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WI CAN Educational Series

Hillary W. Petska, MD, MPH

Child Advocacy and Protection Services

Children’s Hospital of Wisconsin

There are no relevant financial relationships related to this presentation/

program.

There is no sponsorship/commercial support of this presentation/program.

The content being presented will be fair, well-balanced, and evidence-based.

Learners who wish to receive Continuing Education Credit (CME/CLE/CE)

must complete and turn in evaluations to successfully complete this program.

• Drug exposure negatively affects infants and children.

• Drug testing should be considered in cases of suspected child maltreatment.

• Drug testing has many limitations that complicate interpretation.

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• >500,000 kids/yrexposed to drugs

• >50,000 kids/yr treated in ED for drug exposures

• 400,000 infants/yrexposed prenatally:

• Illegal drugs: 4.4%

• Alcohol: 10.8%

• Cigarette: 16.3%

Bond 2012, Behnke 2013

• 8.7 million children with a parent with a substance use disorder

• >270,000 children placed in foster care in 2016

• Infant born every 25 minutes with opioid withdrawal

www.aap.org/OpioidFactsheet

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• Direct• Exposure to the

substance

• Exposure to hazards in the home

• Indirect• Poor supervision, neglect

• Interpersonal violence

Farst 2012, CWIG 2014

• Physical/mental impairments

• ↓ response to child’s needs• Difficulty controlling

emotions• ↓ parent-child attachment• Spending money on

alcohol/drugs instead of food/necessities

• Spending time seeking out, manufacturing, or using alcohol/drugs

• Incarceration• Estrangement from

family/social supports

CWIG 2014

• Caregiver with substance

abuse disorder = ACE

• Mental health issues = ACE

• Child neglect and abuse =

ACE

• Domestic violence = ACE

• Chaotic living environment

(incarceration,

unemployment, housing

instability)

CWIG 2014

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• Adverse Childhood Experiences Study:

• Obesity, drug/alcohol abuse, smoking, depression, suicide, teen pregnancy, incarceration

• Diabetes, hypertension, heart disease, liver disease, cancer, stroke

Felitti 1998

• What is a drug?• Illegal (amphetamine, cannabinoid, cocaine,

opiates, PCP, benzodiazepines)

• Prescription

• OTC

• How are drugs detected?• Signs and symptoms

• History (self-report)

• Lab testing

SymptomsAltered mental

status

Unexplained irritability

Unexplained seizures

Syncope/ arrhythmias

Known/ suspected exposures

Witnessed ingestion

Suicide attempt

Drug-endangered environment

Toxidromes

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Sympathomimetic (meth, amphetamines, cocaine, opiate withdrawal, PCP) Hyperthermia (increased body temperature), tachycardia (increased

heart rate), hypertension (increased blood pressure), mydriasis (dilation of the pupil), warm/moist skin, agitation

Cholinergic (organophosphates, betel nut, VX, soman, sarin) SLUDGE (Salivation, Lacrimation, Urinary incontinence,

Diarrhea/Diaphoresis, GI upset/hyperactive bowel, Emesis)

Anticholinergic (antihistamines, atropine, phenothiazines, TCA)

Hyperthermia, tachycardia, hypertension, hot/red/dry skin, mydriasis or unreactive pupils, urinary retention, absent bowel sounds

Opioids (codeine, dextromethorphan, heroin) Miosis (constriction of the pupil), respiratory depression, sedation

1/3 – 2/3 of families involved with CPS have AODA issues

CWIG 2014

Parental AODA

Child Maltreatment

• Hayek 2009

• 30% of pediatric patients with burn injuries due to child maltreatment also exposed to illicit drugs

• Yin 2010

• 160 cases/year of “malicious” pharmaceutical exposure in children <7 y/o reported to US poison centers

• Oral 2011

• 15% of allegedly maltreated children exposed to illicit drugs

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• Before 2013: Screening based on risk factors

• 2013 – present: Screening of all young, physically abused children

• 2 urine drug screening panels available

• ER drug panel

• Comprehensive drug panel -RECOMMENDED

ER Drug Screen Urine Drug Investigation

Substances Detected 6 >140

Threshold Workplace (high) <<Workplace (low)

Amount of Urine 1 – 5 ml 1 – 6 ml

Time to Result <2 hours 3-5 days

Confirmation No Yes

Methodology Immunoassay GC-MS or LC-tandem MS

Sensitivity and Specificity Low High

Charge $900 $361

• Children ages 2 weeks < 5 years

• Evaluated for PA by Child Advocacy between 2013-2017

• Three groups:

• High concern for abuse

• Intermediate concern for abuse

• Low concern for abuse

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• Most common occult exposure = cocaine• Rosenberg – 460 children 1-60 months

presenting to urban ED for routine complaints – 5.4% had cocaine metabolite in urine

• Shannon – 1,120 children’s hospital patients with urine or blood specimens – 4.6% had cocaine or metabolite and 1.3% had ethanol, benzo or narcotic and cocaine

• Lustbader – Using very sensitive testing, found 36.3% of infants presenting to ED for routine concerns were positive for cocaine

• Most common exposures:

• Caffeine• Formula fed and not Rx,

concerning for administration

• May cause poor sleep, irritability, seizures

• Cotinine• Likely d/t secondhand smoke

• Causes multiple short- and long-term health risks

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• Not all children were tested

