Drug Testing in the Neonate

Impact of Parental Substance Misuse on Children

The potential impact of parental substance misuse extends from the perinatal period through adolescence. Medical management of the affected child should address acute symptoms of toxicity or withdrawal and include a comprehensive assessment of the growth, development, and physical condition. When drug testing is utilized, the results should be part of an overall assessment of risk and protective factors in the child's home environment. The result of a child's drug test should not be the sole indicator of whether a child can safely remain in their home.

"Like a Hot Potato": Breakdown of Clinician-Parent Communication About Newborn Toxicology Testing

OBJECTIVE

Examine the perspectives of newborn clinicians and parents on communication around newborn toxicology testing.

METHODS

We conducted semistructured interviews from 2021 to 2022 with 15 newborn clinicians and 15 parents who experienced perinatal toxicology testing. Clinician interviews explored indications, perceptions of use, and attitudes toward parental consent for newborn toxicology testing. Parental interviews explored attitudes toward, knowledge of, and care team interactions related to perinatal toxicology testing. Researchers open coded transcripts for clinician and parent interviews separately to generate 2 codebooks. Transcripts were independently coded by 2 pairs of researchers. Codes involving communication and clinician-parent relationship from both groups were analyzed together using an inductive thematic analysis approach.

RESULTS

From both sets of interviews, we identified 4 themes: (1) lack of communication about the benefits and risks of newborn toxicology testing led to confusion and misperceptions about the purpose of testing among parents, (2) fear of damaging the clinician-parent relationship and discomfort discussing potential Child Protective Services involvement impacted clinician communication around testing, (3) both clinicians and parents expressed a desire for more transparent communication around newborn toxicology testing, and (4) participants suggested structured consent conversations and improved coordination across prenatal and perinatal care teams.

CONCLUSION

Newborn clinicians rarely discussed clinical benefits of newborn toxicology testing with parents. Both parents and clinicians offered suggestions for improving the transparency and structure of toxicology testing discussions.

Maternal and Neonatal Risk Factors Associated with Positive Toxicology Results

The incidence of substance use disorder (SUD) during pregnancy continues to increase; however, the identification of SUD is challenging. The significance of individual risk factors and their association with toxicology is contentious. To identify maternal and neonatal risk factors associated with positive toxicology results for nonprescribed substance use during pregnancy.This retrospective study included pregnant persons and their infants, who were screened for predetermined risk factors for SUD during pregnancy. The toxicology test results of pregnant persons' urine and infants' urine, meconium/umbilical cord were correlated with risk factors.Maternal risk factors (history of prepregnancy or current SUD, on medication for opioid use disorders, insufficient prenatal care, sexually transmitted and blood-borne infections) and neonatal risk factors (neonatal opioid withdrawal syndrome, intrauterine growth restriction) showed a correlation with toxicology results.Combining maternal and neonatal risk factors with toxicology testing may accurately identify SUD in pregnancy. · Minimal prenatal care can be associated with positive infant toxicology.. · Intrauterine growth restriction/small for gestational age can be associated with positive infant toxicology.. · Combined maternal and infant testing is more sensitive at detecting prenatal substance use..

Assessing Neonatal Opioid Withdrawal Syndrome Severity as a Function of Maternal Buprenorphine Dose and Umbilical Cord Tissue Concentrations

BACKGROUND

Infants born to mothers with opioid use disorder (OUD) and prenatally treated with buprenorphine have a significantly lower incidence of neonatal opioid withdrawal syndrome (NOWS), its treatment duration, and hospital length of stay compared with methadone. However, risk of NOWS remains and clinicians continue to lack an objective methodology to predict NOWS severity among these infants.

OBJECTIVE

The purpose of this study was to assess the relationship between buprenorphine exposure, umbilical cord tissue (UCT) concentrations, and NOWS development and severity.

METHODS

A single-center retrospective observational cohort study from March 2018 through June 2020 of newborns exposed to buprenorphine in utero. Associations between quantified buprenorphine exposure, neonatal UCT concentrations, NOWS diagnosis, and severity were made using regression analyses.

