1. Pediatric case discussion- A CRYING NEONATAL 2006/05/22 R1 王士豪

2. 5/18 02:05(0 min) 曾雨凡之女, 20952725 FEMALE, BIRTHDAY:950516 病人家屬主訴哭鬧不安 T/P/R/BP: 37.9/135/32/- E4V5M6 ? spO2: 96 BW:2.8KG 檢傷分類 : 三級

3. Chief complain irritable crying after birth at LMD 沒有轉診單

4. Pediatric assessment triangle Activity: irritable, Work of Breathing: normal Circulation: skin color: good and pink

5. PALS Pediatric Advanced Life Support study guide, 2nd eidtion What ’ s your initial consideration? Five unstable conditions in PAT Respiratory distress  less likely Respiratory failure  less likely CPR  less likely Cardiopulmonary arrest or failure  less likely Central nerve system abnormal Trauma  less likely Infectious? Metabolic? Neurologic? Toxicology?

6. Present Illness Birth at 中壢 新街 GYN on 950516 G2P2 BBW: 2800GM GA 40 WEEKS age: 2 d/o Irritable crying after birth

7. Physical examination Apperance: irritable crying HEENT: pupil: 2+/2+, no pin pupil throat: not injection Chest and Heart: RHB, COASE Abdomen: soft and flat Extremities: freely NE: can ’ t

8. Do you need more information?

9. Past history 病患母親說 : 懷孕期間有每天施打海洛英 denied HTN and other disease

10. Impression irritable crying r/o drug withdrawal syndrome

11. Initial order 5/18 02:20 am(15 min) CHEST P-A VIEW CBC/DC SUGAR, CRP NA, CL, K, CA, MG BLOOD CULTURE 1 set MORPHINE U IV D0.225S run 20ml/hour ADMITTED TO OBN

12. CXR

13. Lab: CBC/DC WBC 12.7 1000/uL 5.2~13.4(>1d-8d) RBC 3.46 million/uL L 3.99~4.98(>1d-8d) Hemoglobin 12.2 g/dL L 14.0~17.4(>1d-8d) Hematocrit 36.9 % L 41.0~51.4(>1d-8d) MCV 106.6 fL 97.4~106.7(>1d-8d) MCH 35.3 pg/Cell 33.3~36.1(>1d-8d) MCHC 33.1 g/dL 32.9~34.9(>1d-8d) RDW 16.4 % H 11.5-14.5 Platelets 523 1000/uL H 150-400 Nucleated RBC 4.0 /100 WBC H 0 Atypical-Lympho 1.0 % H 0 Segment 63.0 % 32.6~70.7(>1d-8d) Lymphocyte 29.0 % 16.8~48.1(>1d-8d) Monocyte 7.0 % 5.2~19.6(>1d-8d)

14. Lab: biochemistry Sugar 68 mg/dL L 70-105 Calcium 9.8 mg/dL 7.6-10.4 (0-10d) Na 142 meq/L 133-146 (<18Y) K 4.9 meq/L 3.7-5.9 (<1Month) Cl 112 meq/L 102-112 (1-18Y) CRP 2.28 mg/L < 5 Mg 1.9 meq/L 1.3-2.1

15. Sent to the OBN at 5/18 0246 am(41 min)

16. Admission note- birth data This 2d/o female newborn born to a G2P2 mother at GA 40 weeks with BBW 2800 gm via NSD Type of resuscitation: nil

17. Admission note- maternal history AP examinations at 榜生 hopsital. no abnormal finding of the fetal sonograpy. no GDM, PIH, fever, or other systemic disease The mother was a heroin drug abuser which was began 2 weeks before she was pregnant she received heroine injection once everyday by herself via IV injection during the pregnant period

18. Admission note- sign and symptoms After birth, the general condition was fair but irritalbe high pitch crying easily was noted. Besides, jitterness of hands and legs was also noted frequent.

