Today, you are the doctor in the well-baby nursery. As you walk from one hospital room to the next, talking with new parents, most of your patients are healthy. Your job is to ensure that rare but serious health problems don’t go undetected before these babies go home with their parents. As you walk by the nurses’ station, a nurse pulls you aside.
“The baby in room 7 is jittery,” she tells you. “And he just seems fussy. The resident had me check his blood sugar and calcium levels. Both were normal.”
You stand silent for an extra beat, waiting to see what else the nurse might say.
“Has anyone asked the mom how she thinks her baby is doing?” You say this because a parent’s perspective always matters.
“I don’t know,” the nurse offers.
“Thank you for letting me know your concerns. Let me go look at him.”
You knock, open the door, sit down beside this mother, and offer congratulations on the birth of her child. You ask if you can examine him.
As you unwrap his blanket, his arms move with an irregular, exaggerated jerking. As you move his limbs, then lift him up, you notice increased muscle tone in his arms and legs. He starts crying so you place his pacifier in his mouth. He begins to suck and calms.
You talk to his mother about her pregnancy, which was, by her account, uncomplicated. She tells you she missed a few prenatal care appointments because she could not miss work. After three days in the hospital recovering from her unremarkable, repeat cesarean delivery, she is expecting to take her baby home today.
“How do you think your baby is doing overall,” you ask her.
“He seems fine,” she affirms. “He’s acting just like his sister.”
You swaddle him back to sleep then leave their room. The nurse catches you in the hall.
“Do you think we should send a urine drug screen?” she asks. This is a nurse you know well; someone you trust to provide exceptional care to families.
She is worried about opioid withdrawal because babies with this condition can be jittery and fussy. She wants to know for sure what is going on.
Why Are Babies Tested For Drugs?
When clinicians witness signs that may indicate opioid withdrawal in a newborn, they must decide whether or not to order a urine drug screen in the baby or the birthing parent.
It is a decision that must balance the potential harm from not identifying opioid withdrawal at birth with the dangers a family may face from testing babies whose birthing parents have no history of opioid use, including fractured trust in the health care system, potentially unnecessary and traumatic exposure to child protective services or even family separation.
Several recent studies suggest that various forms of racism influence clinician decision making about which birthing parents and babies receive drug testing at the time of delivery or in the days after birth. This research indicates that health care systems must accept and address the bias baked into perinatal and newborn drug testing. This will require clinicians—and the health systems in which we work—to partner with the nation’s child welfare systems to promote family stability and infant well-being equitably and safely.
Failure to identify a baby with neonatal opioid withdrawal syndrome (NOWS) could result in serious complications. Babies with severe withdrawal from opioids who do not receive appropriate medical care may cry inconsolably and struggle to eat. These symptoms are usually apparent within the first few days of life in the newborn nursery. When NOWS goes undetected and managed, the worst-case scenarios may include seizures or death.
When pregnant people partner with their obstetric providers to safely manage opioid use disorder during pregnancy, caring for opioid-exposed newborns is straightforward and severe complications are rare. Newborns with in utero opioid exposure may have a physiologic dependence; they do not manifest addiction or addictive behaviors and thus should not be described as addicted so as to mitigate the cycle of stigma their parents faced. These days, there is strong evidence that in treating babies for opioid dependence, outcomes improve when birthing parents remain together with their baby.
But it’s not always that easy. Sometimes, even without a known history of maternal substance use, newborns develop symptoms that might indicate opioid withdrawal. This could mean that something else is causing the symptoms. Or it could mean that the birthing parent has not disclosed their substance use to their health care providers. In these cases, physicians may need to decide whether to test these babies for opioids both to ensure NOWS is appropriately managed if present and to guide birthing parents with respect to safe infant feeding practices and opioid use disorder treatment for themselves.
One recent study took place in and around a Pittsburgh, Pennsylvania, institution in which the hospital policy recommended performing urine drug testing on birthing people with a positive verbal prenatal screen adapted from the National Institute on Drug Abuse, a history of substance use, few prenatal visits, or abruption/stillbirth without a clear explanation. Researchers found that, at the time of labor and delivery, Black birthing patients were more likely to receive urine drug testing than White birthing patients, regardless of substance use history.
This disparity belied the reality that it was the population of White patients who actually had a higher incidence of positive drug testing for any kind of opioid (prescribed or unprescribed).
A second study concluded that Black infants at a Midwestern medical center were 31 percent more likely to be tested for drugs by their pediatric providers than White infants. Black newborns in this study had more drug testing, even though White infants were more likely to test positive for opioids. The researchers also observed that differential testing practices were not due to differences in maternal self-reports of drug use or prenatal drug testing results.
These researchers’ findings raise questions about how clinicians determine which babies need drug testing. Testing newborns for drugs is fraught with problems in part because there are no universal criteria to guide decision making. This has led to the practice across the United States that, the evidence shows, is not random, but rather reflective of discriminatory practices.
For instance, some hospitals test babies whose mothers had an “inadequate” number of prenatal care visits. However, an inadequate number of prenatal visits may be driven, not by substance use, but instead by a pregnant person’s rurality, living in a maternity care desert, lack of flexible employment or childcare, or experiences of discrimination within traditional health care settings. This research begs stakeholders to address how structural and interpersonal racism experienced by Black families before, during, and after pregnancy impact current newborn drug testing practices.
A Further Complication: Cannabis And Newborn Drug Testing
One unintended consequence of increased perinatal drug testing for opioid use disorder is the increased incidental identification of cannabis exposure. This seems to be the case despite the fact that the two—opioid use and cannabis exposure—are not typically associated.