RESULTS

A total of 24 mothers and 25 neonates were included. Length of maternal buprenorphine therapy (months) positively correlated to norbuprenorphine (r² = 0.234, P = 0.019) and buprenorphine + norbuprenorphine UCT concentrations (r² = 0.203, P = 0.031). A positive relationship was seen between active metabolite concentrations and cumulative morphine dose (mg/kg) for treatment of severe NOWS (r² = 0.471, P = 0.007). A 0.36 ng/g buprenorphine + norbuprenorphine UCT (CI = 0.002-0.72, P = 0.049) equated in a 1-point increase in modified peak Finnegan score.

CONCLUSION AND RELEVANCE

Buprenorphine and norbuprenorphine UCT concentrations can allow for quantification of in utero fetal exposure and demonstrate an association with a longer duration of exposure with the severity and treatment of NOWS in exposed infants.

Clinical features and risk factors associated with prenatal exposure to drugs of abuse

INTRODUCTION

Early identification of neonates exposed to drugs of abuse during pregnancy allows a more precise clinical management.

OBJECTIVES

To describe the clinical characteristics and to identify risk factors associated with the early detection of neonates exposed to drugs of abuse in a Neonatal Intermediate and Intensive Care Unit.

METHODS

Prospective observational study of neonates with and without clinical suspicion of prenatal exposure to drugs of abuse. Meconium was analyzed using standard chromatographic techniques. Univariate and multivariate statistical analyzes were performed.

RESULTS

372 neonates were included. Exposure to drugs of abuse was detected in 49 (13.2%) cases: in 41 (83.7%) one drug and in 8 (16.3%) more than one. Somatometry at birth revealed: a) lower length percentile in those exposed to some drug, more than one and cannabis; b) lower weight percentile in those exposed to cannabis and of these compared to those exposed to alcohol. In neonates older than 34 pregnancy weeks (PW): a) lower length percentile in those exposed to any substance; b) lower percentile of length and weight in exposed to more than one. The most clinically relevant independent risk factors useful to detect cases of prenatal exposure to drugs of abuse were (Odds ratio (95% CI)): reason for admission other than prematurity (5.52 (2.55-1.93)), length percentile less than 33 (1.95 (1.05-3.60) and 2.14 (1.04-3.40) in older than 34 PW) and social dystocia/uncontrolled pregnancy in older than 34 PW (4.47 (1.03-19.29)).

CONCLUSIONS

There are somatometric alterations and risk factors that can help in the early detection of neonates exposed to drugs of abuse. The somatometric alterations identified can be useful to extend the differential diagnosis of these alterations and to study their causes.

Role of Neonatal Biomarkers of Exposure to Psychoactive Substances to Identify Maternal Socio-Demographic Determinants

BACKGROUND

The accurate assessment of fetal exposure to psychoactive substances provides the basis for appropriate clinical care of neonates. The objective of this study was to identify maternal socio-demographic profiles and risk factors for prenatal exposure to drugs of abuse by measuring biomarkers in neonatal matrices.

METHODS

A prospective, observational cohort study was completed. Biomarkers of fetal exposure were measured in meconium samples. The mothers were interviewed using a questionnaire. Univariate and multivariate logistic regression analyses were performed.

RESULTS

A total of 372 mothers were included, 49 (13.2%) testing positive for psychoactive substances use: 24 (49.0%) for cannabis, 11 (22.5%) for ethyl glucuronide, six (12.2%) for cocaine, and in eight (16.3%) more than one psychoactive substance. Mothers who consumed any psychoactive substance (29.7 ± 6.6 years) or cannabis (27.0 ± 5.7 years) were younger than non-users (32.8 ± 6.2 years, p < 0.05). Cocaine (50.0% vs. 96.9%, p < 0.05) and polydrug users (37.5% vs. 96.9%, p < 0.05) showed a lower levels of pregnancy care. Previous abortions were associated with the use of two or more psychoactive substances (87.5% vs. 37.8%, p < 0.05). Single-mother families (14.3% vs. 2.5%, p < 0.05) and mothers with primary level education (75.5% vs. 55.1%, p < 0.05) presented a higher consumption of psychoactive substances. Independent risk factors that are associated with prenatal exposure include: maternal age < 24 years (odds ratio: 2.56; 95% CI: 1.12-5.87), lack of pregnancy care (odds ratio: 7.27; 95%CI: 2.51-21.02), single-mother families (odds ratio: 4.98; 95%CI: 1.37-8.13), and active tobacco smoking (odds ratio: 8.13; 95%CI: 4.03-16.43).

