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Altered Mental Status in a 22 Month Old NAS Child

Shilpa Hari, Sara Ali and Dana Kaplan

Background: Opioid use in the U.S. has become an epidemic resulting in unintended consequences for children. One consequence is increased opioid ingestions and exposures in the pediatric population. This can occur both in a parent who is an active user but also within the setting of reported recovery and active treatment (for example a parent engaged in an opioid treatment program). Differentiating these potential causes of ingestion when suspected involves toxicology testing which can present limitations and challenges.
Case: We present a case of heroin ingestion in a 22 month old child who presented with altered mental status and respiratory distress secondary to ingestion. Mother was noted to be in a methadone maintenance treatment program and therefore an un witnessed methadone ingestion was on the differential as the cause of the patient’s presentation which prompted urine toxicology testing. However, toxicology testing revealed that opiates were present in the patient’s urine, thereby excluding methadone. In order to evaluate further, additional testing was ordered which eventually revealed an elevated 6- acetlymorphine level, the metabolite specific to heroin.
Discussion: This case demonstrates that the subset of patients in the pediatric population with parents in a methadone maintenance treatment program remain at high risk for ingestions, which may include drugs of abuse despite the parent’s reported history of treatment. It is important as pediatricians to know steps to prevent ingestions by eliciting a drug use history prenatally, continuing with consistent follow up with at risk populations postnatal, and incorporating integrated multidisciplinary interventions throughout.