Neonatal Opioid Withdrawal Syndrome Following Prenatal Use of Supplements Containing Tianeptine.

Tianeptine is an opioid receptor agonist that is prescribed as an antidepressant in many countries. In the United States, tianeptine is not approved for medical use because of its potential for abuse and addiction. Nonetheless, products containing tianeptine are easily obtainable and are marketed as dietary supplements. There are increasing reports of adverse effects and fatal toxicities resulting from tianeptine use among adolescents and adults. This emerging public health threat could escalate the opioid epidemic and drive increased newborn perinatal exposure. The impact of in utero exposure to tianeptine has not been studied, and to our knowledge, the authors of only 1 report have documented possible neonatal effects. Here, we describe a case of chronic prenatal exposure to tianeptine in the setting of maternal dependence on dietary supplements. This infant developed signs of severe withdrawal shortly after birth that were refractory to treatment with oral phenobarbital but responded to subsequent oral morphine therapy. On further questioning, the mother revealed the use of a tianeptine-containing dietary supplement. We did not perform confirmatory toxicology testing because tianeptine is not assayed by usual urine drug screening tests. For infants with clinical signs of opioid withdrawal without known etiology, we suggest that the maternal interview should inquire about the use of neurotropic over-the-counter drugs.

Extracorporeal Membrane Oxygenation (ECMO) for suspected neonatal genetic diagnoses with cardiorespiratory failure.

Recent data describe an increasing use of extracorporeal membrane oxygenation (ECMO) in neonates with various clinical conditions besides primary respiratory or cardiac diagnoses. Infants with underlying genetic disorders characterized by cardiopulmonary failure pose unique management challenges. When pathognomonic dysmorphic features for common genetic diagnoses are not present, the prognosis is uncertain at best when determining ECMO candidacy. Lengthy turnaround times of genetic testing often delay definitive diagnosis during the ECMO course. Clinical management pathways to guide practice and evidence to support the use of ECMO in rare genetic conditions are lacking. The decision to initiate ECMO is daunting but may be of benefit if the subsequent genetic diagnosis is non-lethal. In lethal genetic cases warranting discontinuation of care, the time spent on ECMO may still be advantageous as a bridge to diagnosis while allowing for parental bonding with the terminally ill infant. Diagnostic confirmation may also facilitate the attainment of closure for these parents. Here, we report our experience providing ECMO to three neonates presenting with cardiorespiratory failure and later diagnosed with rare genetic syndromes. We share the challenges faced, lessons learned, and outcomes of these critically ill neonates.

Optimizing the hospital discharge process to facilitate family-centered care for well newborns.

BACKGROUND: The perceptions of discharge readiness differ among caregivers and providers. An efficient planning process ensures timely attainment of discharge readiness. Our aim was to increase the percentage of discharge orders placed by 10 a.m. from 0.5% to 10% within 6 months thereby improving discharge readiness. METHODS: We conducted a quality improvement initiative in the newborn nursery between March 2021 and June 2022 (n = 2307). We implemented a physician-led early discharge huddle and standardized the newborn screen (NBS) and circumcision process. RESULTS: By 10 a.m., our primary outcome measure, discharge orders, improved from 0.5 to 19%. Our process measures also increased. NBS specimens collected improved from 56 % to 98 % and circumcision rates increased from 66 to 88%. Balancing measure of postpartum hospital days remained stable. CONCLUSIONS: Optimizing family-centered discharge processes by addressing key drivers is essential and can be achieved without an increase in postpartum hospital days.

Improving timeliness of newborn screens in the neonatal intensive care unit: a quality improvement initiative.

BACKGROUND: Despite the established utility of newborn screening tests (NBS), achieving timely specimen transit is a challenge for neonatal intensive care units (NICU). METHODS: This project was conducted between September 2017 and July 2020 using the Plan-Do-Study-Act (PDSA) tool. Our primary aim was to increase the percent of NBS samples reaching the state laboratory within 1 day of collection by 20% by April 2020. Process, outcome, and balancing measures were monitored. RESULTS: Five hundred and eighty-five NBS were collected. There was special cause variation with improvement in the percent of samples received within 1 day of collection from 28 to 77%. Special cause variation was also observed in the process measures without an increase in the percent of unacceptable samples. CONCLUSIONS: Standardizing the NBS collection processes by adopting a sample collection window and same day courier pickup ensures timely specimen transit without adversely affecting the quality of samples collected.

ECMO as a Platform for Rapid Ammonia Removal in a Neonate with Multienzyme Urea Cycle Disorder.

Since the initial deployment of neonatal extracorporeal membrane oxygenation (ECMO) for respiratory failure, the use of ECMO in this population has diversified. We present a term female infant with carbamoyl phosphate synthetase 1 and partial N-acetylglutamate synthase deficiencies who developed severe hyperammonemia refractory to medical management requiring venoarterial ECMO-driven continuous veno-venous hemodiafiltration for ammonia detoxification. This case report illustrates a subpopulation where neonatal ECMO may improve survival and neurodevelopmental outcomes. To our knowledge, this is the first reported case of a urea cycle defect arising from two proximal enzyme deficiencies. Also, this is one of the few reported patients with UCD associated with peak ammonia levels >2,000 µmol/L who survived to hospital discharge after the successful use of ECMO for ammonia reduction. This case will add to the existing scant literature supporting the use of ECMO as a platform for rapid removal of serum ammonia.