CONCLUSIONS

These results will allow us to develop several risk-based drug screening approaches to improve the early detection of exposed neonates.

Advances in drugs of abuse testing

Drugs of abuse testing is widely used clinically and forensically. Urine is the preferred type of specimen for drugs of abuse screening, but saliva, sweat, hair, and meconium are emerging types of specimens. GC-MS has been used as a gold standard for confirmatory drug testing, but LC-tandem-MS can analyze more diverse types of analytes than GC-MS. Thus, LC-tandem-MS becomes a new gold standard for confirmatory drug testing. Unlike GC-MS, LC-tandem-MS is not suited for non-targeted comprehensive drug screening. But with the advent of high-resolution-MS such as Tof-MS, which can discriminate the compounds of similar molecular masses but with different formulas, LC-hybrid-Tof-MS is usable for non-targeted comprehensive drug screening. Another technical advancement is the advent of miniature ambient ionization MS, which can analyze biological specimens including urine within one minute. Thus these mass spectrometers are promising for rapid drugs of abuse testing in a POC setting.

[Clinical features and risk factors associated with prenatal exposure to drugs of abuse]

INTRODUCTION

Early identification of neonates exposed to drugs of abuse during pregnancy allows a more precise clinical management.

OBJECTIVES

To describe the clinical characteristics and to identify risk factors associated with the early detection of neonates exposed to drugs of abuse in a Neonatal Intermediate and Intensive Care Unit.

METHODS

Prospective observational study of neonates with and without clinical suspicion of prenatal exposure to drugs of abuse. Meconium was analyzed using standard chromatographic techniques. Univariate and multivariate statistical analyzes were performed.

RESULTS

372 neonates were included. Exposure to drugs of abuse was detected in 49 (13.2%) cases: in 41 (83.7%) one drug and in 8 (16.3%) more than one. Somatometry at birth revealed: a) lower length percentile in those exposed to some drug, more than one and cannabis; b) lower weight percentile in those exposed to cannabis and of these compared to those exposed to alcohol. In neonates older than 34 pregnancy weeks (PW): a) lower length percentile in those exposed to any substance; b) lower percentile of length and weight in exposed to more than one. The most clinically relevant independent risk factors useful to detect cases of prenatal exposure to drugs of abuse were (Odds ratio (95% CI)): reason for admission other than prematurity (5.52 (2.55-1.93)), length percentile less than 33 (1.95 (1.05-3.60) and 2.14 (1.04-3.40) in older than 34 PW) and social dystocia/uncontrolled pregnancy in older than 34 PW (4.47 (1.03-19.29)).

CONCLUSIONS

There are somatometric alterations and risk factors that can help in the early detection of neonates exposed to drugs of abuse. The somatometric alterations identified can be useful to extend the differential diagnosis of these alterations and to study their causes.

Hospital Care of Opioid-Exposed Newborns: Clinical and Psychosocial Challenges

In the past two decades, the incidence of neonatal abstinence syndrome (NAS) has risen fivefold, mirroring the rise of opioid use disorder (OUD) among pregnant women. The resulting increases in length of stay and neonatal intensive care utilization are associated with higher hospital costs, particularly among Medicaid-financed deliveries. Pregnant women with OUD require comprehensive medical and psychosocial evaluation and management; this combined with medication-assisted treatment is critical to optimize maternal and newborn outcomes. Multidisciplinary collaboration and standardized approaches to screening for intrauterine opioid exposure, evaluation and treatment of NAS, and discharge planning are important for clinical outcomes and may improve maternal experience of care.

Psychoactive substances in human breast milk: a review of analytical strategies for their investigation

WHO recommends breastfeeding for the first 6 months of newborn's life. Due to its physicochemical properties, breast milk may contain undesirable components originated from mother's feeding, medication and illicit drugs consumption. Some of these substances transferred from bloodstream to milk and delivered to the infant can cause harmful effects. For the last decades, analytical advances enabled the analysis of several substances in milk using different techniques. Thereby, it is possible to evaluate infant's level of exposure to these substances. This review presents the information published in the main scientific dissemination media about psychoactive drugs investigation in human breast milk, involving the sample preparation techniques and chromatographic validated methods developed in the past 10 years.

