baby is no longer getting the drug after birth, withdrawal symptoms may occur as the drug is slowly cleared from the baby's system.
Symptoms often begin within 1 to 3 days after birth, but may take up to a week to appear. Because of this, the baby will most often need to stay in the hospital for observation and monitoring for up to a week, assuming mother discloses drug use prior to delivery.
Symptoms include:
Diarrhea
Mottling
Excessive crying
Excessive sucking
Fever
Hyperactive reflexes
Increased muscle tone
Irritability
Poor feeding
Rapid breathing
Seizures
Sleep problems
Slow weight gain
Stuffy nose, sneezing
Sweating
Trembling (tremors)
Vomiting
Plan/Treatment:
Finnegan scoring system to score the level of NAS
Admission, observation, Urine/Blood drug screen
Tincture of Opium vs Phenobarbital. (Diluted tincture of opium is recommended by the American Academy of Pediatrics for the treatment of neonatal abstinence syndrome due to opioid withdrawal.)
Major learning point:
Remember to ask the mother's drug history in the inconsolable infant.
FOR MORE LEARNING:
The Fussy Infant
Pediatric Emergency Playbook
Listen on Apple Podcasts:
https://podcasts.apple.com/us/podcast/pediatric-emergency-playbook/id1035668219?i=1000404362909
https://dontforgetthebubbles.com/the-crying-game/