Newborn Drug Testing Guidelines

 

Guidelines for Testing and Reporting Drug
Exposed Newborns in Washington State
June 2012
Division of Prevention and Community Health
Office of Healthy Communities
DOH 950-151 June 2012
For more information or additional copies of this report contact:
Office of Healthy Communities
Access, Care and Coordination
310 Israel Road SE
PO Box 47833
Olympia, Washington 98504-7833
Phone: 360-236-3563
FAX: 360-586-7868
Table of Contents
EXECUTIVE SUMMARY ...................................................................................................................... 1
Introduction ............................................................................................................................................... 3
Indicators for Testing ................................................................................................................................ 3
Hospital Policy .......................................................................................................................................... 3
Table 1: Newborn Risk Indicators ............................................................................................................ 4
Table 2: Maternal Risk Indicators ............................................................................................................ 4
Consent Issues for Testing ........................................................................................................................ 5
Table 3: Newborn Drug Testing ............................................................................................................... 6
Table 4: Management of a Newborn with Positive Drug Toxicology ...................................................... 6
Reporting to Children’s Administration ................................................................................................... 7
Appendix A: References and Resources .................................................................................................. 8
Appendix B: Guidelines of Obtaining Consent from Parents for Infant Drug Testing ......................... 10
Appendix C: Sample Parent Letter: Information for Parents Whose Newborn
Has Been Placed on Administrative Hold ......................................................................... 12
Appendix D: Neonatal Abstinence Syndrome Scoring System ............................................................ 13
Appendix E: DSHS Children's Admistration Prenatal Substance Abuse .............................................. 14
Page 1 of 16 2012
EXECUTIVE SUMMARY
This document provides guidance to health care providers and affiliated professionals about maternal
drug screening, laboratory testing and reporting of drug-exposed newborns delivered in Washington
State. We created this document in response to an increasing number of requests from hospital staff
and attorneys seeking information on this complex topic. We want to promote consistent practice
among health care providers. This work is a collaborative effort between the Washington State
Department of Health and the Department of Social and Health Services.
In 2003, Congress enacted the Keeping Children and Family Safe Act which requires each state, as a
condition of receiving federal funds under the Child Abuse Prevention and Treatment Act, to develop
policies and procedures “to address the needs of infants born and identified as being affected by
illegal substance abuse or withdrawal symptoms resulting from prenatal drug exposure.” This law
requires health care providers who deliver or care for such infants, to notify Child Protective
Services. This differs from the existing legal duty to report suspected child abuse or neglect. The
federal law specifies that such reports of prenatal substance exposure shall not be construed to be
child abuse or neglect and shall not require prosecution of the mother.
Department of Health and Department of Social and Health Services cannot provide legal counsel on
this topic, but the following key points are included in this guidelines document:
• Each hospital with perinatal/neonatal services should develop a defined policy for identifying
intrapartum women and newborns for substance use/abuse. Hospital risk management, nursing
and social service, medical staff, and local Department of Social and Health Services Children’s
Services should be involved. The hospital policy should be written in collaboration with
local/regional Child Protective Services guidelines and include consent and reporting issues.
• Newborn testing should be performed only with evidence of newborn and/or maternal risk
indicators.
• Newborn drug testing is done for the purpose of determining appropriate medical treatment.
• No uniform policy or state law exists regarding consent for newborn drug testing.
• Hospitals are encouraged to report all positive toxicology screens (mother or infant) to Child
Protective Services. Reporting of this information, in and of itself, is not an allegation of abuse or
neglect. The healthcare team acts as advocate for mother and newborn.
• Health care providers remain mandated reporters of child abuse and neglect under state law and
are required to notify Child Protective Services when there is reasonable cause to believe a child
has been abused or neglected. The presence of other risk factors or information combined with a
positive toxicology screen may require that a report of child abuse or neglect be made to Child
Protective Services in any given case.
• All women should be informed about planned medical testing, the nature and purpose of the test,
and how results will guide care, including possible benefits and/or consequences of the test. Drug
testing is based on specific criteria and medical indicators, not open-ended criteria such as
“clinical suspicion” that invite discriminatory testing.
