Case Study: Newborn with Vomiting and Diarrhea

A three-day old male infant is brought to the ER by his 22-yr-old mother with vomiting and diarrhea. Diagnostic results will be released upon request, with the final reveal in one week. Specialties Critical Case Study

Updated:  

Chief Complaint

A three-day old male infant is brought to the ER with vomiting and diarrhea by his 22-yr-old white mother. The mother states, "It started yesterday. He sleeps all the time, but when he's awake he just won't stop crying and I can't get him to stop throwing up after he eats.” This is the mother's first pregnancy. The infant was full term and there were no complications during the lady partsl birth. A full assessment is performed, and the infant is admitted to the hospital.

Assessment Findings

  • Depressed fontanels
  • High-pitched cry lasting more than 5 minutes.
  • Moro reflex is hyperactive.
  • Mild tremors when disturbed.
  • Increased muscle tone, no excoriation of chin, knees, elbows, toes or nose, myoclonic jerks present. Yawns frequently. No nasal stuffiness, nasal flaring or sneezing apparent.
  • Skin is dry with no mottling. 

Vital Signs

  • BP 89/60 RA, lying
  • HR 110 bpm
  • RR 70/min with no retractions
  • T 101o F
  • O2 sat 98%
  • Weight at birth 5 lbs 6 ounces
  • Current weight: 5 lbs 4 ounces

What's going on here?

What other information do you need?

What labs do you want?

What other diagnostic tests should we run?

Specializes in Oncology, Home Health, Patient Safety.

And the answer is...Neonatal Abstinence Syndrome.
Neonatal abstinence syndrome (NAS) can occur in response to newborn withdrawal from drugs taken by the mother during pregnancy. It is a group of conditions most often related to opioid abuse. Most babies who get treatment improve in a few days or weeks; however, NAS may lead to long-term health and developmental problems, including hearing and vision loss and problems with learning and behavior.

Signs of NAS can be different for each infant. Most symptoms occur within 3 days (72 hrs) of birth, but some may not happen right away. Signs include tremors, convulsions, twitching, fussiness, poor feeding, breathing problems, fever, trouble sleeping, lots of yawning, diarrhea or vomiting, stuffy nose or sneezing. The signs depend on the drug used during pregnancy.

Finnegan Score

This infant has a Finnegan NAS score of 26

The Finnegan scale assesses 21 of the most common signs of neonatal drug withdrawal syndrome and is scored on the basis of pathological significance and severity of the adverse symptoms.

Infants scoring an 8 or greater are recommended to receive pharmacologic therapy. Link to online calculator: https://www.mdcalc.com/modified-finnegan-neonatal-abstinence-score-nas

There is currently no national monitoring system to collect data about NAS in the US. There are laws in six states that require public health monitoring of NAS (Arizona, Florida, Georgia, Kentucky, Tennessee and Virginia). This type of monitoring could provide information about opportunities for treatment and prevention.

Follow up:

After admission, the infant was started on methadone for  pharmacologic treatment of withdrawal symptoms. NAS score was 20 at 24 hours and 12 at 48 hours. Infant was successfully weaned from methadone after 21 days and discharged with a NAS score of 3 at 24 days.

The mother refused treatment and left the hospital after 3 days of rooming-in. Volunteers found that swaddling was the most effective method of comforting the child. When the child was discharged in the care of foster parents, he weighed 6 lbs. 

References

Ball, J. W., Bindler, R. C., Cowen, K., & Shaw, M. R. (2017). Principles of pediatric nursing: Caring for children (7th ED.) Pearson.

Finnegan, L. P. Modified Finnegan Neonatal Abstinence Score (NAS). MD+Calc. https://www.mdcalc.com/modified-finnegan-neonatal-abstinence-score-nas

MacMullen, N. J., Dulski, L. A. & Blobaum, P. (2014). Evidence-based interventions for neonatal abstinence syndrome. Continuing nursing education. Pediatric Nursing, 40(4). p. 164-173.

Wachman, E. M. & Werler, M. M. (2019). Neonatal abstinence syndrome: Which medication is best? Journal of the American Medical Association Pediatrics, 173(3), p221-223.

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Specializes in ED, Tele, MedSurg, ADN, Outpatient, LTC, Peds.

Yes!

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Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.

There is a lot of evidence that utilization of the Eat, Sleep, Console program decreases the infant length of stay from average of 10+ days to less than 4 days, and the administration of morphine/methadone from 38 doses to <1 dose. We have used it with great success at a few different facilities that I've managed. The use of this method also engages the parents on a much deeper level, which reinforces the parental bond, empowers the mother to have the ability to effectively care for her infant during this time, and results in greater likelihood of the infant going home with the parents, rather than into foster care.

https://hosppeds.aappublications.org/content/9/8/615

https://pubmed.ncbi.nlm.nih.gov/30855311/

https://www.nichq.org/insight/mother-centered-approach-treating-neonatal-abstinence-syndrome

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Specializes in Education, FP, LNC, Forensics, ED, OB.

