Baby Birth What Drugs Show Up on Test

Int J Pediatr. 2011; 2011: 951616.

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

Karen J. Farst

^aneSection for Children at Run a risk, Section of Pediatrics, University of Arkansas for Medical Sciences, one Children'south Way, Slot 512-24A, Little Stone, AR 72202, USA

Jimmie L. Valentine

ⁱⁱSection for Pharmacology and Toxicology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR 72202, The states

R. Whit Hall

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

Received 2010 Sep 1; Accepted 2011 May 19.

Abstruse

Estimates of the prevalence of drug usage during pregnancy vary past region and survey tool used. Clinicians providing care to newborns should be equipped to recognize a newborn who has been exposed to illicit drugs during pregnancy by the effects the exposure might cause at the fourth dimension of commitment and/or by drug testing of the newborn. The purpose of this paper is to provide an overview of the literature and assess the clinical role of drug testing in the newborn. Accurate recognition of a newborn whose mother has used illicit drugs in pregnancy cannot merely bear upon decisions for healthcare in the nursery around the fourth dimension of commitment, but can likewise provide a cardinal opportunity to appraise the mother for needed services. While drug use in pregnancy is not an contained predictor of the female parent'southward ability to provide a safe and nurturing environment for her newborn, other issues that frequently cooccur in the life of a mother with a substance abuse disorder raise concerns for the safety of the discharge environment and should be assessed. Healthcare providers in these roles should advocate for unbiased and effective treatment services for affected families.

1. Introduction

Estimates of illicit drug utilise in pregnancy vary widely. Approximately 5–10% of women self-report the use of illicit drugs in pregnancy [1–iii], while universal testing for illicit drugs in high-risk populations results in a significantly college prevalence (10–40%) of usage than through self-reporting [2, 3]. In that location is a wide range of use varying from infrequent recreational apply to high levels of use with physiologic addiction. Importantly, other substances that can have deleterious furnishings on the mother and infants health (such equally nicotine and alcohol) are often used meantime with illicit drugs [1].

Identification of newborns exposed to illicit drugs in pregnancy cannot only alert the practitioner to problems one might run across in the commitment room and plant nursery, simply tin also serve as an opportunity to recognize and assess families with substance abuse disorders which can pose risks to the newborn afterwards hospital discharge. However, since cocky-reports of illicit drug utilise are often inaccurate and universal drug testing is neither applied for the clinician nor recommended by the American University of Pediatrics [4], every facility that provides care for newborns should establish their own testing protocol including establishing unbiased guidelines to identify those to be tested. Policies should be in place allowing for confirmation of test results that have been performed by screening methods which provide only presumptive results.

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

The short- and long-term agin effects encountered by newborns exposed to illicit drugs in pregnancy can exist difficult to accurately assess. In utero exposure to booze and nicotine has established potentials for negative effects on the newborn such every bit impairments in growth and later noesis [5]. While these substances are often used in conjunction with illicit drugs, they are rarely included in newborn screening or reporting policies [6]. As a result, studies examining the health furnishings of newborns exposed to illicit drugs in pregnancy can exist confounded by the presence of other nonillicit substances whose presence can be difficult to command for in study design (especially if relying on self-reported usage). In utero exposure to booze and nicotine are the premier confounders. Also, effects attributed to illicit substance exposure during pregnancy may be confounded by the problems associated with substance abuse disorders such as poor nutrition, overall health status, and attendance at prenatal visits [7–9].

Table ane provides a summary of possible adverse furnishings associated with exposure to the most unremarkably encountered illicit drugs (stimulants, cannabinoids, opiates/opioids, hallucinogens, and sedatives). While cocaine and methamphetamine both behave pharmacologically as stimulants (increased arousal, vasoconstriction, elevated heart charge per unit, and blood pressure level), much of the data about long-term furnishings in this class is derived from accomplice studies on cocaine-exposed children. While at that place has been a longitudinal cohort report of children exposed to amphetamines in utero [26], long-term studies on children exposed to specifically methamphetamine are underway, but it is not yet known if there will exist pregnant differences in long-term event. Inappropriate employ of prescription hurting medications (narcotics) and benzodiazepines are included equally illicit drug usage [34].