Page 2 of 16 2012
• If the woman refuses testing, maternal testing should not be performed. However, testing of the
newborn may still occur if medically necessary or if newborn and/or maternal risk indicators are
present. Department of Health strongly recommends that each institution develop, in
collaboration with its attorneys, justification and process for newborn testing. The justification
and process for newborn testing will be specific to the written policy of each institution.
• If there exists reasonable cause to believe leaving a newborn in the custody of the child’s parent
or parents would place the child in danger of imminent harm, a hospital may choose to place an
administrative hold on the newborn and notify Child Protective Services per Revised Code of
Washington (RCW).26.44.056. Department of Health recommends that each institution develop
in collaboration with its attorneys the justification and process for placing administrative hold on
a newborn. Child Protective Services may obtain custody of the newborn by court order or a law
enforcement transfer of protective custody and may then give permission to test the newborn in
order to safeguard the newborn’s health.
Page 3 of 16 2012
Introduction
The purpose of this document is to provide consistent guidance to health care professionals and
hospitals about to maternal screening* and testing** and reporting drug-exposed newborns born in
Washington State hospitals.
This document is a collaborative effort between the Department of Health and Department of Social
and Health Services, two separate agencies. The Washington State Department of Health is
responsible for preserving public health, monitoring health care costs, maintaining minimal standards
for quality health care delivery, and planning activities related to the health of Washington citizens.
The Washington State Department of Social and Health Service is the state umbrella social service
agency. Its mission is to improve the quality of life for individuals and families in need by helping
people achieve safe and self-sufficient, healthy and secure lives.
Indicators for Testing
Maternal drug testing is based on specific criteria and medical indicators, not open-ended criteria
such as “clinical suspicion” that invite discriminatory testing. Evidence-based risk indicators should
also be used as a guide for performing drug toxicologies on newborns. Due to the limited time
window for detection of drugs, difficulties in collecting specimens, as well as costs incurred for
testing, all newborns with evidence of newborn risk indicators (Table 1) and/or maternal risk
indicators (Table 2) should be tested for drug exposure, unless a different medical cause is identified.
Laboratory testing of newborns should be done for the purpose of determining appropriate medical
treatment. It is unnecessary to test a newborn whose mother has positive drug toxicology; her
newborn is presumed to be drug exposed.
Hospital Policy
Each hospital should work with risk management attorneys, nursing, social service, and medical staff
to develop a defined policy for identifying intrapartum women and newborns for substance
use/abuse. This policy should address specific evidence-based criteria for testing the woman and her
newborn, timing of tests, test types, and consent issues. The justification and process for newborn
testing will be specific to the written policy of each institution. All healthcare providers should be
informed of the policy and educated in its use. Health care professionals may need additional
education regarding how to approach and motivate women to make an informed choice regarding
testing.
For in-depth guidance for screening, identifying, and referring women for treatment please refer to
the Substance Abuse During Pregnancy: Guidelines for Screening best practice booklet located
online at: http://here.doh.wa.gov/materials/guidelines-substance-abuse-pregnancy
Another referral resource is the Pregnant Women Chemical Dependency/Abuse Resource
Guide/Matrix.
http://www.dshs.wa.gov/pdf/dbhr/PPW%20Services%20Guide%20February%202012.pdf
*Screening: methods used to identify risk of substance abuse during pregnancy and postpartum,
including self-report, interview and observation.
Page 4 of 16 2012
**Testing: process of laboratory testing to determine the presence of a substance in a specimen.
Table 1
Newborn Risk Indicators
It is not necessary to test a newborn with signs of drug withdrawal whose mother has a positive drug
test. This newborn may be presumed drug-exposed. This does not preclude doing a separate test of
the child if medically indicated.
Newborn characteristics that may be associated with maternal drug use include: (American College
Obstetricians and Gynecologists, 2008)
• Positive maternal toxicology screen
• Jittery with normal glucose level
• Marked irritability
• Preterm birth
• Unexplained seizures or apneic spells
• Unexplained intrauterine growth restriction
• Neurobehavioral abnormalities
• Congenital abnormalities
• Atypical vascular incidents
• Myocardial infarction
• Necrotizing enterocolitis in otherwise healthy term infants
• Signs of neonatal narcotic abstinence syndrome include: marked irritability, tremors, increased
wakefulness, hyperactive deep tendon reflexes, exaggerated Moro reflex, seizures, high pitched
cry, feeding disorders, excessive sucking, vomiting, diarrhea, rhinorrhea, diaphoresis (Hudak
2012; see Appendix A):
Note: Neonatal signs of fetal dependence may be delayed as long as 10-14 days, depending upon
the half-life of the substance in question.
