Perinatal Drug Abuse and Neonatal Drug Withdrawal Workup

Updated: Dec 09, 2020
  • Author: Marvin Wang, MD; Chief Editor: Dharmendra J Nimavat, MD, FAAP  more...
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Workup

Laboratory Studies

Generally, perinatal information is enough to provide clues about the mother and her history of drug abuse, as well as urine toxicology screening at the time of admission to the hospital for delivery. Based on the information obtained, clinicians also need to examine the infant and see if further investigation is clinically warranted in addition to sending urine and meconium or umbilical cord samples for toxicology screening.

Typically, a sepsis work-up is not routinely performed solely because of drug exposure; however, a thorough review of the perinatal history and examination of the newborn is warranted.

The following studies are indicated when assessing perinatal drug abuse and neonatal drug withdrawal:

  • Obtain serum glucose and calcium levels.

  • Obtain a complete blood cell (CBC) count with differential and platelets.

  • Consider blood culture and other cultures to rule out newborn sepsis.

  • Confirm maternal hepatitis status and treat accordingly.

  • Confirm human immunodeficiency virus (HIV) status.

  • The advent of umbilical cord testing has shown promise, as such tissue can be more readily sampled at the time of birth. There is a high correlation between this tissue sample with meconium specimens. [36]

  • Neonatal hair analysis may prove useful in confirming fetal drug exposure and possibly predicting neonatal withdrawal severity. Hair analysis should be used in conjunction with urine and meconium analysis.

Toxicology screening

A maternal urine toxicological screen may be helpful in determining drug use. A urine screen only signifies recent use or heavy use of drugs. In general, the length of time that a drug is present in urine after use is as follows:

  • Marijuana: 7 days to 1 month in an adult, perhaps even longer in an infant

  • Cocaine: 24-28 hours in an adult, 72-96 hours in an infant

  • Heroin: 24 hours in an adult, 24-48 hours in an infant

  • Methadone: Up to 10 days in an infant

Neonatal toxicology screening should also include algorithms using meconium testing. [37]  Meconium testing provides higher sensitivity than urine testing and is comparable to umbilical cord tissue samples.

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Other Tests

In 1986, Finnegan et al created the Neonatal Abstinence Scoring System, which provides an objective measure of a newborn's symptom severity (see image below). [38]

Perinatal Drug Abuse and Neonatal Drug Withdrawal. Perinatal Drug Abuse and Neonatal Drug Withdrawal. Neonatal abstinence scoring form.

This system is currently used as a diagnostic tool and as a monitor for the response of a newborn with withdrawal to pharmacotherapy.

  • Each of the 21 different symptoms is scored depending on severity. All scores are then added. Scoring is performed in 4-hour intervals. If the newborn receives a score of 8 or greater, then scoring should occur every 2 hours. If the scores in the first 96 hours of life are consistently 8 or less, then scoring can be discontinued and pharmacotherapy is typically not needed.

  • If the maternal urine screen or history is positive for drug use, first assess the infant at 2 hours after birth. Scores should reflect the symptoms observed during the entire interval, not just at a single point. Scores involving sleep and behavior should reflect any changes during the test period. For instance, if the child was awakened for the examination, do not score against the child for diminished sleep.

  • A higher total score implies a more severe withdrawal syndrome. Likewise, as the child responds to treatment, use the scores to titrate the amount of pharmacotherapy needed.

  • Although the scoring system is primarily designed for withdrawal from opiates or CNS depressant drugs, it has been used for other drugs (eg, cocaine, amphetamines). Its efficacy in these situations is likely from a preponderance of polypharmacy use.

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Imaging Studies

Magnetic resonance imaging (MRI)

In a study that evaluated the the brains of 118 newborns born to 118 mothers with marijuana, cocaine, and/or methadone maintenance and/or heroin use, there appeared to be anatomic abnormalities at similar sites among the three groups, including smaller volumes in the dorsal, medial, and ventral surfaces of the frontal lobe, as well as dose-related increases in volumes in the lateral temporal lobe, dorsal parietal lobe, and superior frontal gyrus. [39]  Also similar among the drug exposures were dose-related increases in diffusion tensor measures of tissue organization, decreases in T2 relaxometry times, and increases in spectroscopy metabolite concentrations. The investigators indicated the findings suggest an association between prenatal drug exposure and measures of newborn brain tissue in patterns that may indicate such exposures accelerate normal fetal brain maturation as well as mediate associations of these drug exposure with poorer 12-month infant outcomes. [39]

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