Neonatal nicotine withdrawal in a newborn exposed to maternal e-cigarette use

The increasing use of e-cigarettes amongst pregnant women has raised public health concerns about the effects of nicotine exposure on neonates. Nicotine crosses the placenta, accumulates in fetal blood and amniotic fluid, and can be detected in breast milk during lactation. It may lead to withdrawal symptoms in newborns, such as irritability, tremors, high-pitched crying, and sleep disturbances, similar to those observed in opioid-induced neonatal abstinence syndrome (NAS). This case report presents a full-term male neonate who developed persistent symptoms consistent with NAS, despite negative toxicology screenings for opioid or other illicit substances. The infant was started on morphine therapy, based on elevated Finnegan scores; however, symptoms persisted despite increase in dosage. Further review of maternal history revealed heavy e-cigarette use during and after pregnancy. Symptoms were noted to worsen when breast milk was limited, raising the possibility of nicotine withdrawal related to fluctuating exposure through breastfeeding. Elevated urine cotinine level in the neonate helped to support this theory. This case highlights the potential for neonatal nicotine withdrawal and the importance of routine maternal screening for all forms of nicotine use during pregnancy and lactation. Clinicians should maintain a high index of suspicion for nicotine exposure in neonates presenting with NAS-like symptoms. Increased awareness and further research are essential to help guide management strategies and avoid mismanagement of non-opioid withdrawal syndromes.