Tens of thousands of infants are impacted yearly by prenatal opioid exposure. The term neonatal opioid withdrawal syndrome (NOWS) is now replacing the more familiar term neonatal abstinence syndrome (NAS). Ongoing debate continues related to standard regimens for treatment of this oftentimes perplexing condition. Historically, treatment has focused on pharmacologic interventions. However, there is limited research that points to nonpharmacologic methods of treatment as viable options, whether alone or in addition to pharmacologic interventions. This article, utilizing a review of pertinent literature, outlines the physical aspects of NOWS, including its pathophysiology and the resulting physical clinical signs. In addition, we present an overview of how age-appropriate, nonpharmacologic interventions, centered on developmental care, may be a valuable approach to organize and prioritize routine care for these infants, their families, and the health care team facing the challenges of NOWS. Finally, the need for further research to better define evidence-based standards of care for these infants and their families is discussed.

In recent years, the clinical definition of neonatal abstinence syndrome (NAS) has been expanded to describe neonates experiencing withdrawal due to in utero exposure to numerous neuroactive substances, not exclusively opioids. Complex NAS cases involving exposure to multiple and unusual narcotics have become widespread. Kratom is one such substance. It is extracted from tropical tree leaves, and can be used both as a recreational drug and to mitigate opioid withdrawal. Although kratom may potentially serve as a viable opioid alternative, its activity and the consequences of controlled use are largely unstudied, particularly in the pregnant population. A newborn male infant was not initially identified as being at risk for withdrawal due to no maternal admission of substance use and maternal urine drug screen was negative. On the first day of life (DOL), the neonate was observed to exhibit significant signs of withdrawal including high-pitched crying, facial grimacing, irregular respiratory pattern, mottling, and mild undisturbed tremors. Upon interview with the mother it was noted that there was heavy caffeine use, daily cigarette smoking, daily use of the "herbal alternative" (kratom) throughout the pregnancy. In this report, we present a case of NAS precipitated by in utero exposure to kratom, discuss the present body of research regarding kratom and consider potential implications of escalating kratom use on the incidence and severity of NAS. For this prenatally exposed neonate, clonidine was successfully used to control withdrawal symptoms.

Nodular localized cutaneous amyloidosis is a rare form of cutaneous amyloidosis and is characterized by an extracellular deposition of insoluble amyloid fibrils which are either primarily cutaneous or a manifestation of an underlying systemic amyloidosis. Biopsy of the lesion is mandatory for the diagnosis, and histopathology shows diffuse amyloid deposits with plasmacytic infiltration. Apple-green birefringence characteristic of amyloidosis is observed when stained with Congo red and viewed under polarized light. Amyloid subtyping is done with laser microdissection followed by mass spectrometry. Majority of these lesions do not require any treatment but surgical excision, shave excision, laser therapy, and radiotherapy can be considered for symptomatic nodular localized primary cutaneous amyloidosis (NLPCA). We present a case of recurrent NLPCA in a 64-year-old woman who was treated with bortezomib and dexamethasone after failing several local therapies with excellent response.

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