Risk-Based Newborn Drug Testing in a Setting With a Low Prevalence of Maternal Drug Use

OBJECTIVES

Our objective in this study was to determine the predictive value of an institutional risk-based newborn drug-testing tool for detecting maternal drug use during pregnancy.

METHODS

For 5.5 months, the umbilical cords of all newborns born at the study institution were collected and analyzed at a national reference laboratory. In the context of usual clinical care, the decision to perform newborn drug testing is based on an institutional risk assessment tool. For the cohort without clinical indication for testing, cords were deidentified during the study period. Chart review was not performed. Study data were compared with a national data set during the same time period and to previous institutional data.

RESULTS

We tested 857 newborns, 257 of which had 1 or more identified risk factors. There were no drugs or drug metabolites that were significantly more common in the cohort without risk factors than in the clinical cohort. Alprazolam, methamphetamine, hydrocodone, and oxycodone were all significantly more commonly found in the risk-identified cohort. Amphetamine, methamphetamine, and cocaine were not detected in umbilical cords from any of the 600 newborns that would not have been identified for testing. Tetrahydrocannabinol (1.0%; n = 6) was the only illegal substance in the institution's state that would not have been detected.

CONCLUSIONS

Performing universal newborn drug testing in the study population would have identified an additional 6 newborns who were exposed prenatally to tetrahydrocannabinol out of 600 who were additionally tested. In areas with a low prevalence of maternal drug use, universal testing may not be cost-effective.

Understanding barriers to timely identification of infants at risk of neonatal opiate withdrawal syndrome

Neonatal opiate withdrawal syndrome (NOWS), previously known as neonatal abstinence syndrome (NAS), is a growing public health concern as opiate misuse and opioid-related overdoses, from both prescription and illicit sources, continue to rise in the USA. As more than 90% of females abusing opioids are of child-bearing age, the failure to adequately address the opioid epidemic continues to negatively impact the next generations. Accurate and timely identification of infants at risk for withdrawal from in-utero exposure is critical to ensure high-quality perinatal and neonatal care. Beginning with an evaluation of current best practices and performing a literature review, we identify the challenges to current screening processes and how these limitations limit the ability to provide appropriate care to infants at the risk of withdrawal. We first describe the limitations of the available assays for the detection of opioid and opioid metabolites across different biological sources from both the mother and the infant. We then present a discussion surrounding factors that contribute to maternal willingness to disclose use. Particularly, in light of the limitations of biological screening, any barrier to maternal disclosure further complicates effective care delivery. Barriers to disclosure include legal ramifications and state policies, provider and societal behaviors and biases, and maternal factors. Moving forward, universal prenatal screening surveys coupled with enhanced outreach and education to providers centering on the limitations of both patient report and biological sampling, as well as comprehensive and supportive services for women of reproductive age with substance use disorders, are needed to both enhance detection for NOWS and improve long-term maternal-child health.

Alternate Matrices: Meconium, Cord Tissue, Hair, and Oral Fluid

Drug testing commonly involves serum, blood, or urine. More recently, alternative specimens for drug testing have been increasingly used for clinical and forensic toxicology. Examples include oral fluid (saliva), hair, meconium, and umbilical cord tissue. Each of these matrices has unique properties that provide advantages for certain applications. Oral fluid has easier and less invasive collection requirements than urine, the most common specimen for drug screening. Oral fluid drug testing is common in Europe and steadily gaining popularity in the United States. Hair accumulates drugs and drug metabolites and provides a much longer window of detection than blood or urine. Meconium and umbilical cord tissue each allow for assessment of prenatal drug exposure over the course of months. Limitations of these alternative matrices include need for laboratory-developed tests (exception being some oral fluid immunoassays), challenges with the specimen matrix, and incomplete understanding of drug incorporation and kinetics. This chapter briefly describes each of the above alternative specimens in terms of their utility, advantages, and limitations.

The Association Between Antenatal Maternal Self-reported Substance Use, Maternal Characteristics, and Obstetrical Variables

BACKGROUND

Substance use disorders during pregnancy are a concern both to the public and medical community, because the negative consequences can be detrimental to both mother and the fetus. The accurate identification of prenatal drug exposure is necessary to determine appropriate medical and psychosocial intervention, and to identify risk factors that may affect outcomes for the mother and her newborn. The prevalence of prenatal drug exposure is very difficult to estimate because of flaws in all methods of identification.