Table i

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

Drug	Possible furnishings on the newborn
Stimulants:	Perinatal:
Methamphetamine, Cocaine….	Low birth weight [10–12] CNS irritability/lability of state [xiii–fifteen] —crying, jittery, sleep/wake alterations may have connected exposure through breastfeeding Neurodevelopmental alterations [sixteen] Necrotizing enterocolitis [17] (Teratogenicity suggested by case studies just non confirmed by larger accomplice or animal studies) [18]
	Long term: Minor simply measurable longitudinal differences of cocaine-exposed infants in growth [xix, twenty], cognition [21], language [22], and impaired behavioral self-regulation [23, 24]. Other risk and protective factors tin moderate outcome [23–25]. Longitudinal cohort of amphetamine-exposed infants showed school and behavioral issues (only surroundings impacts likewise) [26]. Longitudinal methamphetamine studies are underway [27].
Opiates/Opioids:	Perinatal:
Heroin, morphine, codeine, oxycodone, hydrocodone, meperidine, fentanyl, (and others)	Low nascence weight [eight, nine] Neonatal Forbearance Syndrome (NAS) [fifteen, 28] scoring arrangement available: (i) CNS irritability (two) Autonomic dysfunction (iii) Respiratory symptoms (four) GI disturbances
	Long term: Longitudinal studies limited, problems with behavioral cocky-regulation reported [27].
Cannabinoids:	Perinatal:
Marijuana	Depression birth weight with heavy exposure [29] Lability of country [15]
	Long term: Impulsivity [8] and furnishings on executive functioning later on in life [8, thirty]
Hallucinogens:	Perinatal:
PCP, MDMA, LSD	Low nativity weight [7, 8, 13] CNS irritability [13] Neurodevelopmental alterations [31]
	Long term: Longitudinal studies not available
Sedatives:	Perinatal:
Benzodiazepines, barbiturates	Low nativity weight [32] Respiratory low, Hypotonia [33]
	Long term: Longitudinal studies not available

Beyond the possible brusque- and long-term wellness effects, concern for the welfare and rubber 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 problems, intergenerational addiction disorders within the family back up system, and involvement in relationships with interpersonal violence [35–38]. The Adverse Childhood Experiences report group has shown that as the frequency of interpersonal violence increases in a child's home, so does the risk of condign a victim of child abuse [39].

All newborns exposed to illicit drugs during pregnancy will not have adverse short- or long-term wellness effects, and the identification of a mother with a substance abuse disorder does not automatically infer the kid volition become a victim of abuse or neglect [40, 41]. The adequacy of the home surroundings is a strong cistron in neurodevelopmental outcome [21, 23, 42] further highlighting the need to apply identification of a newborn exposed to illicit drugs in pregnancy as an opportunity to exist aware of bug that may manifest in the delivery room or nursery and assess the safety of the newborn's domicile environment to be along 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 Child Abuse Prevention and Treatment Human action (CAPTA) by passing the Keeping Children and Families Rubber Act. With this amendment, lawmakers conditioned a state's receipt of federal CAPTA funds on the establishment of procedures by the state to develop a program of prophylactic care when newborns exposed to illicit substances during pregnancy are reported past healthcare providers [43]. All the same, the Human activity 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 assumed to be more of a problem, objective protocols for recognition of which newborns should be tested can be implemented [44–46]. The guideline from the authors' institution which was compiled from a previously published evidenced-based approach that identified maternal and newborn factors associated with illicit drug usage [43] and subsequently vetted with perinatal staff at the authors' institution is available in Table 2. The authors provide their guidelines and discussion and are non 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
(ii) No prenatal intendance
(three) Unexplained placental abruption
(4) 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 state of the newborn (jittery, fussy, lethargic)

Each healthcare facility should develop its own policy to address problems of consent in newborn drug testing. The intent of the exam must be clearly defined. Testing for the purpose of guiding healthcare and followup later on belch may be covered on the general consent to treatment for the facility [47], whereas in the U.s., testing for illicit substances in the absenteeism of medical indications may be discriminatory and violate the patient's ceremonious rights [48].

