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Best practice №6

Implement selective newborn biological toxicology testing

screening-assessment-level-of-care-determination

by David Golembeski, David Kim, Helen DuPlessis, Jadene Wong, Robert Castro, Vaneet Kalra

Last updated October 7th, 2020

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Overview

Newborn toxicology testing is an important identification tool. However, it is limited by testing sensitivity and timing requirements.

Why we are recommending this best practice

  • The incidence of substance use in pregnancy is difficult to quantify. Maternal screening using validated surveys, and when necessary, toxicology testing in pregnancy may still underrepresent the true incidence.

  • If in utero substance exposure has been identified from either prenatal history (including inquiries into prescription and nonprescription drug use) or maternal toxicology testing, this information is vital for guiding assessment and treatment options and may lead to improved outcomes for mothers and newborns.

  • If maternal toxicology testing or treatment history has been confirmed, testing of the newborn may not be clinically necessary; however, it is often requested by external agencies such as child protective services (CPS). Education of CPS about the validity of other information can avoid unnecessary and in appropriate use of screening resources.

  • Newborn health care providers should be provided with information on the usefulness and limitation of the birth center’s biological toxicology testing and the availability/appropriateness of confirmatory testing.

Strategies for implementation

  • When the information would influence healthcare treatment, Selective biological toxicology testing should be considered for newborns when diagnostic information about the mother is limited or not available, or when the clinical picture indicates risk for in utero exposure, including but not limited to: 
    • Mother with limited or no prenatal care
    • Maternal symptoms of drug intoxication or withdrawal that are otherwise unexplained
    • Newborn signs and symptoms of potential substance exposure (i.e., withdrawal) that are otherwise unexplained

  •  Hospital policies and procedures should include protocols that would trigger newborn biological toxicology testing.

  • Toxicology testing is limited by substance levels (concentrations) and timing.  Therefore, samples should be collected and sent for analysis as soon as possible after delivery.

  • Review available biological toxicology testing methods at each birth center.  Traditionally, urine immunoassay has been used as the initial screen, and multiple commercial antibodies are validated.

  • For certain substances, immunoassay-based urine toxicology testing is a reliable method with rapid turnaround time.  For opioid exposure, routine opioid testing panels usually only detects morphine, codeine, and heroin metabolites.  Synthetic opioids such as methadone, oxycodone, fentanyl, buprenorphine, etc. may require more specific testing.

  • A newborn who has a biological toxicology test with unexpected positive results should have confirmatory testing (gas chromatography-mass spectrometry) and/or confirmation of drug presence by a more time specific test sample (i.e., meconium, umbilical cord).

  • Providers should be aware of false-positive drug testing from common maternal medications including antihistamines, antidepressants, antibiotics, decongestants, analgesics, antipsychotics, and over-the-counter products (See table below).

  • Due to assay limitations, a negative biological toxicology result does not represent an absence of in utero substance exposure, specifically if the newborn exhibits clinical signs consistent with neonatal abstinences syndrome (NAS) and all other diagnoses have been appropriately ruled out.

  • A positive biological toxicology result, in and of itself, does not represent child abuse or neglect. Hospitals must ensure that the multidisciplinary team caring for mothers and newborns includes social workers trained in care and treatment resources for affected families. Care should be taken to ensure that policies which delineate criteria for toxicology testing do not directly or indirectly target low income women and women of color (refer to Best Practice #3 for more information on this).
Commonly prescribed medications in obstetrics that may result in false positives