Preterm infants are less likely to overtly exhibit at-risk behaviors in spite of substance exposure. In a
recent study, lower gestational age was associated with lower risk of withdrawal. The decrease in
severity of signs in the preterm infant may relate to developmental immaturity of the CNS,
differences in total drug exposure or lower fat deposits of the drug. (Hudak 2012). Immature organ
systems may also modify test results. In addition, scoring tools for withdrawal were developed in
term or late preterm infants.
Table 2
Maternal Risk Indicators
Maternal characteristics that suggest a need for biochemical testing of the newborn include:
(American College Obstetricians and Gynecologists, 2008)
• No prenatal care
• Previous unexplained fetal demise
• Precipitous labor
• Abruptio placentae
• Hypertensive episodes
• Severe mood swings
• Cerebrovascular accidents
• Myocardial infarction
Page 5 of 16 2012
• Repeated spontaneous abortions
Additional characteristics that suggest methamphetamine use:
(American College Obstetricians and Gynecologists, 2011)
• Gum or periodontal disease including broken teeth, severe decay, infections
• Significant weight loss, low BMI, malnutrition
• Psychiatric symptoms such as anxiety, panic, hallucinations and psychosis
• Skin conditions: abscesses, dry or itchy, acne type sores.
Consent Issues for Testing
Controversies still exist regarding the extent to which maternal consent is required prior to toxicology
testing of either the mother or the newborn. No uniform policy or state law exists regarding consent
for newborn drug testing. This is a complex issue and hospitals, with advice from their risk
management staff and legal counsel, should determine when it is necessary to obtain specific consent
to test newborns and their mothers. A positive drug test is not in itself a diagnosis, nor does
substance abuse by itself prove child neglect or inadequate parenting capacity (American College
Obstetricians and Gynecologists, 2005).
Refer to Substance Abuse During Pregnancy: Guidelines for Screening, for a more detailed
discussion of consent issues: http://here.doh.wa.gov/materials/guidelines-substance-abuse-pregnancy
The importance of clear and honest communication with the woman regarding drug testing cannot be
overstated. The health care team should act as advocate for mother and newborn. This relationship is
more difficult to establish if a woman is notified of testing after the fact. Therefore, all women
should be informed about planned medical testing. Explain and document the nature and purpose of
the test and how results will guide management, including possible benefits and/or consequences of
the test.
The rationale for testing and the parental discussion should be documented in the medical record. If
the woman refuses testing, this should be documented and maternal testing should not be performed.
In Ferguson v Charleston, SC, 532 US 67 (2001) the Supreme Court ruled that testing without
maternal consent for the purposes of criminal investigation violated the mother’s Fourth
Amendment rights. (Lester, 2004)
However, testing of the newborn may still occur if newborn and/or maternal risk indicators are
present. Department of Health strongly recommends that each institution develop, in collaboration
with its attorneys, justification and process for newborn testing. If there exists reasonable cause to
believe leaving a newborn in the custody of the child’s parent or parents would place the child in
danger of imminent harm, a hospital may choose to place an administrative hold on the newborn and
notify Child Protective Services per RCW.26.44.056. Department of Health recommends that each
institution develop in collaboration with its attorneys the justification and process for placing
administrative hold on a newborn. Child Protective Services may obtain custody of the newborn by
court order or a law enforcement transfer of protective custody and may then give permission to test
the newborn in order to safeguard the newborn’s health.
See Table 3 for information about newborn drug testing. The procedure for obtaining samples for
testing is institution-specific. See attached policy samples for guidance.
Page 6 of 16 2012
Comprehensive guidelines for hospital care of the drug-exposed newborn are beyond the scope of
this document. See Table 4 for basic information about newborn management.
Table 3
Newborn Drug Testing
About Newborn Urine Toxicologies:
• Correlation between maternal and newborn test results is poor, depending upon the time interval
between maternal use and birth, properties of placental transfer, and time elapsed between birth
and neonatal urine collection.
• The earliest urine of the newborn will contain the highest concentration of substances.
• Failure to catch the first urine decreases the likelihood of a positive test.
