Do Babies Get Tested for Drugs at Birth

Int J Pediatr. 2011; 2011: 951616.

Drug Testing for Newborn Exposure to Illicit Substances in Pregnancy: Pitfalls and Pearls

Karen J. Farst

¹Section for Children at Risk, Section of Pediatrics, University of Arkansas for Medical Sciences, ane Children's Fashion, Slot 512-24A, Little Rock, AR 72202, U.s.a.

Jimmie L. Valentine

^twoDepartment for Pharmacology and Toxicology, Department of Pediatrics, University of Arkansas for Medical Sciences, Picayune Rock, AR 72202, USA

R. Whit Hall

³Section for Neonatology, Department of Pediatrics, University of Arkansas for Medical Sciences, 4301 Due west Markham, Slot 512-B, Little Rock, AR 72205, USA

Received 2010 Sep ane; Accepted 2011 May 19.

Abstruse

Estimates of the prevalence of drug usage during pregnancy vary past region and survey tool used. Clinicians providing intendance to newborns should exist equipped to recognize a newborn who has been exposed to illicit drugs during pregnancy by the effects the exposure might cause at the time of commitment and/or by drug testing of the newborn. The purpose of this newspaper is to provide an overview of the literature and appraise the clinical role of drug testing in the newborn. Authentic recognition of a newborn whose mother has used illicit drugs in pregnancy cannot but touch on decisions for healthcare in the plant nursery effectually the fourth dimension of commitment, only tin likewise provide a key opportunity to appraise the mother for needed services. While drug use in pregnancy is not an independent predictor of the mother'south ability to provide a safe and nurturing surroundings for her newborn, other issues that oft cooccur in the life of a mother with a substance abuse disorder raise concerns for the safety of the belch surround and should be assessed. Healthcare providers in these roles should advocate for unbiased and effective treatment services for affected families.

i. Introduction

Estimates of illicit drug use in pregnancy vary widely. Approximately five–10% of women self-study the apply of illicit drugs in pregnancy [i–3], while universal testing for illicit drugs in loftier-risk populations results in a significantly college prevalence (10–xl%) of usage than through self-reporting [2, 3]. There is a wide range of apply varying from infrequent recreational use to loftier levels of utilise with physiologic addiction. Importantly, other substances that can have deleterious effects on the mother and infants health (such equally nicotine and alcohol) are oft used concurrently with illicit drugs [one].

Identification of newborns exposed to illicit drugs in pregnancy cannot only warning the practitioner to problems one might run into in the delivery room and nursery, but can also serve as an opportunity to recognize and assess families with substance corruption disorders which tin pose risks to the newborn after hospital belch. Still, since self-reports of illicit drug use are ofttimes inaccurate and universal drug testing is neither practical for the clinician nor recommended by the American Academy of Pediatrics [4], every facility that provides intendance for newborns should establish their own testing protocol including establishing unbiased guidelines to identify those to be tested. Policies should exist in place allowing for confirmation of examination results that have been performed past screening methods which provide only presumptive results.

two. Possible Effects on Neonates due to Illicit Drug Utilize in Pregnancy

The curt- and long-term agin effects encountered by newborns exposed to illicit drugs in pregnancy tin can exist difficult to accurately assess. In utero exposure to alcohol and nicotine has established potentials for negative effects on the newborn such as impairments in growth and afterwards cognition [five]. While these substances are often used in conjunction with illicit drugs, they are rarely included in newborn screening or reporting policies [6]. Every bit a result, studies examining the wellness furnishings of newborns exposed to illicit drugs in pregnancy can be confounded by the presence of other nonillicit substances whose presence can be difficult to control for in study blueprint (particularly if relying on self-reported usage). In utero exposure to alcohol and nicotine are the premier confounders. Likewise, furnishings attributed to illicit substance exposure during pregnancy may be confounded by the problems associated with substance abuse disorders such as poor diet, overall health status, and attendance at prenatal visits [seven–9].

