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 Buprenorphine Withdrawal in a Toddler

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PostSubject: Buprenorphine Withdrawal in a Toddler   Sun 30 Aug 2009, 1:38 am

Buprenorphine Withdrawal in a Toddler
To the Editor:

A 2 year old, 13.4 kg female was transferred to our service

for opioid withdrawal. The patient was previously healthy

and met all of her developmental milestones. Her mother

had been surreptitiously administering two-thirds of a tablet

of 2 mg of buprenorphine daily since birth. Two days before

admission, the patient’s mother attempted suicide. In the

suicide note, she described giving the buprenorphine and

instructed the patient’s father to continue administering

the buprenorphine so the patient would not undergo

withdrawal.

The patient last ingested buprenorphine approximately 48

hours before admission. The father reported the patient had not

slept in the previous 24 hours, and had become increasingly

irritable and inconsolable for 12 hours before admission.

Despite measures to calm the patient, she became increasingly

irritable and agitated. She was taken to an emergency

department at an outside hospital. Her blood pressure was 89/

43 with a pulse rate of 118. She was afebrile. Her exam was

notable for crying, yawning, and piloerection. Her pupils were 4

mm. Her exam was otherwise normal. She was given 1 mg of

intravenous morphine, and all of her symptoms resolved. She

was transferred to our hospital.

Upon arrival in the pediatric intensive care unit, the

patient was again crying and agitated. Her blood pressure at

this time was 113/66, with a pulse rate of 154. The exam

again was notable for rhinorrhea, yawning, and piloerection.

Approximately 2.5 hours after the first dose of morphine was

given, an additional 1 mg of intravenous morphine was

administered, and her symptoms resolved. The patient was

started on 1 mg of oral methadone. Blood work, including a

complete blood count and a comprehensive metabolic

profile, were normal. A basic drug of abuse screen (enzyme

multiplied immunoassay technique [EMIT]) was negative

except for opiates and acetone. The opiates had been

administered at the outside hospital. The only additional

drug detected on a comprehensive urine drug screen, which

screens urine via thin layer chromatography with subsequent

gas chromatography/mass spectroscopy (GC-MS) for

confirmation, was methadone. This comprehensive drug

screen was obtained after methadone was administered.

The patient was initially maintained on 1 mg of methadone

daily. She was discharged on the third hospital day. The

methadone was successfully tapered over 5 weeks. The patient

tolerated the outpatient taper fairly well.

Acute withdrawal, including neonatal abstinence syndrome is

well-described in neonatal patients born to mothers using

buprenorphine.

1 However, to our knowledge, buprenorphine
withdrawal has never been described in children who themselves

were consuming buprenorphine.

In summary, we report a case of withdrawal from

buprenorphine in a young child, who presented to the

emergency department with irritability. The history provided

made the diagnosis easy in our case. However, we would like to

remind emergency physicians to consider the diagnosis of

opioid withdrawal in pediatric patients presenting to the

emergency department with irritability, with no other clear

etiology for their symptoms.

Volume

, .  : September  Annals of Emergency Medicine 477
Michael Levine, MD

Anne-Michelle Ruha, MD

Department of Medical Toxicology

Banner Good Samaritan Medical Center

Phoenix, AZ

Department of Medical Toxicology

Phoenix Children’s Hospital

Phoenix, AZ

doi:10.1016/j.annemergmed.2009.03.032

Funding and support:

By Annals policy, all authors are required to
disclose any and all commercial, financial, and other relationships

in any way related to the subject of this article that might create

any potential conflict of interest. The authors have stated that no

such relationships exist. See the Manuscript Submission Agreement

in this issue for examples of specific conflicts covered by this

statement.

1. Marquet P, Chevrel J, Lavignasse P, et al. Buprenorphine

withdrawal syndrome in a newborn.
Clin Pharmacol Ther.1997;62:569-571

Aris K. Exadaktylos, MD

University Department of Emergency Medicine

Inselspital Bern

University Hospital

Bern, Switzerland

doi:10.1016/j.annemergmed.2008.06.475

Funding and support:

By Annals policy, all authors are required to
disclose any and all commercial, financial, and other relationships

in any way related to the subject of this article that might create

any potential conflict of interest. The author has stated that no

such relationships exist. See the Manuscript Submission Agreement

in this issue for examples of specific conflicts covered by this

statement.

1. Green S.Trauma surgery: discipline in crisis.

Ann Emerg Med.
2009:53:198-207.

2. Exadaktylos A, Velmahos GC. Emergency medicine and acute care

surgery: a modern “Hansel and Gretel” fairytale?

Emerg Med J.

Posted by:Dee

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