Why we are recommending this best practice
- The incidence of substance use in pregnancy is difficult to quantify. Toxicology testing in pregnancy combined with self-reporting may underrepresent the true incidence.
- If in utero substance exposure has been identified from either prenatal history or maternal toxicology testing, this information is vital for guiding assessment and treatment options and leads to improved outcomes for mothers and newborns.
- 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
- Newborns at risk for in utero exposure should undergo selective biological toxicology testing when the index of suspicion is high and diagnostic information from or about the mother is not available, such as when the mother had limited or no prenatal care, has unexplained symptoms of drug intoxication, or when the newborn has symptoms of potential substance exposure. 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 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 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).
- Hudak ML, Tan RC. Neonatal drug withdrawal. Pediatrics. 2012;129(2):e540-560.
- 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.
- Worley J. Identification and management of prescription drug abuse in pregnancy. J Perinat Neonatal Nurs. 2014;28(3):196-203.
- Bogen DL, Whalen BL, Kair LR, Vining M, King BA. Wide variation found in care of opioid-exposed newborns. Academic Pediatrics. 2017;17(4):374-380.
- 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. Frontiers in Pharmacology. 2018;9:961.
- 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.