Table 1 provides a summary of possible adverse furnishings associated with exposure to the most commonly encountered illicit drugs (stimulants, cannabinoids, opiates/opioids, hallucinogens, and sedatives). While cocaine and methamphetamine both acquit pharmacologically equally stimulants (increased arousal, vasoconstriction, elevated heart rate, and blood pressure), much of the information about long-term effects in this form is derived from accomplice studies on cocaine-exposed children. While there has been a longitudinal accomplice study of children exposed to amphetamines in utero [26], long-term studies on children exposed to specifically methamphetamine are underway, just it is non nonetheless known if there will be significant differences in long-term outcome. Inappropriate utilize of prescription pain medications (narcotics) and benzodiazepines are included every bit illicit drug usage [34].

Tabular array 1

Possible effects on newborns due to illicit drug utilize in pregnancy (not a complete list).

Drug	Possible effects on the newborn
Stimulants:	Perinatal:
Methamphetamine, Cocaine….	Low nascency weight [10–12] CNS irritability/lability of country [13–fifteen] —crying, jittery, slumber/wake alterations may have continued exposure through breastfeeding Neurodevelopmental alterations [xvi] Necrotizing enterocolitis [17] (Teratogenicity suggested by case studies merely non confirmed past larger cohort or animal studies) [18]
	Long term: Small-scale but measurable longitudinal differences of cocaine-exposed infants in growth [19, 20], cognition [21], language [22], and impaired behavioral cocky-regulation [23, 24]. Other run a risk and protective factors can moderate issue [23–25]. Longitudinal cohort of amphetamine-exposed infants showed schoolhouse and behavioral bug (but environment impacts too) [26]. Longitudinal methamphetamine studies are underway [27].
Opiates/Opioids:	Perinatal:
Heroin, morphine, codeine, oxycodone, hydrocodone, meperidine, fentanyl, (and others)	Low nascence weight [viii, 9] Neonatal Abstinence Syndrome (NAS) [xv, 28] scoring system available: (i) CNS irritability (ii) Autonomic dysfunction (iii) Respiratory symptoms (iv) GI disturbances
	Long term: Longitudinal studies express, problems with behavioral self-regulation reported [27].
Cannabinoids:	Perinatal:
Marijuana	Depression nascence weight with heavy exposure [29] Lability of land [fifteen]
	Long term: Impulsivity [8] and effects on executive operation later in life [8, xxx]
Hallucinogens:	Perinatal:
PCP, MDMA, LSD	Depression birth weight [7, viii, 13] CNS irritability [13] Neurodevelopmental alterations [31]
	Long term: Longitudinal studies not available
Sedatives:	Perinatal:
Benzodiazepines, barbiturates	Low birth weight [32] Respiratory depression, Hypotonia [33]
	Long term: Longitudinal studies not available

Beyond the possible brusque- and long-term health effects, business for the welfare and safety of newborns exposed to illicit drugs in pregnancy exists due to the cooccurring issues that many women with substance abuse disorders struggle with including undiagnosed/undertreated mental health bug, intergenerational addiction disorders within the family support system, and involvement in relationships with interpersonal violence [35–38]. The Adverse Childhood Experiences study group has shown that as the frequency of interpersonal violence increases in a child'due south home, so does the risk of condign a victim of child abuse [39].

All newborns exposed to illicit drugs during pregnancy will non have adverse short- or long-term health effects, and the identification of a mother with a substance abuse disorder does not automatically infer the child will become a victim of abuse or neglect [xl, 41]. The adequacy of the home environment is a strong factor in neurodevelopmental outcome [21, 23, 42] farther highlighting the demand to use identification of a newborn exposed to illicit drugs in pregnancy every bit an opportunity to be enlightened of issues that may manifest in the delivery room or nursery and assess the safety of the newborn'southward dwelling house environment to be forth with the psychosocial situation of the family for needed supportive services [15].