The healthcare provider has the responsibility to differentiate between 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 mother has not admitted to usage. The potential for false positive testing by immunoassay screening should be acknowledged [49] and investigated further by ordering a direct identification, confirmation method such as gas chromatography-mass spectroscopy [44, fifty]. The charge per unit of faux-positive immunoassay screening is particularly crucial with amphetamines and benzodiazepines [49].

Testing in newborns tin exist performed on urine, blood, meconium, hair, or umbilical cord claret or tissue samples. Immunoassay screening of urine and blood provide the most rapid results with urine usually preferred due to availability through noninvasive purse specimen collection. Drugs volition clear chop-chop from urine making false negative results possible when there is a delay in drove [8, 51, 52]. A laboratory's use of workplace standards for drug detection as opposed to lowest detectable limits can also lead to simulated negative screening results [44].

Meconium formation begins in 2nd trimester, and positive results typically reflect exposure in the final calendar month or longer prior to commitment [44, 52]. Tests of meconium volition more than accurately identify a history of drug use rather than immediate drug employ and are oftentimes more authentic than urine due to collection issues [three, 51]. Beginning time drug usage just earlier delivery may upshot in a false negative meconium as the drug may not accept had time for deposition. Therefore, urine testing may still be needed to embrace the possible time periods of exposure prior to commitment. Results may non be available for several days afterwards collection equally meconium specimens that screen positive for drugs are typically confirmed by a directly identification method in a reference laboratory that performs such testing. While meconium results offer a wider window of exposure and more routine usage of confirmatory methods [53], it is non possible to clearly distinguish when in the last several weeks-months exposure occurred, and specimen collection can be hard in newborns who have passed meconium in utero prior to delivery and in those who are very pocket-size/critically ill.

Neonatal hair growth begins in the 3rd trimester [44, 52]. While not all newborns will have sufficient hair growth to allow for adequate specimen drove, hair drug testing may be helpful if meconium is not available due to transition to neonatal stool or clinical condition of the baby [52, 54]. Testing of the umbilical string for in utero drug exposure is an alternative to meconium collection [55], but information technology is difficult to know how far back into pregnancy exposure would produce a positive test.

Clinicians in the nursery may be asked if information technology is reasonable that second mitt fume inhalation past the mother resulted in a positive newborn drug test. Passive exposure to heavy amounts of 2nd-hand marijuana or fissure cocaine smoke can consequence in a positive drug examination in an exposed adult, but low levels of second-hand fume exposure do not typically effect in positive drug tests [56, 57]. If a female parent is in an environment with others using drugs to the bespeak that it is causing the mother and her newborn to test positive from passive exposure, the same concerns about home stability and cooccurring psychosocial risk factors should be communicated to personnel assessing the mother'southward state of affairs since the newborn would exist exposed to the same environs at belch.

Confirmatory drug testing results may study 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 beingness 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 tin can metabolize to benzoylecgonine, norcocaine, ecgonine methyl ester (methylecgonine from crack), and if coingested with alcohol, cocaethylene [58]. Clinicians with questions almost the consistency of clinical history with drug exam results should consider consultation with a scientist from the reference laboratory that performed the confirmatory testing for the clinician'due south facility.

The opiate/opioid class of medications can be one of the most complex in regards to interpreting drug testing results [59]. These medications may exist used legitimately for medical management of labor and delivery pain in the mother, neonatal hurting after commitment, chronic medical weather 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 mostly reveal urinary levels less than 800 ng/mL. However, they are as well one of the nearly commonly inappropriately used/abused classes of prescription medications. Consultation with clinical toxicology experts is recommended to fully explore the estimation of positive opiate results. Figure 1 shows the division of this group of medications into master opiates, semisynthetic opioids, and constructed opioids with listing of mutual metabolites. It is important for the clinician in the nursery to understand that the synthetic opioids such as fentanyl or methadone would non exist detected on routine toxicology screen for opiates. Specific testing would be required so their usage during labor and delivery or post delivery for pain management would not account for a positive screening exam for opiates every bit is frequently assumed (run into Figure 2).

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

iv. Beyond the Nursery

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

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