Friday, August 29, 2014

The Governor’s Action Plan on Child Protective Services Reform Substance-Exposed Newborn Committee GUIDELINES FOR IDENTIFYING SUBSTANCE-EXPOSED NEWBORNS

A Publication Of:
The Governor’s Action Plan on Child Protective Services Reform
Substance-Exposed Newborn Committee
GUIDELINES FOR
IDENTIFYING
SUBSTANCE-EXPOSED
NEWBORNS
TABLE OF CONTENTS
LETTER FROM THE CHAIR 1
COMMITTEE LIST 3
INTRODUCTION 4
GUIDELINES 5
REFERRAL LIST 10
WEBSITES 12
REFERENCE ARTICLES 13
LETTER FROM THE CHAIR
January 2005
TO: Chairman, Obstetrics Department
Chairman, Pediatric Department
Chairman, Neonatology Departments
RE: Statewide Initiative to Identify Substance-Exposed Newborns
There is growing concern for the care and safety of substance-exposed newborns in Arizona
and nationwide. The care and safety of this vulnerable population has a profound effect on the
medical community and the child welfare system.
Under the direction of Governor Janet Napolitano, Arizona physicians with expertise in prenatal
substance abuse, Child Protective Services (CPS), Arizona Department of Health Services
(ADHS), Indian Health Services (IHS), and hospital social services have come together to
develop a consistent approach to identifying substance-exposed newborns.
Based on extensive medical literature review, review of other state guidelines, and input from
Arizona hospital newborn programs, this committee drafted Guidelines for Identifying
Substance-Exposed Newborns.
As a health care provider, you have an important role in identifying substance-exposed
newborns. These Guidelines have been developed to assist health care professionals:
· To improve your ability to effectively identify substance-exposed newborns;
· To standardize guidelines for maternal and neonatal screening in Arizona; and
· To improve the health and well-being for women and their at-risk newborns.
These Guidelines support the state law requirement that a health care professional, who
reasonably believes that a newborn infant may be affected by the presence of alcohol or
a drug, to immediately report this information, or cause a report to be made, to Child
Protective Services. For reporting purposes, "newborn infant" means a newborn infant who is
under thirty days of age (A.R.S. § 13-3620).
These Guidelines have been reviewed and commented upon by the following organizations:
American Academy of Pediatrics-Arizona Chapter (AzAAP), Arizona Medical Association
(ArMA) – Maternal Child Health Committee, Arizona Perinatal Trust, and the American College
of Obstetricians and Gynecologists – Arizona Chapter.
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Including these Guidelines in your policies and procedures for nursing staff, social services, and
medical staff will provide a consistent approach and avoid potential bias in the identification of
these newborns.
The attached documents will be maintained and updated on the Arizona Department of Health
Services website: www.azdhs.gov
Any questions related to these Guidelines may be directed to Susan M. Stephens-Groff, MD,
Medical Director, Comprehensive Medical & Dental Program, via email address:
susanstephens@azdes.gov
Sincerely,
Linda Johnson, MSW, LCSW
Manager, Policy and Program Development
Division of Children, Youth, and Families
Substance-Exposed Newborns Committee Chair
2
COMMITTEE LIST
Michelle Bez, MD
Phoenix Children’s Hospital, Neonatologist
Joanne Butler, MSW, LMSW
Navajo Nation Division of Social Services
Carla Conradt, MSW
ADES Division of Children Youth and
Families / Child Protective Services Hotline,
Program Manager
Nelda Dugi-Huskie, MSW, LMSW
Navajo Nation Division of Social Services
Juan Espitia, MSW, LCSW
Yuma Regional Hospital, Care Coordination/
Social Worker
Mary Ferrero, RN
ADES Division of Children, Youth and
Families / Children’s Medical and Dental
Program, Medical Services Manager
Carlos Flores, MD
Arizona Perinatal Trust, Neonatologist
Patty Graham, MD
Maricopa Medical Center, OB/GYN Specialist
in Perinatal Substance Abuse
Nancy Hansen,
ADES Division of Children Youth and
Families, Arizona Families F.I.R.S.T.,
Program Specialist
Linda Johnson, MSW, LCSW
ADES Division of Children, Youth, and
Families, Manager, Policy and Program
Development
Patti Mooers, MSW, ACSW, LCSW
Arizona Perinatal Social Workers
Association; Maricopa Medical Center,
NICU Social Worker
Carol Renslow,
ADES Division of Children, Youth and
Families / Children’s Medical and Dental
Program, Provider Services Manager
Marilyn Riebel, MSW, LCSW
