Recent headlines have shown wide-ranging ideas about what should happen when those with substance use disorders (SUD) have babies born with unprescribed drugs, including alcohol, in their systems.
The American Medical Association cautions “Don’t criminalize pregnant patients with substance use disorders,” and it seems that Ohio has taken that advice to heart, given this inflammatory headline: “In Ohio Women Can Take Fentanyl And Other Opioids While Pregnant, Court Rules.” And now another state has joined the conversation: “Washington no longer requires hospitals to report all substance-exposed infants.”
Superficially, these seem reasonable: less stigma means more treatment; more treatment means better outcomes. Sure, but for whom? Is this approach helping the newborn babies?
The federal government enacted Child Abuse Prevention and Treatment Act (CAPTA) legislation in January 1974 to address child abuse and neglect. The act was last amended in January 2019, with a 2018 amendment specifically targeting opioid misuse (Child Preventing). Unfortunately, this may have led some to believe that child abuse ONLY occurs when opioids are misused.
The goal of states’ legislation – a great goal – is to divert newborns who are substance-exposed and their caregivers away from the Child Protective Services (CPS) and into community-based services. That’s really a great goal, I agree, but far too often we concentrate on what we can address. That’s where the focus on opioid misuse is problematic. We know there are great interventions for babies who are born with neonatal opioid withdrawal syndrome (NOWS), both pharmacological and through the “Eat, Sleep, Console” (NIH) approach. And when the lives of those babies improve because of those interventions and CPS need not be engaged, everyone wins. But what about all those babies who are being born substance-exposed with OTHER substances? What about alcohol, known to be “a leading preventable cause of birth defects and neurodevelopmental abnormalities in the United States”? (NIAAA) What about the growing evidence around the dangers of cannabis use during pregnancy? (March)
“CAPTA provides Federal funding and guidance to States in support of prevention, assessment, investigation, prosecution, and treatment activities and also provides grants to public agencies and nonprofit organizations, including Indian Tribes and Tribal organizations, for demonstration programs and projects.” This means that the federal government provides support and funding to State governments, but the feds don’t make the rules about how to address child abuse and neglect. Rule-making is left to the states.
However, CAPTA does provide a federal definition of child abuse and neglect, which is, in part: “the term ‘child abuse and neglect’ means, at a minimum, any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm.”
So, keeping this in mind, let’s go back to the headlines:
“In Ohio Women Can Take Fentanyl And Other Opioids While Pregnant, Court Rules” and “Washington no longer requires hospitals to report all substance-exposed infants.”
The rationale in Washington – and other states that are rightfully devoted to keeping children out of CPS and getting them community-based services – is that infants who are born substance-exposed will receive those community services without hospitals reporting them to Child Protective Services as long as there is “no safety concern.”
I think MY idea of what constitutes a safety concern and the states’ idea must be VASTLY different. If a baby is born substance-exposed and is determined to need wraparound services, how can that baby NOT have a safety concern? I’m not suggesting that referring to community services rather than CPS is bad; I AM suggesting that more referring – to whomever – is necessary.
Rules throughout the states regarding drug testing at birth vary widely. The rules are so far flung…some states have no specific rules about testing and whether or not a baby born substance-exposed is abused while others specifically identify what substances can be tested for and determine what substances to test…urine, blood, meconium, and/or umbilical cord…can be used (Child Systemwide).
So, back to my earlier point: we concentrate on what we can address. Far too often babies who are born substance-exposed have no interventions sought. The reasons why are myriad. For example, no one knows the baby has substances on board because no one is testing for legal substances like alcohol or cannabis or the babies don’t even exhibit symptoms until they’ve been discharged or the symptoms don’t look like what we expect so they are missed or…or…or…
We now need to address what we know is happening. Universal umbilical cord (UC) collection for testing would mitigate all these issues. If hospitals collect UC on every baby and use it only when there’s evidence to indicate testing is necessary, there’s no bias in testing and all drugs, including alcohol, would be screened for, as appropriate. More importantly, it removes the dangers of newborn substance-exposed babies falling through the safety nets set up specifically for them.
References
https://www.childwelfare.gov/topics/preventing/overview/
https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/fetal-alcohol-exposure
https://www.marchofdimes.org/find-support/topics/pregnancy/marijuana-and-pregnancy
Guided by Guida 
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