Buprenorphine Withdrawal in a Toddler

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.