Sierra Vista Regional Health Center, Social
Worker
Kelli Sieczkowski, MSW, LCSW
Flagstaff Medical Center, Social Work
Manager
Peggy Stemmler, MD
American Academy of Pediatrics, Arizona
Chapter President
Susan Stephens-Groff, MD
ADES Division of Children Youth and
Families / Children’s Medical and Dental
Program, Medical Director
Kathy Stribrny, RN
Arizona Health Care Cost Containment
System, EPSDT Coordinator
Christine Tien, MPH
Arizona Department of Health Services /
Office of Women and Children’s Health, High
Risk Perinatal Program Unit Manager
Alan Tupponce, MD
Phoenix Indian Medical Center
Glen Waterkotte, MD
Banner Desert Samaritan Hospital,
Neonatologist
Mary Wodecki, MSW
ADES Division of Children, Youth and
Families, Child Protective Services Specialist
III, Investigator – District 2
3
INTRODUCTION
Prenatal substance abuse of drugs or alcohol is a complex public health problem often resulting
in multiple consequences for a woman and her newborn. Drug use during pregnancy may result
in adverse effects on the health and well-being of the newborn in addition to the woman’s
health. Early intervention services for the newborn and mother are critical in minimizing the
acute and long-term effects of prenatal substance exposure. Thus, even if the newborn exhibits
no clinically significant difficulties in the neonatal period, identification of the substance-exposed
newborn may improve the infant’s long-term outcome.
In addition to the direct toxic effects of the drugs to the newborn, continued substance abuse by
the mother increases the risk for child abuse and neglect. Indeed, reports of child abuse and
neglect have increased dramatically over the past decade and are correlated with an increase
in drug use among primary caregivers.
Prenatal substance abuse is a condition that crosses all social, racial and ethnic groups. The
National Pregnancy and Health Survey estimated in 1995 that 5 percent of four million women
who gave birth in 1992 used illicit drugs during their pregnancies. According to the Arizona
Department of Health Services, in 2002, there were 87,379 births in Arizona. When national
statistics regarding the prevalence of prenatal substance abuse are applied, more than 4,500
Arizona newborns are affected by prenatal drug exposure annually.
A recent Centers for Disease Control and Prevention (CDC) survey found that 500,000
pregnant women reported alcohol use, with approximately 80,000 reporting binge drinking.
Every year in the United States, approximately 40,000 newborns will experience some degree
of learning or behavioral dysfunction or physical effect as a result of in-utero exposure to
alcohol. Approximately 5,000 newborns will be identified with Fetal Alcohol Syndrome.
In addition to individual negative outcomes, societal impact related to prenatal substance abuse
profoundly affects many facets of our communities. Successful identification and intervention
may result in substantial cost savings in health care, foster care, special education and
incarceration.
As a health care provider, you have an important role in identifying substance-exposed
newborns. These guidelines have been developed to assist health care professionals:
· To improve your ability to effectively identify substance-exposed newborns;
· To standardize guidelines for maternal and neonatal screening in Arizona; and
· To improve the health and well-being for women and their at-risk newborns.
Arizona Revised Statutes § 13-3620 requires a health care professional, who reasonably
believes that a newborn infant may be affected by the presence of alcohol or a drug, to
immediately report this information, or cause a report to be made, to Child Protective
Services. For reporting purposes, "newborn infant" means a newborn infant who is
under thirty days of age.
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GUIDELINES
Maternal Screening Criteria
Prenatal screening begins initially with the maternal interview. The following screening criteria
may identify substance use/abuse, which can impact the health of the mother and the newborn.
· History of previous or current substance use by mother and/or significant others living in
the home, or history of a previous delivery of a substance-exposed newborn.
· Non-compliance with prenatal care (late entry to care, multiple missed appointments, or
no prenatal care).
· Evidence of unexplained poor weight gain during the pregnancy.
· Medical non-compliance.
· Medical symptoms of withdrawal in the mother.
· Signs of substance use/abuse.