3. Drug Testing in Newborns

In 2003, the United States Congress amended the Kid Abuse Prevention and Handling Act (CAPTA) by passing the Keeping Children and Families Safe Human action. With this subpoena, lawmakers conditioned a state's receipt of federal CAPTA funds on the institution of procedures by the state to develop a plan of prophylactic intendance when newborns exposed to illicit substances during pregnancy are reported by healthcare providers [43]. Nevertheless, the Act leaves the decision on who should be tested to the healthcare provider. To avoid bias in testing towards newborns of women from poverty or minority backgrounds where substance corruption is sometimes causeless to exist more of a trouble, objective protocols for recognition of which newborns should exist tested can be implemented [44–46]. The guideline from the authors' institution which was compiled from a previously published evidenced-based arroyo that identified maternal and newborn factors associated with illicit drug usage [43] and later on vetted with perinatal staff at the authors' establishment is available in Table 2. The authors provide their guidelines and discussion and are not making a recommendation for adoption of what has been established at their institution as a universal standard.

Table 2

Sample guideline for newborn drug testing.

Medical indications for NEWBORN drug testing for possible exposure to illicit drugs
University of Arkansas for Medical Sciences, ANGELS Neonatal Guidelines [46]
(1) History of maternal drug use or agitated/altered mental condition in the mother
(2) No prenatal care
(3) Unexplained placental abruption
(iv) Unexplained CNS complications in the newborn (seizures, intracranial hemorrhage)
(5) Symptoms of drug withdrawal in the newborn (tachypnea, hypertonicity, excessive stooling/secretions)
(6) Changes in behavioral country of the newborn (jittery, fussy, lethargic)

Each healthcare facility should develop its own policy to address issues of consent in newborn drug testing. The intent of the test must be clearly defined. Testing for the purpose of guiding healthcare and followup later on discharge may be covered on the full general consent to handling for the facility [47], whereas in the United States, testing for illicit substances in the absence of medical indications may be discriminatory and violate the patient's civil rights [48].

The healthcare provider has the responsibility to differentiate betwixt screening and confirmatory drug testing results. This is especially true in cases in which a newborn has tested positive for an illicit drug and the female parent has not admitted to usage. The potential for simulated positive testing by immunoassay screening should be best-selling [49] and investigated further by ordering a direct identification, confirmation method such every bit gas chromatography-mass spectroscopy [44, l]. The rate of imitation-positive immunoassay screening is particularly crucial with amphetamines and benzodiazepines [49].

Testing in newborns tin be performed on urine, claret, meconium, pilus, or umbilical cord blood or tissue samples. Immunoassay screening of urine and blood provide the well-nigh rapid results with urine commonly preferred due to availability through noninvasive bag specimen collection. Drugs will articulate apace from urine making fake negative results possible when there is a delay in collection [eight, 51, 52]. A laboratory's use of workplace standards for drug detection as opposed to lowest detectable limits can also lead to faux negative screening results [44].

Meconium formation begins in 2nd trimester, and positive results typically reverberate exposure in the concluding month or longer prior to delivery [44, 52]. Tests of meconium volition more than accurately identify a history of drug use rather than immediate drug use and are often more accurate than urine due to collection issues [3, 51]. First time drug usage but earlier delivery may result in a faux negative meconium every bit the drug may not have had time for degradation. Therefore, urine testing may withal be needed to cover the possible time periods of exposure prior to delivery. Results may not be available for several days later on collection as meconium specimens that screen positive for drugs are typically confirmed by a direct identification method in a reference laboratory that performs such testing. While meconium results offering a wider window of exposure and more than routine usage of confirmatory methods [53], it is not possible to conspicuously distinguish when in the terminal several weeks-months exposure occurred, and specimen drove can exist difficult in newborns who take passed meconium in utero prior to delivery and in those who are very small/critically ill.

Neonatal hair growth begins in the third trimester [44, 52]. While not all newborns will have sufficient hair growth to let for adequate specimen drove, pilus drug testing may be helpful if meconium is not available due to transition to neonatal stool or clinical status of the babe [52, 54]. Testing of the umbilical cord for in utero drug exposure is an culling to meconium collection [55], only information technology is difficult to know how far back into pregnancy exposure would produce a positive test.