• Threshold values (the point at which a drug is reported to be present) have not been established
for the newborn.
• Fetal effects cannot be prevented by newborn testing.
• Newborn urine reflects exposure during the preceding one to three days.
• Cocaine metabolites may be present for four to five days.
• Marijuana may be detected in newborn urine for weeks, depending on maternal usage.
• Alcohol is nearly impossible to detect in newborn urine.
Other Methods of Newborn Drug Testing:
• Meconium: Meconium in term infants reflects substance exposure during the second half of
gestation; preterm infants may not be good candidates for meconium testing. The high sensitivity
of meconium analysis for opiate and cocaine and the ease of collection make this test ideal for
perinatal drug testing. Meconium analysis is most useful when the history and clinical
presentation strongly suggest neonatal withdrawal but the material urine screening is negative.
(Hudak 2012). Meconium analysis is available for mass screening with an enzyme immunoassay
kit or by radioimmunoassay. Cost of analysis per specimen approximates the cost of urine
toxicology. (J Pediatrics 2001; 138:344-8)
• Breast milk: Breast milk is not a viable alternative for drug testing.
• Hair: Hair testing has high sensitivity for detecting perinatal use of cocaine and opiate but not
for marijuana. Hair testing is restricted to a few commercial laboratories and the cost of testing is
higher than for meconium. (J Pediatrics 2001; 138:344-8) Hair has a high false positive rate
because of passive exposure to minute quantities of illicit substances in the environment.
(ACOG, 2008)
• Umbilical cord segments may be a viable testing medium in the future, but is evolving
technology at present. Recent testing of umbilical cord tissue by using drug class-specific
immunoassays was shown to be in concordance with testing of paired meconium specimens for
detection of amphetamines, opiates, cocaine and cannabinoids (Hudak, 2012). More information
is available at www.usdtl.com.
Table 4
Management of a Newborn with a Positive Drug Toxicology
• Confirm any positive test with gas chromatography/mass spectroscopy particularly if opiates are
found.
Page 7 of 16 2012
• Consider the fact that intrapartum drugs prescribed to control labor pain can be detected in
meconium.
• Notify newborn’s provider for diagnostic work-up.
• Use the Neonatal Abstinence Scoring tool to document symptoms of narcotic withdrawal. See
Appendix D for sample.
• Newborn assessment should include newborn health status, maternal drug use history and current
family situation. Document assessment of family interaction (or lack of interaction). Include
positive observations as well as areas of concern.
• Notify social worker or other designated staff member to coordinate comprehensive drug/alcohol
assessment and outside referrals, including Child Protective Services. If designated staff member
is not available, reporting to Child Protective Services is the responsibility of all health care
providers. Child Protective Services after hours, weekends and holidays intake telephone number
is: 1-800-562-5624.
Note: Child Protective Services may use a patient’s chart as documentation in court. A release
of information is not required.
Reporting to Children’s Administration
Hospitals should contact their local Department of Social and Health Services Children’s
Administration office and request an in-service on mandatory reporting and other Children’s
Protective Services processes. The hospital's risk management staff should attend the in-service.
After the in-service, parties may have a better idea of points needing clarification. Starting at the
local level is important for developing key relationships and ensuring smooth and consistent
procedures. See Page 14 for Department of Social and Health Services Children’s Administration
Prenatal Substance Abuse Policy.
The DSHS guide for reporting allegations of child abuse and neglect can be found online at
http://www.dshs.wa.gov/pdf/publications/22-163.pdf or by following this link, Mandatory Reporting.
You can find your local Children’s Administration office by entering your zip code at the following
website, http://www.dshs.wa.gov/ca/general/index.asp or by following this link, Local Children's
Administration Office locator.
Page 8 of 16 2012
Appendix A
References and Resources:
American Academy of Pediatrics Committee on Drugs. 1998. Neonatal Drug Withdrawal. Pediatrics;
101:1079-1088.
American Academy of Pediatrics Committee on Substance Abuse. 1998. Tobacco, Alcohol and Other
Drugs: The Role of the Pediatrician in Prevention and Management of Substance Abuse. Pediatrics;
101:125-128.
American Academy of Pediatrics Committee on Substance Abuse. 2001. Alcohol Use and Abuse: A
Pediatric Concern. Pediatrics; 108: 185-189.