· Maternal medical history of Hepatitis B or C, HIV infection, or 2 or more sexually
transmitted diseases.
· Previous or current history of placental abruption or unexplained vaginal bleeding.
· Cardiovascular accident of the mother.
· Pre-term labor may be seen in association with substance use or abuse as reported in
the literature. It may be considered prudent to screen, if any of the above factors exist in
association with pre-term labor.
If positive for one or more of the above screening criteria, recommend:
· Testing of the mother*; and
· A referral for further assessment, including possible treatment services.
*Toxicology Consideration
Maternal urine toxicology will generally identify only common drugs of abuse (eg. cocaine,
marijuana, opiates, barbiturates, benzodiazopines, amphetamines, and PCP) that have been
used within the last 24 to 48 hours and will be negative if drugs were used earlier in the
pregnancy. Alcohol use is best identified by blood or saliva testing and some drugs such as
volatile inhalants can only be identified by special testing. You may wish to consult with a
toxicologist to determine the best way to screen for drugs that are not included in routine urine
drug screening.
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Neonatal Screening Criteria
Identification of substance-exposed newborns is determined primarily by clinical indicators in
the prenatal period including maternal and newborn presentation, history of substance use/
abuse, medical history, and/or toxicology results. Newborn toxicology screening should be
performed if the results will influence management of medical care for the mother and newborn,
including treatment options, and/or to confirm the maternal pattern of drug use.
Newborn toxicology screening:
· Confirms presence of substance of use and abuse.
· Determines use of multiple substances, which were not identified during the maternal
interview.
· Identifies the newborn that is at risk for withdrawal.
· Identifies substances or drugs that may be contraindicated in breastfeeding.
· Identifies newborns that may need protective services, and/or developmental follow-up.
· Identifies the mother who may need treatment services.
The recommended screening criteria for the newborn includes:
· Signs of neonatal abstinence syndrome which may include marked irritability, highpitched
cry, feeding disorders, excessive sucking, vomiting, diarrhea, rhinorrhea, or
diaphoresis.
· Unexplained apnea in the newborn.
· Microcephaly (when accompanied by additional symptoms).
· Birth weight <5th percentile for gestational age (unexplained intrauterine growth
restriction, or newborns who are small for gestational age).
· Cerebral vascular accident in the newborn (not otherwise considered at-risk).
· Other vascular accident in the newborn.
· Necrotizing enterocolitis (NEC) in the full-term newborn (or newborn not otherwise
considered at-risk for NEC).
· Positive maternal drug screen.
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If positive for one or more of the above screening criteria, recommend:
· Testing of the newborn* and a social service referral to identify potential
accompanying diagnoses; and
· Consider testing of the mother.
*Toxicology Consideration
Newborn urine toxicology: The first urine contains the highest concentration of drug or
metabolites. If this urine sample is missed, a confirmatory test is less likely, even in the
presence of intrauterine drug exposure. A negative urine toxicology result is common even in
the presence of substance use or abuse.
Limitations of newborn urine testing include:
· The first urine sample may be easy to miss.
· Bag urine collections for newborns are difficult to collect.
· Positive drug threshold values have not been scientifically determined.
· The threshold values for the newborn have been arbitrary set at the adult reference range.
· False negative urine toxicology may be the result of using a higher adult reference range in
the newborn population.
Meconium Testing: Meconium testing is the most reliable and comprehensive toxicology
screen in the newborn. Meconium formation starts between 16 to 20 weeks gestation, and
continues until birth. Newborn meconium testing will identify most substance used by the
mother after 20 weeks, such as: cocaine, marijuana, opiates, barbiturates, benzodiazopines,
amphetamines, and PCP. Best results are obtained by collecting multiple meconium
specimens. In addition, meconium is easier to collect.
Fatty acid ethyl esters (FAEEs) have been identified as an important biomarker of alcohol
consumption. They are formed by esterification of ethanol with free fatty acids. High levels of
FAEEs in meconium are a “direct biomarker reflective of true fetal exposure to ethanol in-utero”.
Supplemental meconium testing can identify FAEEs, by gas chromatography/mass
spectrometry (GC/MS) analysis and provides a 99% level of sensitivity in identifying FAEEs. If
the level is in the 3rd or 4th quartile, this is indicative of heavy alcohol exposure, which would
identify the infant at higher risk for effects from alcohol exposure.