OBJECTIVE

The study is designed to identify risk factors and demographic variables that contribute to nondisclosure of illicit and nonillicit substance use. In addition, this study aims to determine if nondisclosure leads to adverse neonatal outcomes.

STUDY DESIGN

Newborns delivered with a positive meconium or urine toxicology, and/or known maternal exposure to illicit and nonillicit substances, were identified. Maternal records were reviewed for disclosure of substance use during pregnancy at admission for delivery along with other medical and demographic variables. Women with antenatal prescription drug use that may alter toxicology screens were excluded from analysis. Pediatric records were also reviewed to obtain neonatal variables.

RESULTS

One hundred sixty-eight newborns were identified as having prenatal exposure to an illicit or nonillicit substance over the 4-year period. Eighty-six per cent (145/168) of women tested positive or their newborn tested positive for at least 1 illicit substance, and 49% (82/168) tested positive for multiple illicit substances. Fifty-four per cent (91/168) of women did not disclose using at least one illicit drug for which she or her newborn tested positive.With regards to maternal characteristics, there was no statistically significant difference between age (P = 0.958), parity (P = 0.300), or race (P = 0.531), and disclosure or failure to disclose about illicit drug use. However, patients who did not report prenatal illicit drug use (33/82 = 40%) were less likely (P = 0.049) to receive complete prenatal care (defined as 3 or more visits) compared with those who acknowledged their substance use (40/70 = 57%).

CONCLUSION

Substance use disorders during pregnancy are an often underestimated cause of maternal, fetal, and neonatal complications. Limited studies have examined the relationship between maternal characteristics and associated illicit or nonillicit drug use. The absence of correlation between maternal demographics and disclosure of illicit substance use demonstrates the fact that all antepartum patients are at risk for these behaviors. Furthermore, the fact that women who did not disclose their illicit drug use were less likely to seek complete prenatal care reflects the need for physicians to provide a destigmatized healthcare environment, encouraging pregnant women to disclose their substance use so they can be provided with appropriate counseling and treatment.

Screening for substance use in pregnancy and the newborn

Substance use during pregnancy is common, costly and associated with maternal and newborn health consequences. Assessment of substance use should be integrated into prenatal care. Substance use identification methods include patient interview, screening instruments, and biological testing. In this review, we critically evaluate screening and testing for substance use during pregnancy, highlighting the benefits and barriers of integrated assessment into prenatal care. We also discuss the limitations and negative consequences that should be considered when implementing screening and/or testing procedures. Lastly, we provide recommendations for the ethical implementation of screening and testing for substance use in the context of prenatal care.

Neonatal abstinence syndrome

Neonates exposed prenatally to opioids will often develop a collection of withdrawal signs known as neonatal abstinence syndrome (NAS). The incidence of NAS has substantially increased in recent years placing an increasing burden on the healthcare system. Traditional approaches to assessment and management have relied on symptom-based scoring tools and utilization of slowly decreasing doses of medication, though newer models of care focused on non-pharmacologic interventions and rooming-in have demonstrated promise in reducing length of hospital stay and medication usage. Data on long-term outcomes for both traditional and newer approaches to care of infants with NAS is limited and an important area of future research. This review will examine the history, incidence and pathophysiology of NAS. We will also review diagnostic screening approaches, scoring tools, differing management approaches and conclude with recommendations for continued work to improve the care of infants with NAS.

Screening Pregnant Women and Their Neonates for Illicit Drug Use: Consideration of the Integrated Technical, Medical, Ethical, Legal, and Social Issues

North America is currently suffering from one of the worst epidemics of illicit drug use in recent history: the opioid crisis. Pregnant women are not immune to the ravages of substance misuse which affects themselves, their pregnancies, and the wider community. The prevalence of drug misuse in pregnancy is not well quantified due to the lack of good validated tests, cooperation between clinicians and scientists developing tests, and consensus as to who should be tested and how results should be used. A wide range of tissues can be tested for drug use, including maternal blood, urine, and hair; neonatal meconium, urine, and hair; and placenta and umbilical cord tissues. Testing methods range from simple spectrophotometry and clinical chemistry to sophisticated analytical HPLC or mass spectrometry techniques. The drive for ever greater accuracy and sensitivity must be balanced with the necessities of medical practice requiring minimally invasive sampling, rapid turnaround, and techniques that can be realistically utilized in a clinical laboratory. Better screening tests have great potential to improve neonatal and maternal medical outcomes by enhancing the speed and accuracy of diagnosis. They also have great promise for public health monitoring, policy development, and resource allocation. However, women can and have been arrested for positive drug screens with even preliminary results used to remove children from custody, before rigorous confirmatory testing is completed. Balancing the scientific, medical, public health, legal, and ethical aspects of screening tests for drugs in pregnancy is critical for helping to address this crisis at all levels.