American Academy of Pediatrics and American College of Obstetricians and Gynecologists. 2002.
Guidelines for Perinatal Care, Fifth Edition. Elk Grove Village IL.
American College of Obstetricians and Gynecologists. 2008. At-Risk Drinking and Illicit Drug Use:
Ethical Issues in Obstetric and Gynecologic Practice, ACOG Committee Opinion, Number 422.
American College of Obstetricians and Gynecologists, 2011. Methamphetamine Abuse in Women of
Reproductive Age, ACOG Committee Opinion, Number 479.
American College of Obstetricians and Gynecologists Committee Opinion. (2012) Opioid Abuse,
Dependence, and Addiction. Number 524.
American College of Obstetricians and Gynecologists. 2005. Substance Use: Obstetric and
Gynecologic Implications. In Special Issues in Women’s Health. ACOG Committee on Health Care
for Underserved Women.
Creanga, AA, et. (2011). Maternal Drug Use and its Impact on Neonates: population-based study in
Washington State. Obstetrics and Gynecology, 119(5), 924-933.
Weiners and Finnegan LP (2002). Drug Withdrawal in the Neonate in Handbook of Neonatal
Intensive Care, 5th Edition. Merenstein and Gardner, eds. CV Mosby: 163-178.
Finnegan LP. 1986. Neonatal abstinence syndrome: assessment and pharmacotherapy. In: Rubaltelli
FF, Granati B, eds. Neonatal therapy: an update. New York: Excerpta Medica: 122-46.
Hudak L, Tan RC and the Committee on Drugs and the Committee on Fetus and Newborn. (2012).
Neonatal Drug Withdrawal. Pediatrics,129(2), e540-e560.
Jansson L and Velez M. (2012). Neonatal abstinence syndrome. Current Opinion Pediatrics,
24(00),1-7.
Lester BM, et al. 2004. Substance use during pregnancy: time for policy to catch up with research.
Harm Reduction Journal; http://www.harmreductionjournal.com/content/1/1/5.
Patrick SW, Schumacher RE, Benneyworth BD, Krans EE, Mcallister JM, Davis MM. (2012).
Neonatal Abstinence Syndrome and Associated health Care Expenditures United States, 2000-2009.
Journal of American Medical Association, published online April 30, 2012.
Page 9 of 16 2012
Ostrea EM, et al., 2001. Estimates of illicit drug use during pregnancy by maternal interview, hair
analysis, and meconium analysis. Journal of Pediatrics; 138:344-8.
Washington State Department of Health. 2009. Substance Abuse During Pregnancy: Guidelines for
Screening;
Additional Resources
To order or download “The Parent’s Guide to CPS” (mentioned in letter on Page 11):
http://www.dshs.wa.gov/ca/pubs/pubcats.asp?cat=Child_Abuse_and_Neglect
Swedish Medical Center, Seattle: Center for Perinatal and Pediatric Excellence (Phone: 206-215-
2073)
Washington State Department of Health, Maternal and Infant Health Program (Phone: 360-236-
3563)
Washington State Department of Social and Health Services Children’s Administration website –
video and materials for mandatory reporters: http://www1.dshs.wa.gov/ca/general/index.asp
Child Protective Services after hours, weekends and holidays intake phone number: 1-800-562-5624.
Washington State Hospital Association (Phone: 206-216-2531)
Page 10 of 16 2012
Appendix B
Guidelines for Obtaining Consent from Parents
For Infant Drug Testing
Set the Scene
The healthcare provider’s attitudes and feelings about maternal substance use, as well as the
environment in which this discussion takes place, often influences the success or failure of obtaining
parental consent for infant drug testing. Often, the way the subject is approached will be the major
determinant in obtaining consent.
• Be aware of your own beliefs and values that may interfere with your ability to remain neutral
and non-judgmental.
• Assess the environment for privacy and when possible, discuss the issue in a non-emergent
setting.
• Attend to your non-verbal behavior including body stance, facial expression, eye contact, muscle
tension, and arm and hand positioning.
Introduce the Topic
• Begin with open ended questions. Ask the mother how she is doing and what she needs.
• Reflect back to the mother what she has just stated and respond to any questions.
• Inform the mother that there is another topic you need to discuss.
• Give reasons / describe in a non-judgmental manner why you want to test her infant for evidence
of maternal drug use during pregnancy (see script below).