19. Family history Her mother: heroin abuser

20. Physical Examination Respiration: normal Color: good and pink Cry: lusty Spontaneous movement: good

21. Physical Examination Skin: Lanugo(+) Milia(+) over nose; # HEENT: Anterior fontanel: soft and flat, 2 f.b.; Posterior fontanel: <1 f.b. Cephalohematoma(-); Caput succedaneum(-) Epstein's Pearl(-) # Neck: supple # Chest: Symmetrical expansion, no retraction Heart sounds: regular, heart beat: murmur(-) Breath sounds: clear # Abdomen: Soft and flat, normoactive bowel sound # Anus: patent # Genitalia: normal appearance # Extremities: freely movable # Neurological exam: normal

22. Examinatiob of the newborn, Up To Date vision 14.1 Examination of the newborn Maternal history General approach: PAT Measurement: birth data Vital signs Physical examination Neurologic examination

23. Impression and plan: Impression irritable crying r/o sepsis r/o drug withdrawal syndrome Plan septic work up empiric antibiotics: ampicillin+ GM check HIV, morphine and amphatamine close monitor s/s of drug withdrawal syndorme

24. Textbllk of Pediatric Emergency Medicine, Table 17.1 Conditions Associated with Abrupt Onset of Inconsolable Crying in Young Infants Discomfort Caused by Identifiable Illness Head and neck Gastrointestinal Cardiovascular Genitourinary Integumentary Musculoskeletal Toxic/metabolic Colic — Recurrent Paroxysmal Attacks of Crying

25. Textbook of Pediatric Emergency Medicine, Fig. 17.1

26. Diagnostic tests after the admission STREPTOCOCCUS GROUP B of Urine U/A and SEDIMENTS U/C HBSAG(EIA) BILIRUBIN D and T of blood ANTI-HIV (HTLV-III) AB(EIA) AMPHETAMINE of urine MORPHINE of urine

27. U/A Color YELLOW Yellow Turbidity CLEAR Clear SP.Gravity 1.010 1.005-1.030 pH 8.0 4.5 - 8.0 Leukocyte Negative Negative Nitrite Negative Negative Protein Negative mg/dL Negative Glucose Negative g/dL Negative Ketone Negative Negative Urobilinogen 0.1 EU/dL 0.1 - 1.0 EU/dL Bilirubin Negative Negative Blood Negative Negative RBC 0 /uL <20/uL WBC 0 /uL <30/uL Epith-Cell 20 /uL <30/uL

28. Other lab GrB. Strep Negative Bilirubin-D 0.5 mg/dL <0.5 (child) Bilirubin-T 5.9 mg/dL <12(1-2d) RPR Negative HBsAg Negative HIV 1+2 Ab Negative B/C and U/C pending

29. Drug screening tests Morphine/Op(U) Pos >600 ng/mL (<300, 法規標準 ) Amphetamine(U) Pos >1548 ng/mL (<500, 法規標準 )

30. Treatment order IV, Monitor Antibiotics: AMP+GM Incubator use Phenobarbital 25MG STAT IV and 5mg TID PO ZnO oint (FOR PERIANAL USE PRN) Consult 社福 CHECK neonatal abstinence scoring system Q8H

31. 5/18: 10-10-14 5/19: 8

32. Final diagnosis irritable crying r/o narcotics withdrawal syndrome

33. Textbook of Pediatric Emergency Medicine Neonatal Drug withdrawal Narcotics Avoid naloxone at delivery Heroin: onset within 1 day Methadone: onset within 24-48 hours irritability, jitteriness, tremors, seizures, disorganized suck and poor feeding, vomiting, diarrhea, sweating, and sneezing,

34. Textbook of Pediatric Emergency Medicine Neonatal Drug withdrawal Cocaine lethargic and poorly responsive, easily overstimulated and become irritable when alert, making feeding a challenge Amphetamines too quiet and may need to be awakened regularly for feedings. Prolonged sleep, depression, and voracious appetite when awakened

35. Textbook of Pediatric Emergency Medicine Evaluation the Neonatal Drug withdrawal The Neonatal Abstinence Score (NAS) Assessing severity scored Q4H for the first several days of life pharmacologic therapy scores>8 * 3 times Scores>12 * 2 times used to guide pharmacologic therapy NOT USE FOR DIAGNOSIS!!

36. Key point When face on a crying baby, maternal history, complete physical examination, neurologic examination, and lab. data are essential!!

37. Thank you for your attention!!