Clinicians in the plant nursery may exist asked if information technology is reasonable that 2d paw smoke inhalation by the female parent resulted in a positive newborn drug test. Passive exposure to heavy amounts of 2d-hand marijuana or crack cocaine smoke can issue in a positive drug test in an exposed adult, just low levels of second-hand smoke exposure do not typically issue in positive drug tests [56, 57]. If a female parent is in an environment with others using drugs to the point that information technology is causing the female parent and her newborn to test positive from passive exposure, the aforementioned concerns near abode stability and cooccurring psychosocial take a chance factors should be communicated to personnel assessing the mother'southward state of affairs since the newborn would be exposed to the same environment at discharge.

Confirmatory drug testing results may written report either the parent drug and/or its metabolites. Therefore, the clinician should be familiar with basic drug metabolism of commonly abused drugs in order to account for exposure to certain parent compounds by the metabolites being detected during testing instead of the parent drug. In the stimulant class of drugs, methamphetamine is metabolized to amphetamine by the liver, but prescription amphetamine compounds will not metabolize to methamphetamine. Cocaine can metabolize to benzoylecgonine, norcocaine, ecgonine methyl ester (methylecgonine from scissure), and if coingested with alcohol, cocaethylene [58]. Clinicians with questions about the consistency of clinical history with drug test results should consider consultation with a scientist from the reference laboratory that performed the confirmatory testing for the clinician's facility.

The opiate/opioid class of medications can be one of the near complex in regards to interpreting drug testing results [59]. These medications may be used legitimately for medical management of labor and delivery pain in the mother, neonatal pain after delivery, chronic medical conditions in the mother, and in addiction rehabilitation programs. Positive opiate results (morphine) can also be observed due to dietary intake of poppy seed containing foods although confirmation and quantitation of morphine volition generally reveal urinary levels less than 800 ng/mL. However, they are also ane of the most commonly inappropriately used/abused classes of prescription medications. Consultation with clinical toxicology experts is recommended to fully explore the interpretation of positive opiate results. Figure 1 shows the sectionalization of this group of medications into principal opiates, semisynthetic opioids, and synthetic opioids with listing of common metabolites. It is important for the clinician in the nursery to understand that the synthetic opioids such every bit fentanyl or methadone would not be detected on routine toxicology screen for opiates. Specific testing would be required so their usage during labor and delivery or post delivery for hurting management would not account for a positive screening examination for opiates equally is often assumed (see Effigy 2).

High morphine can show up with some hydromorphone, but generally hydro will break to hydro and oxy to oxy. Codeine can go to morphine and hydrocodone (non a metabolite of other opiates). Heroin breaks downward to morphine and 6MAM. Codones tin pause to morhpones but not backwards. Hydrocodone can go to hydrocodol (= dihydrocodeine) and hydromorphone. Hydromorphone can become to hydromorphol (same for oxy only separate).

four. Beyond the Nursery

As function of discharge planning, all newborns exposed to illicit drugs in pregnancy should accept a primary care provider specifically designated to allow flow of information on risk condition, referrals, and followup [60]. Caregivers with a substance abuse disorder are more likely to perceive intendance of a child as stressful and miss well-child visits [61]. Early intervention services should be considered considering they tin positively bear upon drug-exposed newborns at risk for developmental delay [62]. Nurse home visitation may be an appropriate referral in select cases [63]. Such programs may help in reduction of subsequent encounters for ingestions, injuries, and maltreatment compared to controls [63, 64], or behavioral bug in children and in parental distress [65]. Perinatal healthcare providers should work collaboratively to brainwash state legislators that identification of drug utilise alone is non adequate to address the problems related to pregnant women with substance abuse disorders. States must develop a plan to assess families at risk by providing supportive services through their child welfare departments and include admission to evidence-based substance abuse handling programs. Providers should advocate for appropriate funding in child welfare budgets to ensure manageable case loads and staff training time. Prevention and family unit preservation instead of punishment will benefit the state in the long term past decreasing many of the other public health expenditures related to untreated substance abuse disorders.

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