• If the testing is requested by Child Protective Services, inform the mother of this and bring the
focus back to the health of the mother and infant.
• Ask if she has any questions; if yes, answer them to the best of your ability.
• Ask permission for consent: “Do we have your permission to test the baby?” If yes, thank the
mother for her cooperation and reinforce that she is working in the best interest of her child.
• Review what the testing process involves for the baby.
If the Parent is Angry, Resistant, Agitated and/or Defensive:
• Determine if the parent is intoxicated or has mental health issues that will interfere with her
ability to comprehend.
• Stay calm.
• Do all of the steps described above: bring the focus back to the health of the infant; re-explain
that her cooperation with this step shows that she is interested in the health of her baby.
• Allow more time for the parent to talk about what is happening and her concerns. Reassure as
appropriate.
• Be matter of fact about the issue while remaining supportive and non-judgmental.
• Refer to your agency’s policies regarding drug testing and Child Protective Services protocols.
Page 11 of 16 2012
Sample Scenario:
Hello Mary, how are you doing today? Do you have any questions or concerns you’d like to talk
about?
(Patient responds and her questions concerns are addressed).
Those are good questions, Mary. Now, I have something else to discuss with you that will help us
provide the best care for your baby. This may be uncomfortable to discuss but it is very important.
(Give patient time to respond).
There is some concern about your drug use during this pregnancy and the impact it has had or may
have on your baby. I know you want the best for your baby and wouldn’t purposefully do anything
to hurt her. When a woman uses drugs when she is pregnant or breastfeeding, there is a risk to the
baby’s health. We would like to get your permission to test your baby for drugs so we can give her
the best medical care. Will you sign a consent form to test your baby?
If parent responds “Yes”: I know this is scary but it’s the best decision for your baby. Here is the
consent form. Is there anything you’d like me to know or do you have any questions?
(Patient Response)
Okay, do you want to hear how this done and what you may be asked to do?
If parent responds “No”: (Use the same steps as above until the patient refuses.)
I can’t imagine how scary this sounds to you and I hope we can come to an agreement about you
consenting but if we can’t I am still required to do what I think is needed to make sure your baby is
given appropriate medical care. Can we talk about this more?
(Client nonresponsive or says “No.”)
This facility and I are required to notify Child Protective Services when there is concern about the
effect a parent’s drug use has on the health of an infant. What happens now is staff here will contact
Child Protective Services to let them know the situation. Your baby may then be placed on an
administrative hold. When Child Protective Services gains custody, Child Protective Services can
then give permission to test the baby. It would be great if we get consent and test now and begin any
treatment your baby may need. What do you think?
(If the patient still refuses, follow the agency protocols and do what is necessary to keep the baby in
the hospital and complete the testing after Child Protective Services has approved).
“OK, I hear you saying no to drug testing for your baby. I’ll let the staff here know of that decision
and we’ll take it from here. It’s important for you to know that your baby may still get tested for
drugs. We would do that to protect your baby’s health. We’ll keep you informed about what will
happen next.”
Page 12 of 16 2012
Appendix C
Sample Parent Letter:
Information for parents of newborn placed on administrative hold
Hospital Letterhead
Dear Parent:
This letter tells about what is happening to you and your newborn. People who care for you and your
baby have concerns about your drug and/or alcohol use and the impact it has on your baby. For this
reason, your newborn has been placed on an administrative hold at the hospital. This means that you
may not leave the hospital with your baby at this time.
The enclosed purple booklet “Parent’s Guide to Child Protective Services (CPS)” provides some
important information that will help you through this time. Please take a few minutes to read it. You
may ask your questions to the person from CPS who will come and speak with you at the hospital, or
at your house if you have already left the hospital.
Each person’s situation is different, and the social worker from CPS will explain what will happen
next. This social worker will talk with you and develop a plan for keeping your newborn safe. This
person will give you information about services for you and your new baby. This may include dates
and times of appointments or meetings that you need to attend.
We know this is a difficult time. Your nurses and hospital social worker want to help you in your
efforts to ensure the health and safety of your baby. Please ask questions and let your nurses and
social worker know your thoughts and feelings.
We believe the best place for a new baby is with the family. We hope you will work with CPS to
make a safe and healthy home for your new baby.
