The opioid-exposed newborn with evolving withdrawal — methadone maintenance

OSCE on a 36-week infant of a mother on a methadone maintenance programme who at 48 hours develops a high-pitched cry, tremor on handling and poor feeding, testing the neuroadaptive mechanism, the Eat Sleep Console functional assessment, the Finnegan threshold, the non-pharmacologic first-line bundle, and the morphine-versus-buprenorphine pharmacologic ladder.

osce neonatal abstinence syndrome scenario3 min readVerification in progress

Prompt

A 36-week infant whose mother is on a supervised methadone maintenance programme (90 mg/day) is admitted to the postnatal ward for rooming-in. At 48 hours of life the infant has a high-pitched cry, a fine tremor when handled, sweating, a stuffy nose and poor feeding; the bedside glucose is 2.2 mmol/L. The candidate must explain the neuroadaptive mechanism, apply the Eat Sleep Console functional assessment, exclude the mimics, deliver the non-pharmacologic first-line bundle, and defend the pharmacologic ladder from morphine to buprenorphine with a structured wean.

Clinical information for the examiner

Setting: Tertiary postnatal ward, 48 hours after an uneventful vaginal delivery at 36 weeks. The mother is on a supervised methadone maintenance programme at 90 mg/day and is stable; she has been rooming-in and breastfeeding since birth. She is HIV-negative and does not smoke. [9]

On your arrival:

Axillary temperature 37.0 C; heart rate 158; respiratory rate 64. [3]
High-pitched cry, fine tremor when handled, mildly increased tone, sweating over the brow, nasal stuffiness. [1]
The infant last fed 90 minutes ago and took only a fraction of the expected volume; the mother reports fractured sleep. [7]
Bedside glucose 2.2 mmol/L. [3]

Paediatrics Fellowship Pro

You have read the opening of this case. The complete unit — every section and its primary-source references — is part of the Paediatrics Fellowship fellowship atlas.

References5Show ledger

[1]Finnegan LP Neonatal abstinence syndrome: assessment and management. Addict Dis, 1975.PMID 1163358
[3]Hudak ML Neonatal drug withdrawal. Pediatrics, 2012.PMID 22291123
[6]Kraft WK Buprenorphine for the Neonatal Abstinence Syndrome. N Engl J Med, 2017.PMID 28877016
[7]Grossman MR Neonatal Abstinence Syndrome: Time for a Reappraisal. Hosp Pediatr, 2017.PMID 28137921
[9]Welle-Strand GK Breastfeeding reduces the need for withdrawal treatment in opioid-exposed infants. Acta Paediatr, 2013.PMID 23909865

The opioid-exposed newborn with evolving withdrawal — methadone maintenance

osce neonatal abstinence syndrome scenario3 min readVerification in progress

Clinical information for the examiner

On your arrival:

Axillary temperature 37.0 C; heart rate 158; respiratory rate 64. [3]

High-pitched cry, fine tremor when handled, mildly increased tone, sweating over the brow, nasal stuffiness. [1]

The infant last fed 90 minutes ago and took only a fraction of the expected volume; the mother reports fractured sleep. [7]

Bedside glucose 2.2 mmol/L. [3]

Paediatrics Fellowship Pro

You have read the opening of this case. The complete unit — every section and its primary-source references — is part of the Paediatrics Fellowship fellowship atlas.

References5Show ledger

[1]Finnegan LP Neonatal abstinence syndrome: assessment and management. Addict Dis, 1975.PMID 1163358
[3]Hudak ML Neonatal drug withdrawal. Pediatrics, 2012.PMID 22291123
[6]Kraft WK Buprenorphine for the Neonatal Abstinence Syndrome. N Engl J Med, 2017.PMID 28877016
[7]Grossman MR Neonatal Abstinence Syndrome: Time for a Reappraisal. Hosp Pediatr, 2017.PMID 28137921
[9]Welle-Strand GK Breastfeeding reduces the need for withdrawal treatment in opioid-exposed infants. Acta Paediatr, 2013.PMID 23909865