Once again, here are the responses from members who came to the Admin Help Desk to submit their diagnoses for the "Newborn with Vomiting and Diarrhea" 9th Case Study Investigation (CSI).

EXCELLENT job everyone!

A DOUBLE THUMBS UP to those with the correct FINAL diagnosis!

A TRIPLE THUMBS UP for those who posted their rationale(s) for the correct dx.

??? klone

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12/30/20 - More information that I need - what is baby eating? Is infant breast or formula fed? I would want to know frequency and quantity of feeds, as that's a very important piece of the puzzle and I'm surprised that it was omitted from the original post. What was mother's GBS status during pregnancy?

Things that jump out at me:

High-pitched cry, hyperactive reflexes, frequent yawning, increased temperature, increased RR.

This presents as classic NAS (neonatal abstinence syndrome). I would want a drug use history from the mother. I would also want to do a CBC and CMP on the infant to rule out other causes of the symptoms. Assuming the meconium has already passed (diarrhea), I could not do a meconium or urine drug test on the infant. 

Differential diagnosis: milk protein sensitivity/allergy (from either the infant formula or something in mother's diet if breastfeeding), GBS sepsis, other underlying infection.

If a history on the mother uncovers prenatal drug use, I would teach her about Eat, Sleep, Console techniques (which has been found to minimize/eliminate the need for morphine or Suboxone administration in the infant). I would show her how to do NAS scoring, and what scores would necessitate further interventions/possible inpatient admission of the newborn for additional treatment.

?? chare

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12/30/20 - Neonatal abstinence syndrome

?? i3mn

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12/31/20 - Neonatal Abstinence Syndrome

? Kooky Korky

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12/31/20 - Atresia? Under developed GI system of newborn?

??? spotangel

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12/31/20 - This child has Neonatal Abstinence Syndrome with classic Neuro and GI symptoms.

Has the mother been using drugs as this child presents with withdrawal symptoms?

I will work up for sepsis given the fever.

This child needs an environment that has minimal stimulus, small frequent feeds, correction of dehydration and a hugger. Needs to be monitored in an NICU.

?? TheMoonisMyLantern

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12/31/20 - I know nothing about peds, but my guess is that he's experiencing opiate withdraw.

?? Skips

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1/1/21 - I believe the infant is withdrawing. Maybe from narcotic use of mom during pregnancy. 

? Babyboss 19

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1/2/21 - So replying to this case study, without results of labs yet. Just based on PE, ROS and HPI, would make a tentative Diagnosis of Early Onset Sepsis, meningitis. Causative organisms maybe be: GBS, Listeria, HSV, E coli.   Although all require treatment, E coli and HSV being most ominous, requiring rapid treatment, with severe neurological and renal consequences.  Would start Amp, Gent, and Acyclovir, admit to NICU.  

dd:  GBS pneumonia

??? evastone

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1/3/21 - This one had me stumped for a few minutes. After researching the symptoms, I found NAS or Neonatal Abstinence Syndrome. Symptoms include high pitched cry, sleeping issues, poor feeding, yawning, stuffy nose, sneezing, overactive reflexes, fever, vomiting, and diarrhea. Low birth weight is one of the potential complications of NAS.

I would ask for the mother's complete medical and psychiatric history, ask what medication she is on or if she uses any recreational drugs. In addition to basic labs (cbc, bmp) blood alcohol levels and U tox should be ordered on the baby. The NAS scoring system should be used as well. This baby would score over 12 on the Finnegan NAS scoring form.

?? PoultryGirl17

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1/4/21 - My answer to this case study is SSRI abstinence syndrome (aka withdrawal)

?? kswick

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1/4/21 - Case study sound like neonatal abstinence syndrome. 

Thank you very much @SafetyNurse1968 for these excellent, professional, nursing Case Studies.

COMING SOON: CSI installment #10

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Specializes in Oncology, Home Health, Patient Safety.
On 1/6/2021 at 6:25 PM, klone said:

There is a lot of evidence that utilization of the Eat, Sleep, Console program decreases the infant length of stay from average of 10+ days to less than 4 days, and the administration of morphine/methadone from 38 doses to <1 dose. We have used it with great success at a few different facilities that I've managed. The use of this method also engages the parents on a much deeper level, which reinforces the parental bond, empowers the mother to have the ability to effectively care for her infant during this time, and results in greater likelihood of the infant going home with the parents, rather than into foster care.

https://hosppeds.aappublications.org/content/9/8/615

https://pubmed.ncbi.nlm.nih.gov/30855311/

https://www.nichq.org/insight/mother-centered-approach-treating-neonatal-abstinence-syndrome

Thank you so much - I've posted before that I'm a generalist, so I always appreciate it when folks who know more than I do add to the discussion.

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