Sincerely,
XXXXX
Enclosure
Page 13 of 16 2012
Appendix D
Neonatal Abstinence Scoring System
Morphine Sulfate Dose
System Signs and Symptoms
Date/Time
Score
Central
Nervous
System
Disturbance
Crying: Excessive high pitched
Crying: continuous high pitched
2
3
Sleeps < 1 hour
Sleeps < 2 hours after feeding
Sleeps < 3 hours after feeding
3
2
1
Hyperactive Moro reflex
Markedly hyperactive Moro reflex
2
3
Mild tremors: Undisturbed
Moderate-severe tremors:
Undisturbed
3
4
Mild tremors: Disturbed
Moderate-severe tremors:
Disturbed
1
2
Increased muscle tone 2
Excoriation (specify area) 1
Myoclonic Jerks 3
Generalized convulsions 5
Metabolic,
Vasomotor,
and
Respiratory
Disturbances
Sweating 1
Fever 37.2-38.3OC ( 99-101 F)
Fever > 101 F (>38.4OC)
1
2
Frequent yawning (>3)* 1
Mottling 1
Nasal Stuffiness 1
Sneezing (>3) * 1
Nasal flaring 2
Respiratory rate (>60/min.)
Respiratory rate (>60/min. with
retractions)
1
2
Gastro-
Intestinal
Disturbances
Excessive sucking 1
Poor feeding 2
Regurgitation+
Projectile vomiting+
2
3
Loose stools
Watery stools
2
3
Total Score
Initials of Scorer
*As they have occurred in the entire scoring period (i.e., within the previous 2 or 4 hours, whatever the scoring interval).
+ More than or equal to 2 times during or after feeding.
Adapted from Finnegan, L.P. 1986. Neonatal abstinence syndrome: assessment and pharmacotherapy. In F.F.,
Rubatelli and B. Granadi (ed.) Neonatal therapy: an update. Exerpta Medica, NY.
Page 14 of 16 2012
Appendix E
Children’s Administration
Prenatal Substance Abuse Policy
The Federal Child Abuse Prevention and Treatment Act (CAPTA) as amended by the Keeping
Children and Families Safe Act of 2003 requires health care providers to notify Child Protection
Services (CPS) of cases of newborns identified as being AFFECTED by illegal substance abuse or
withdrawal symptoms resulting from prenatal drug exposure.
Washington State statute does not authorize Children's Administration (CA) to accept referrals for
CPS investigation or initiate court action on an unborn child.
In Washington State, health care providers are mandated reporters and required to notify CPS when
there is reasonable cause to believe a child has been abused or neglected. If a newborn has been
identified as substance exposed or affected, this may indicate child abuse/neglect and should be
reported. It is critical that mandated reporters provide as much information regarding concerning
issues/behaviors, risk factors or positive supports that were observed during the interaction with the
family.
HOW DO I MAKE A REPORT?
Children’s Administration offices within local communities are responsible for receiving and
investigating reports of suspected child abuse and neglect. Reports are received by CPS Intake
staff either by phone, mail or in person and are assessed to determine if the report meets the legal
definition of abuse or neglect and how dangerous the situation is.
Children’s Administration offers several ways to report abuse:
Daytime: Contact local Children’s Administration CPS office. A local CPS office can be located
on the following link:
https://fortress.wa.gov/dshs/f2ws03apps/caofficespub/offices/general/OfficePick.asp
Nights and Weekends: Call the Child Abuse and Neglect Hotline at 1-866-ENDHARM
(1-866-363-4276), which is Washington State’s toll-free, 24 hour, 7 day-a-week hotline where you
can report suspected child abuse or neglect.
Additional information about reporting abuse and neglect of children can be located at:
http://www.dshs.wa.gov/ca/safety/abuseReport.asp?2
AS A MANDATED REPORTER WHAT INFORMATION WILL I BE ASKED TO PROVIDE?
Mandated reporters will be asked to provide as much of the following information as they are able:
1. The name, address and age of the child and parent(s) stepparents, guardians, or other persons
having custody of the child.
2. The nature and extent of alleged
• Injury or injuries
• Neglect
• Sexual Abuse
3. Any evidence of previous injuries.
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4. Any other information that may be helpful in establishing the cause of the child’s death, injury, or
injuries and the identity of the alleged perpetrator(s).