Comparison of Biological Screening and Diagnostic Indicators to Detect In Utero Opiate and Cocaine Exposure Among Mother-Infant Dyads

BACKGROUND

Opioid and cocaine antenatal substance use can result in significant obstetric and pediatric health implications. Accurate detection of in utero-exposed neonates can improve patient care and health outcomes. Therefore, the effectiveness of mother-infant biological and diagnostic indicators collected at labor and delivery to provide accurate detection of in utero opiate and cocaine exposure was assessed.

METHODS

A retrospective medical chart review included 335 mother-infant dyads exposed to antenatal substances who were delivered between January 2009 and March 2014. Mother-infant dyads were a subset of a larger retrospective cohort of 560 substance-using mothers, who had a valid meconium drug screen (MDS) and anesthesia before delivery. Alternative biological and diagnostic indicators of maternal urine drug screens (UDS), maternal substance use International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes, and neonatal exposure diagnostic ICD-9-CM codes were compared against MDS. Data were analyzed using classification accuracy measures.

RESULTS

Compared with MDS, maternal UDS had the highest sensitivity [0.52, 95% confidence interval (CI), 0.39-0.65] and specificity (0.88, 95% CI, 0.79-0.97) to detect intrauterine opiate exposure. Maternal substance use diagnosis had the highest sensitivity (0.39, 95% CI, 0.16-0.61) and maternal UDS had the highest specificity (1.00, 95% CI, 0.99-1.00) to detect intrauterine cocaine exposure. Cocaine exposure had significantly higher accuracy scores across detection methods compared with opiate exposure.

CONCLUSIONS

Alternative indicators collected at delivery were ineffective at identifying in utero substance exposure, especially neonatal-exposed ICD-9-CM codes. Low sensitivity scores indicate that many exposed neonates could be misdiagnosed or left untreated. Accurate antenatal exposure identification at delivery is an important form of tertiary assessment that warrants the development of improved screening methodology and standardization of hospital biological drug testing.

Simultaneous accelerated solvent extraction and hydrolysis of 11-nor-Δ9-tetrahydrocannabinol-9-carboxylic acid glucuronide in meconium samples for gas chromatography-mass spectrometry analysis

Cannabis misuse during pregnancy is associated with severe impacts on the mother and baby health, such as newborn low birth weight, growth restriction, pre-term birth, neurobehavioral and developmental deficits. In most of the cases, drug abuse is omitted or denied by the mothers. Thus, toxicological analyzes using maternal-fetal matrices takes place as a suitable tool to assess drug use. Herein, meconium was the chosen matrix to evaluate cannabis exposure through identification and quantification of 11-nor-Δ9-tetrahydrocannabinol-9-carboxylic (THCCOOH). Accelerated solvent extraction (ASE) was applied for sample preparation technique to simultaneously extract and hydrolyze conjugated THCCOOH from meconium, followed by a solid-phase extraction (SPE) procedure. The method was developed and validated for gas chromatography-mass spectrometry (GC-MS), reaching hydrolysis efficiency of 98%. Limits of detection (LOD) and quantification (LOQ) were, respectively, 5 and 10 ng/g. The range of linearity was LOQ to 500 ng/g. Inter and intra-batch coefficients of variation were <8.4% for all concentration levels. Accuracy was in 101.7-108.9% range. Recovery was on average 60.3%. Carryover effect was not observed. The procedure was applied in six meconium samples from babies whose mothers were drug users and showed satisfactory performance to confirm fetal cannabis exposure.

Pharmacotherapy for Neonatal Abstinence Syndrome: Choosing the Right Opioid or No Opioid at All

Neonatal abstinence syndrome (NAS) from in utero opioid exposure has reached epidemic levels in the United States. Although nonpharmacologic therapies form the foundation of care, many neonates require pharmacotherapy. Morphine represents the most widely used first-line agent and effectively treats the symptoms of withdrawal. However, methadone or buprenorphine may facilitate earlier discharge. Although phenobarbital is traditionally used when opioids fail, clonidine may be a more appropriate adjunctive agent to minimize negative neurodevelopmental impact. Consideration of the available data allows hospitals to generate effective pharmacologic strategies to manage NAS while further research continues.