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Further recommendations if above screening criteria are positive:
· Consider maternal and newborn testing for identification of related infections (Syphilis,
Hepatitis B or C, HIV).
· If maternal or newborn toxicology is positive for opiates, watch for onset of abstinence
syndrome in the newborn.
· Counsel mother that breastfeeding is contraindicated in the presence of a positive
history of cocaine, heroin, methamphetamine, PCP, or marijuana use.
· If the medical provider reasonably believes that a newborn infant may be affected by the
presence of alcohol or a drug, (per A.R.S. § 13-3620) immediately report this
information, or cause a report to be made, to Child Protective Services (CPS) at 1-888-
767-2445 (1-888-SOS-CHILD).
· Consider consultation with CPS prior to the newborn’s discharge.
· Consider Home Health nursing visit(s).
· The Primary Care Provider should notify CPS if there is poor follow-up with
recommended medical care, or if the newborn’s medical needs are being neglected.
Ethical Considerations
The subject of testing for drugs of abuse, particularly testing for those that are illegal, presents
ethical dilemmas for health professionals. On the one hand, the screening for the detection of
substances of abuse holds the promise of benefit to the mother with addiction problems that
may be remedied by treatment. On the other, the detection of illegal substances may lead to the
discovery of information that may require reporting to authorities. Reporting of detected illegal
substances in the mother may lead to criminal prosecution and incarceration as a form of
punishment. Similarly, detection in the infant may lead to mandated reporting to child protection
service agencies and lead to custodial litigation, prosecution, or other disruptions to the mother
and infant relationship.
Punitive approaches and incarceration have not been demonstrated to be beneficial in
improving health for mothers and infants. Foster placement of children and mandated entry to
complex child welfare systems with limited resources and capabilities may also lead to suboptimal
outcomes for both mother and infant. This may be especially true in our own State of
Arizona, where many of our child protective organizations and agencies are undergoing
dynamic change and development to improve the delivery of services for children. Hence, as is
the case with all decisions in medicine, practitioners are often faced with dichotomous choices,
each carrying broad implications that must be carefully weighed before potentially causing harm
to mothers and infants under their care.
Health professionals, when entering into a relationship with a patient, are bound by duty to act
in their best interest. Hence, the decision to obtain information through the use of body fluids or
tissues should be carefully weighed with an anticipated expectation of benefit for infant and
mother. As with any other medical intervention, drug, or treatment, the provider should weigh
the anticipated benefits carefully against the potential risks. For a health professional to do
otherwise is unethical.
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Another dilemma involves the patient’s right to privacy. Recent Supreme Court actions suggest
that collection of health information without the express consent of the patient, such as that
obtained during urine drug screening for other than directly medical indications, represents
unreasonable search and seizure. Thus, health professions organizations, including the
American Academy of Pediatrics, the American College of Obstetricians and Gynecologists,
and the Department of Health and Human Services generally recommend that drug screening
for substances of abuse be obtained on mother and infant only with the consent of the mother,
unless the medical situation demands otherwise.
These considerations demand care and thoughtfulness in the decision by health professionals
or institutions to implement procedures that involve the use of drug screening.
In an effort to maintain the interests of the pregnant woman and the newborn foremost in the
delivery of their care, the following guiding principles are suggested:
· Health professionals should be knowledgeable about state and local laws regarding
mandatory reporting of illegal drug detection in pregnant women and infants.
· Health professionals should be knowledgeable regarding the resources and facilities
available for treatment and management of substance abuse in their communities.
· Health providers should remain cognizant of the duty they assume when engaged in
the delivery of care to their patients. This duty requires their actions to be performed
in the best interest of the patient.
· Medical decision-making requires an assessment of risk and benefit to mother and
newborn. The potential risk and adverse consequences of screening and
identification of substance–exposed newborns should be weighed against the
potential benefits in a manner no different than as applied to other medical
interventions.
· Health providers should be aware of the legal implications of their actions in the
context of recent court decisions that uphold the rights of mothers against unlawful
search and seizure.
· In keeping with recommendations by health professions organizations, health
providers should obtain informed consent from patients (or the mother of an infant)
before chemical drug screening procedures except where this is not possible for
medical reasons.