It is important to provide as much information about why you have reasonable cause to believe there
is child abuse or neglect. This information will assist DSHS at intake or during the course of a CPS
investigation if the case screens in. Examples include:
• Issues, i.e., substance use, mental health that may impact a child’s safety.
• Parents’ resources and strengths that can help the parents’ care for and protect the children.
• Parents’ response to interventions, etc.
• Names of family members.
• Whether the child may be of Indian ancestry for Indian Child Welfare planning, if applicable.
• Parent(s) attitude about their newborn.
• Did the mother participate in prenatal care.
• Extended family and family strengths which can help the parent(s) to care for and protect
children and their family.
• Parent(s) resources and family strengths.
• Rational for toxicology testing.
If you are in doubt about what should be reported, it is better to make your concerns known and
discuss the situation with your local CPS office or Child Abuse and Neglect Hotline.
If a crime has been committed law enforcement must be notified. The name of the person making
the report is not a requirement of the law, however, mandated reporters must provide their name in
order to satisfy their mandatory reporting requirement.
WHAT HAPPENS AFTER A REPORT IS MADE?
When a report of suspected child abuse or neglect is made, CA intake staff determines whether the
situation described meets the legal definition of child abuse or neglect. In order for CPS to intervene
in a family the report must meet the legal definition of child abuse or neglect or there is a safety
threat(s) to the child.
Referrals which are determined to contain sufficient information may be assigned for investigation or
other community response.
CPS investigations include the following:
• Determining the nature and extent of abuse and neglect.
• Evaluating the child’s condition, including danger to the child, the need for medical attention,
etc.
• Identifying the problems leading to or contributing to abuse or neglect.
• Evaluating parental or caretaker responses to the identified problems and the condition of the
child and willingness to cooperate to protect the child.
• Taking appropriate action to protect the child.
• Assessing factors which greatly increase the likelihood of future abuse or neglect and the
family strengths which serve to protect the child.
If a child is of Indian ancestry social services staff must follow requirements of the Federal Indian
Child Welfare Act (ICWA), state laws, and the RCW.
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WHAT SERVICES MAY BE PROVIDED?
Protective services are provided to abused/neglected children and their families without cost. Other
rehabilitative services for prevention and treatment of child abuse are provided by the Department of
Social and Health Services and other community resources (there may be a charge for these
services) to children and the families, such as:
• Home support specialist services
• Day care
• Foster family care
• Financial and employment assistance
• Parent aides
• Mental health services such as counseling of parents, children and families
• Psychological and psychiatric services
• Parenting and child management classes
• Self-help groups
• Family preservation services
WHAT HAPPENS IF A REPORT DOES NOT MEET THE DEFINITION OF CHILD ABUSE OR
NEGLECT?
When CA receives information that does not meet the definition of child abuse or neglect and CA
does not have the authority to investigate, intake staff documents this information in the systems
database as an “Information Only” referral.
When CA receives information about a pregnant woman who is not parenting other children and is
allegedly abusing substances, intake staff documents this information and available information
about risk and protective factors in an “Information Only” referral. This referral is then forwarded to
First Steps Services.
When CA receives information about a substance exposed but not substance-affected newborn,
intake will ask about available information, including information about safety threats and protective
factors to determine if there is an allegation of child abuse or neglect or safety threat(s). If there are
no allegations of child abuse or neglect or safety threats, CA does not have the authority to conduct
a CPS investigation and the referral is documented as “Information Only.” If a decision is made not
to respond, and you disagree, you may discuss your concerns with the Intake Supervisor. When a
case is not appropriate for CPS, you may consult with the local Children’s Administration office for
suggestions or guidance in dealing with the family.
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CA Practices and Procedures – Prenatal Substance Abuse Policy -- Definitions
A Substance-Exposed Newborn is one who tests positive for substance(s) at birth, or the mother tests positive for
substance(s) at the time of delivery or the newborn is identified by a medical practitioner as having been prenatally
exposed to substance(s).
A Substance-Affected Newborn is one who has withdrawal symptoms resulting from prenatal substance exposure and/or
demonstrates physical or behavioral signs that CAN BE attributed to prenatal exposure to substances and is identified by a
medical practitioner as affected.
DOH 950-151 June 2012
For people with disabilities, this document is available on request in other formats.
To submit a request, please call 1-800-525-0127 (TDD/TTY call 711).