Work from Massachusetts illustrated that when pregnant patients acknowledge cannabis use, unexpected opioid exposure is rarely discovered with newborn drug screening. What is more, infants exposed to cannabis during pregnancy do not display symptoms consistent with opioid withdrawal in the newborn period.
Still, isn’t identifying cannabis exposure a good thing—even if that’s not what a provider was initially screening for? In theory, yes. When pregnant people use cannabis, their babies are more likely to be born preterm or struggle with low birthweight. Children exposed to cannabis in utero may later have difficulty with memory, attention, impulse control, learning challenges, and executive functioning as they get older, although not all studies support these observations. Cannabis exposure may thus not be ideal for fetal development, but cannabis exposure alone does not require additional medical care at birth.
To be sure, perinatal drug testing could theoretically identify infants exposed to cannabis who may be at risk for developmental delay. Such identification could then set the stage for potential developmental screening later in childhood, and the subsequent provision of extra services if necessary. But this is not currently standard practice.
Yet, there are also potential harms from the unintentional identification of cannabis exposure. The repercussions of a newborn drug test that is positive for cannabis can be severe for a family.
The 2016 Child Abuse and Prevention and Treatment Act (CAPTA) stipulates that states must arrange plans of safe care for any substance-exposed newborn including a notification to child protective services. Cannabis is currently regulated for legal use in 38 states, three territories, and the District of Columbia. And it has been decriminalized even in places where it is not yet legalized. Nevertheless, cannabis is still an illicit substance under federal law and must be reported. Although CAPTA does not require that newborns be tested or that reports be filed as neglect or abuse, these are common misconceptions.
Different municipalities handle reports of prenatal cannabis exposure differently. Some states and local municipalities, such as Pennsylvania, where we live and practice, are trying to individualize their response to hospital reports of newborns who test positive for any illicit drug, including cannabis. This approach aims to determine which families require further child welfare investigation and which may need only educational resources and access to social support programs in the newborn period. An individualized approach is not, however, immune to racism.
Because child welfare protocols differ based on municipality, policies vary around the nation regarding how to handle cases of fetal exposure to cannabis. A newborn drug test that results as positive for cannabis alone may lead to an in-depth investigation of a family by the local child welfare system. Unfortunately, data also show that child welfare systems disproportionately take Black children from their biological parents. The Biden administration recently noted that infant foster placements account for the fastest-growing age group in foster care.
Approaches to positive neonatal drug screens that are punitive and are known to disproportionately increase some families’ risk of separation over others have another potential unintended consequence. Such policies may discourage families who would benefit from substance use cessation resources from disclosing personal or family history of these disease conditions, thereby preventing clinicians from providing appropriate medical care and support.
Next Steps
Healing from generations of racial injustice requires understanding and dismantling practices rooted in structural racism that disadvantage our nation’s Black residents.
The recent large studies reviewed here confirm findings from smaller contemporary cohorts and older papers that Black maternal-infant dyads are more likely to receive drug testing, irrespective of risk factors. Furthermore, such testing is most likely to identify cannabis. Public health strategies such as those surrounding alcohol and tobacco use in pregnancy can and should be bolstered to also support maternal avoidance of cannabis during pregnancy. However, reporting parents to child welfare when their newborns test positive solely for cannabis is problematic; it raises the risk of intrusive investigations and has the potential to harm families.
We also strongly believe that systems should not universally test every pregnant person or baby, for at least three reasons. First, routine drug testing is rarely clinically indicated. Second, universal surveillance of pregnant patients has historically exacerbated racial disparities in child protective service referrals. And finally, under current law incidental identification of cannabis exposure is treated with variable and potentially punitive consequences that may cause far more harm to the child and family.
So how do we keep babies safe and ensure we are providing just and equitable newborn care to all families? Eliminating the potential for discrimination in hospitals requires systemic change and cannot rest on the shoulders of individual clinicians caring for babies.
One path forward includes standardized guidelines advising pediatric clinicians on newborn drug test practices across hospitals locally and nationally. Such guidelines should be developed collaboratively by pediatrician and obstetric providers, who already formally oppose criminalization of individuals during pregnancy. De-siloeing and standardizing maternal and newborn drug testing guidelines can help ensure a streamlined equitable approach to drug testing for the entire maternal-infant dyad that is focused on only testing families who consent and for whom further data are needed to better tailor clinical management or counseling.
For instance, situations in which an infant may possibly have NOWS and is responding to the evidence-based practice of Eat, Sleep, Console, neonatal drug testing will not change clinical management and may thus be avoided.
Another structural solution would be to remove cannabis from the hospital-based newborn laboratory drug tests used for clinical toxicology testing pathways as this result serves only to trigger reporting without adding benefit to newborn clinical care or follow-up.
In addition, local municipalities could consider an approach to newborn drug screens that prioritizes keeping families together and increasing access to local support programs that optimize parental and infant well-being. Finally, health care systems might consider aggregating the notification data that are sent to child protective services systems, as is allowed by CAPTA, to decrease the odds of potentially punitive investigations for families without concerns of abuse or neglect.
Pediatricians across our nation are striving to eliminate systemic racism from our clinical care and maintain trusting partnerships with the families we serve. Part of this work will require constant reflection on how our medical decision making regarding newborn drug testing impacts the families we serve. By reclaiming urine toxicology testing for clinically relevant medical care and decoupling it from the child welfare system, we can work toward keeping families together, safely—at birth and always.