Disclaimer
These guidelines are not an exclusive course of management. Variations that incorporate
individual circumstances or institutional preferences may be appropriate.
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REFERRAL LIST
Regional Behavioral Health Authorities
Maricopa County
ValueOptions
Four Gateway Plaza
444 N. 44th Street, Suite 400
Phoenix, Arizona 85008
Customer Service Number: 1-800-564-5465
Pima, Graham, Greenlee, Santa Cruz & Cochise counties
Community Partnership of Southern Arizona (CPSA)
4575 East Broadway Blvd.
Tucson, Arizona 85711
Customer Service Number: 1-800-771-9889
Mohave, Coconino, Apache, Navajo & Yavapai counties
Northern Arizona Regional Behavioral Health Authority (NARBHA)
1300 S Yale Street
Flagstaff, Arizona 86001
Customer Service Number: 1-800-640-2123
Pinal & Gila counties
Pinal Gila Behavioral Health Association, Inc. (PGBHA)
2066 West Apache Trail, Suite 116
Apache Junction, Arizona 85220
Customer Service Number: 1-800-982-1317
Yuma & La Paz counties
The Excel Group
2573 Arizona Ave. Ste. #1
Yuma, AZ 85364
Customer Service Number: 1- 800- 880-8901
Community Information and Referral
Yuma, La Paz, Cochise, Maricopa, Mohave, Coconino, Apache, Navajo, Yavapai, Pinal and
Gila counties
1-800-352-3792 or (602) 263-8856
Information and Referral
Pima, Graham, Greenlee, Cochise & Santa Cruz counties
1-800-362-3474 or (520)-881-1794
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Specialty Programs for Mothers and
Infants
Maricopa County
ValueOptions
Native American Connections
609 N 2nd Avenue, #120
Phoenix AZ
(602) 424-2060
Elba House (owned and operated by Ebony
House)
6222 S. 13th Street
Phoenix AZ
(602) 276-4288
New Arizona Family, Inc.
3301 E. Pinchot
Phoenix AZ
(602) 553-7300
Casa de Amigas (no children)
1648 W Colter #8
Phoenix AZ
(602) 265-9987
Center for Hope (owned and operated by
Community Bridges)
554 S. Bellview
Mesa, AZ 85204
(480) 831-7566
Pima, Graham, Greenlee, Santa Cruz &
Cochise counties
Community Partnership of Southern
Arizona (CPSA)
CODAC Behavioral Health Services
333 W Ft. Lowell #219
Tucson, AZ 85705
(520) 327-4505
Fax: (520) 792-0033
Las Amigas
502 Silverbell Road
Tucson, AZ 85745
(520) 882-5898
The Haven
1107 E. Adelaide
Tucson, AZ 85719
(520) 623-4590)
Amity Foundation
Robin Rettmer
Director of Family Services
(520) 749-5980
Fax: (520) 749-5569
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WEBSITES
American Academy of Pediatrics
www.aap.org
American College of Nurse Midwives (ACNM)
www.acnm.org
American College of Obstetrics and Gynecologists (ACOG)
www.acog.org
American Society of Addiction Medicine
www.asam.org
Arizona Department of Economic Security
www.azdes.gov
Arizona Department of Health Services
www.azdhs.gov
Association of Women’s Health Obstetric and Neonatal Nurses (AWHONN)
www.awhonn.org
National Clearinghouse for Alcohol and Drug Information
www.health.org
National Institute for Drug Abuse
www.nida.nih.gov
National Organization on Fetal Alcohol Syndrome (NOFAS)
www.nofas.org
Pacific Southwest Technology Transfer Center
www.psattc.org
Physician Leadership on National Drug Policy
www.plndp.org
Substance Abuse Mental Health Services Administration (SAMHSA)
www.samhsa.gov
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REFERENCE ARTICLES
Chasnoff IJ, et.al.: Prenatal substance exposure: Maternal screening and neonatal identification
and management. NeoReviews 2003; 4(9) 228-234.
Graham K, Koren G, Klein J, Scheiderman J, Greenwald M. et.al.: Determination of gestational
cocaine exposure by hair analysis. JAMA 1989;262:3328-3330.
Gillogley KM, Evans AT, Hansen RL, Samuels SJ, Batra KK, et.al.: The perinatal impact of
cocaine, amphetamine, and opiate use detected by universal intrapartum screening. Am J
Obstet Gynecol 1990;163:1535-1542.