Resources

References

  • Hudak ML, Tan RC. Neonatal drug withdrawal. Pediatrics. 2012; 129(2): e540- 560. doi: https://doi.org/10.1542/peds.2011-3212.
  • Committee opinion no. 633: alcohol abuse and other substance use disorders: ethical issues in obstetric and gynecologic practice. Obstet Gynecol. 2015; 125(6): 1529-1537. doi: 10.1097/01.AOG.0000466371.86393.9b.
  • Worley J. Identification and management of prescription drug abuse in pregnancy. J Perinat Neonatal Nurs. 2014; 28(3): 196-203. doi: 10.1097/JPN.0000000000000039.
  • Bogen DL, Whalen BL, Kair LR, Vining M, King BA. Wide variation found in care of opioid-exposed newborns. Acad Pediatr. 2017; 17(4): 374-380. doi: 10.1016/j.acap.2016.10.003.
  • Price HR, Collier AC, Wright TE. Screening pregnant women and their neonates for illicit drug use: consideration of the integrated technical, medical, ethical, legal, and social issues. Front Pharmacol. 2018; 9:961. doi: 10.3389/fphar.2018.00961.
  • Yee LM, Wu D. False-positive amphetamine toxicology screen results in three pregnant women using labetalol. Obstet Gynecol. 2011; 117(2 Pt 2): 503-506.

David Golembeski

MD, FAAP

Dr. David Golembeski is a neonatologist at Rady Children's Hospital-San Diego and a professor of pediatrics at UC San Diego School of Medicine. He is medical director of Rady Children's NICU at Palomar Medical Center and of the NICU at Pomerado Hospital. Dr. Golembeski is a mentor for the CMQCC/CPQCC Mother & Baby Substance Exposure Initiative where he assists hospitals in improving patient-centered care to mothers and babies with substance exposure.  

David Kim

MD

Dr. David Kim is Associate Medical Director of the NICU at CHOC at Mission Hospital. He is also the Physician Leader for Quality Improvement in the management of Neonatal Abstinence at CHOC at Mission Hospital, Hoag Hospital, and Pomona Valley Hospital Medical Center.

Helen DuPlessis

MD, MPH

Dr. Helen DuPlessis is a Physician Principal at Health Management Associates.

She has a rich history of involvement in healthcare administration for a variety of organizations, expertise in program and policy development, practice transformation, public health, maternal, and child health policy, community systems development, performance improvement, and managed care. Prior to joining HMA, Dr. DuPlessis served as the chief medical officer with St. John’s Well Child and Family Center. Other notable professional experiences include her work as senior advisor to the UCLA Center for Healthier Children, Families and Communities where she provided leadership, research, program development support, counsel and representation to local, state and national efforts, and community level systems transformation. She also trained and mentored students in various disciplines and educational levels.

Jadene Wong

MD

Dr. Jadene Wong is Clinical Associate Professor of Pediatrics at Stanford University School of Medicine. She has practiced as a neonatal hospitalist at Lucile Packard Children’s Hospital Stanford for more than 10 years, and practiced in primary care outpatient community settings for more than 20 years.  She is a member of the task force for the joint CMQCC/CPQCC Mother & Baby Substance Exposure Initiative. She is also the Newborn Clinical Lead for this project and mentors Central California hospitals participating in the initiative.

Robert Castro

MD, FAAP

Dr. Castro is a Board-Certified Pediatric physician with a specialization in Neonatal-Perinatal Medicine.  Dr. Castro is currently the Director of the LPCH-affiliated NICU in Monterey County, CA and a Clinical Professor of Pediatrics at Stanford University School of Medicine.  He has completed a term as the President of the Southern Society of Pediatric Research and is a Fellow of the American Academy of Pediatrics (AAP).  He served on the AAP Perinatal Section Executive Committee and completed a six-year term on the AAP NeoReviews Journal Editorial Board.  More recently, he is a member of the CPQCC Advisory Board and in 2016, he was elected to the California Association of Neonatologists Board of Trustees.  In 2019, Dr. Castro was selected to serve on the American Board of Pediatrics-Subboard Neonatal Perinatal Medicine.

Vaneet Kalra

MD

Dr. Vaneet Kumar Kalra is a neonatologist and Associate Clinical Professor of Pediatrics (Neonatology) at UC Davis Children’s Hospital. He is also the Medical Director of Newborn Medicine at Adventist Health Lodi Memorial Hospital.