The microbiome during pregnancy and early postnatal life

We are changing our concept that the newborn infant emerges from a sterile environment. In-utero colonization may have major impacts on the developing mammal in terms of development of immunity and metabolism that, with epigenetic modifications, will lead to diseases in later life. In addition, the microbial profile that develops during and after birth depends on mode of delivery, type of feeding (human milk versus formula) and various other environmental factors to which the newborn is exposed. The goal of this review is to clarify that the microbiome in the maternal fetal unit as well as the immediate changes that occur as new microbes are acquired postnatally play major roles in subsequent health and disease. Rapidly developing technologies for multi-omic analyses and systems biology are shifting paradigms in both scientific knowledge and clinical care.

Drug Screening in Neonates

Gestational substance exposure continues to be a significant problem. Neonates may be exposed to various substances including illicit drugs, prescription drugs, and other legal substances that are best not used during pregnancy because of their potential deleterious effects as possible teratogens or their potential to create dependence and thus withdrawal in the neonate. Screening the newborn for gestational substance exposure is important for both acute care and early intervention to promote the best possible long-term outcomes. This column provides insight into what is known about the extent of substance use by pregnant women, an overview of neonatal biologic matrices for drug testing, and a discussion of the legal implications of neonatal substance screening.

Neonatal opioid withdrawal syndrome

Neonatal opioid withdrawal syndrome is common due to the current opioid addiction epidemic. Infants born to women covertly abusing prescription opioids may not be identified as at risk until withdrawal signs present. Buprenorphine is a newer treatment for maternal opioid addiction and appears to result in a milder withdrawal syndrome than methadone. Initial treatment is with nonpharmacological measures including decreasing stimuli, however pharmacological treatment is commonly required. Opioid monotherapy is preferred, with phenobarbital or clonidine uncommonly needed as adjunctive therapy. Rooming-in and breastfeeding may decease the severity of withdrawal. Limited evidence is available regarding long-term effects of perinatal opioid exposure.

Neonatal abstinence syndrome

Neonatal abstinence syndrome (NAS) is a result of the sudden discontinuation of fetal exposure to substances that were used or abused by the mother during pregnancy. Withdrawal from licit or illicit substances is becoming more common among neonates in both developed and developing countries. NAS continues to be an important clinical entity throughout much of the world. NAS leads to a constellation of signs and symptoms involving multiple systems. The pathophysiology of NAS is not completely understood. Urine or meconium confirmation may assist the diagnosis and management of NAS. The Finnegan scoring system is commonly used to assess the severity of NAS; scoring can be helpful for initiating, monitoring, and terminating treatment in neonates. Nonpharmacological care is the initial treatment option, and pharmacological treatment is required if an improvement is not observed after nonpharmacological measures or if the infant develops severe withdrawal. Morphine is the most commonly used drug in the treatment of NAS secondary to opioids. An algorithmic approach to the management of infants with NAS is suggested. Breastfeeding is not contraindicated in NAS, unless the mother is taking street drugs, is involved in polydrug abuse, or is infected with HIV. Future studies are required to assess the long-term effects of NAS on children after prenatal exposure.

Retrospective analysis of the diagnostic yield of newborn drug testing

Background

The objective of this study was to identify high-yield screening risk factors for detecting maternal non-medical drug use during pregnancy.

Methods

A four year retrospective analysis was conducted at an academic medical center. Detailed chart review of both the newborn and mother’s medical record was performed on all cases for which one or more drug(s) or metabolite(s) were identified and confirmed in meconium or urine.

Results

229 (9.2%) of 2,497 meconium samples out of 7,749 live births confirmed positive for one or more non-medical drugs. History of maternal non-medical drug and/or tobacco use in pregnancy was present in 90.8% of non-medical drug use cases. Addition of social risk factors and inadequate prenatal care increased the yield to 96.9%.

Conclusions

Use of focused screening criteria based on specific maternal and social risk factors may detect many prenatal non-medical drug exposures.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2393-14-250) contains supplementary material, which is available to authorized users.