Callahan CM, Grant TM, Phipps P, Clark G, Novack AH, Streissguth AP, Raisys VA, et.al.:
Measurement of gestational cocaine exposure: Sensitivity of infants’ hair, meconium, and urine.
J Pediatr 1992;120:763-768.
Hansen RL, Evans AT, Gillogley KM, Hughes CS, Krener PG, et.al.: Perinatal Toxicology
Screening. Journal of Perinatology 1992; XII:220-224.
Ostrea EM, Welch RA, et.al.: Detection of prenatal drug exposure in the pregnant woman and
her newborn infant. Clinics in Perinatology September 1991;18:629-645.
Osterloh JD, Lee L, et.al.: Urine drug screening in mothers and newborns. AJDC July
1989;143:791-793.
Maynard EC, Amoruso LP, Oh W, et.al.: Meconium for drug testing. AJDC June 1991;145:650-
652.
Woolf AD, Shannon MW, et.al.: Clinical toxicology for the pediatrician. Pediatric Clinics of North
America April 1995;42:317-333.
Chasnoff IJ, Landress HJ, Barrett ME, et.al.: The prevalence of illicit-drug or alcohol use during
pregnancy and discrepancies in mandatory reporting in Pinellas County, Florida.
Howard CR, Lawerence RA: Breast-feeding and drug exposure.
Obstetric and Gynecology Clinics of North America 1998; 25(1), 195-217.
Kandall, SR: Treatment strategies for drug-exposed neonates. Clinics in Perinatology 1999;
231-243.
American Academy of Pediatrics, Committee on Drugs. The transfer of drugs and other
chemicals in human milk. Pediatrics 2001; 108(3):776-789.
American Academy of Pediatrics, Committee on Drugs. Neonatal drug withdrawal. Pediatrics
June 1998; 101(6):1079-1088.
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American Academy of Pediatrics, Committee on Fetus and Newborn. Hospital stay for healthy
term newborns. Pediatrics Oct 1995; 96(4):788-790.
American Academy of Pediatrics, Committee on Fetus and Newborn. Hospital discharge for
the high-risk neonate--proposed guidelines. Pediatrics Aug 1998; 102(2):411-417.
Perinatal substance use: A guide for hospitals and health care providers. Virginia Department
of Health Services, Division of Women and Infant’s Health 2003.
Hale’s Medications and Mother’s Milk 2004; 119, 198-199, 405.
Madden JD, Payne TF, Miller S: Maternal and fetal effect on the newborn. Pediatrics 1986;
77:209-211.
Oro AS, Dixon SD: Perinatal cocaine and methamphetamine exposure: Maternal
and neonatal correlates. J Pediatr 1987; 111:571-578.
Bauer CR, Shankaran S, Bada HS, et al: Maternal Lifestyles Study (MLS):
Effects of substance abuse exposure during pregnancy on acute maternal
outcomes. Pediatr Res 1996; 39:257A.
Kwong TC, Ryan RM: Detection of intrauterine illicit drug exposure by newborn drug testing.
Clinical Chemistry 1997; 43:235-242.
Drugs and pregnancy. American Council for Drug Education’s Facts for Parents 1999.
Drinking and your pregnancy. National Institute on Alcohol Abuse and Alcoholism 1996;
96:4101.
American Academy of Pediatrics, Committee on Substance Abuse. Drug-exposed infants.
Pediatrics 1993; 96:364.
American College of Obstetricians and Gynecologists. Substance abuse in pregnancy.
Technical Bulletin #195: July 1995.
Mitchell JL: Pregnant, substance-using women, treatment improvement protocol. U.S.
Department of Health and Human Services 1993; DHHS Publication No. (SMA) 95-3056.
Millard D: Toxicology testing in neonates: Is it ethical, and what does it mean? Clinics in
Perinatology 1996; 23:491.
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Arizona Department of Economic Security
Administration for Children, Youth and Families
1789 West Jefferson, Third Floor SE
Phoenix, Arizona 85007
(602) 542-3598
www.azdes.gov
Every child, adult and family in Arizona will be safe and economically secure.

 

http://www.governor.state.az.us/cps/documents/SenGuidelines.pdf