• May have missed some drugs

• Unable to determine source/intent

• Did not examine outcomes or cost-benefit

• Breath

• Blood

• Saliva

• Sweat

• Meconium

• Hair

• Urine

• Detects alcohol or drug use within 2-12 hours

• Correlated with level of impairment

• Invasive, sample collection by trained

personnel

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• Detects drug exposure during the 2nd and 3rd trimester

• Cannot be used to determine timing or amount (self-report)

• Negative result ≠ drug-free pregnancy

• Advantages:

• Longer window of detection

• First 3 cm = 90 days

• Non-invasive

• Decreased risk of tampering

• Collection can be observed

• Easily stored/transported

• Disadvantages:• Not useful clinically d/t long window of detection

• Interpretation = Challenging• Positive:

• Contact with drug smoke or the actual drug

• Contact with sweat/sebum of a drug user

• Accidental/intentional ingestion of the drug

• Cannot differentiate who, where, when, why, or how /how much

• Negative ≠ no exposure

• Results may be affected by hair structure, growth rate, melanin content, hygiene, cosmetic treatment

• May be misused in child protection cases

Cuypers 2018, Kintz 2017

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• Myth: Hair drug testing proves a child was exposed to meth in their home.

• The child could have been exposed to:

• Another environment in which meth was used/manufactured

• A caregiver that used meth

• In utero (< 1 yo)

• The strongest evidence of exposure is meth in their home.

• What if hair is negative?

• Myth: Hair drug testing can determine whether a

drug was ingested or just in the environment.

• Washing – drug incorporation from the

environment

• “Cut-offs” = anecdotal, not evidence-based

• “Environmental exposure will only generate a

positive for the parent drug.” EXCEPT IF:

• The exposure was from the sweat/sebum of a drug

user

• The drug contains a metabolite

Cuypers 2018, Kintz 2017

• Standardized

• Indicates systemic exposure

• Less invasive and longer window of detection than blood

• Most commonly used specimen in primary care

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Qualitative Presence of drug

What’s there?

Green, yellow, and purple birds

Quantitative Amount of drug

How much?

3 green, 2 yellow, 2 purple birds

ER Drug Screen Urine Drug Investigation

Substances Detected 6 >140

Threshold Workplace (high) <<Workplace (low)

Amount of Urine 1 – 5 ml 1 – 6 ml

Time to Result <2 hours 3-5 days

Confirmation No Yes

Methodology Immunoassay GC-MS or LC-tandem MS

Sensitivity and Specificity Low High

Charge $900 $361

• False +

• Test is positive for

a drug that is not

present

• ER Drug Screen –

structural cross-

reactivity

• False –

• Test is negative

for a drug that is

actually present

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• Negative ≠ no exposure

• Substance not on the test panel

• Substance at levels too low to be detected

• Missed window of detection

• Must be interpreted

in context of history

• Cannot differentiate

appropriate use v.

misuse or intent

• Young children

more likely to be

positive

• Large exposure

days ago

OR

• Small exposure

hours ago

• Positive

50 ng/mL cocaine

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Previous exposure

Provides no additional information

Positive = child still being exposed OR still positive from initial exposure

Negative = child not re-exposed OR child re-exposed but missed window of detection

Should not be relied on for safety decisions

SAMHSA 2010

Environmental

Neglect

Illicit drug exposure during pregnancy or breastfeeding

Supervisory neglect

Drug-endangered environment

Momentary lapse of supervision

Breastmilk

In utero

Farst 2012

Environmental

“Studies on room air concentrations of marijuana and cocaine indicate that low levels of passive exposure do not result in positive urine drug tests.”

“Room air concentration required to detect drug exposure in the urine is high and results in noxious effects.”

Farst 2012

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Environmental

Neglect

Momentary lapse of supervision

Breastmilk Contraindicated for women with ongoing drug/alcohol use

Not contraindicated for women in methadone-maintenance programs

Physician guidance – LactMed (http://toxnet.nlm.nih.gov)

In utero

Active exposure

Unintentionalingestion, inhalation, dermal absorption

Intentionaladministration

• Drugs are bad for kids.

• Not all drug tests are created equal.

• Know your test (or a medical professional who does)!

• Test results must be interpreted in the context of history.

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AAP Committee on Nutrition and the Council on Sports Medicine and Fitness. Sports drinks and energy drinks for children and adolescents: are they appropriate? Pediatrics. 127(6):1182-9; 2011.

Behnke M, Smith M, Committee on Substance Abuse, Committee on Fetus and Newborn. Prenatal substance abuse: short- and long-term effects on the exposed fetus. Pediatrics.131(3):e1009-24; 2013.

Bond RG, Woodward RW, Ho M. The growing impact of pediatric pharmaceutical poisoning. J Pediatr. 160(2):265-70; 2012.

Boroda A, Gray W. Hair analysis for drugs in child abuse. J R Soc Med. 98(7):318-9; 2005.

Brown DW, Anda RF, Tiemeier H, et al. Adverse childhood experiences and the risk of premature mortality. Am J Prev Med. 37(5):389-396; 2009.

Center for Substance Abuse Treatment. Drug Testing in Child Welfare: Practice and Policy Considerations. HHS Pub. No. (SMA) 10-4556 Rockville, MD: Substance Abuse and Mental Health Services Administration, 2010.

Child Welfare Information Gateway. Parental Substance Use and the Child Welfare System. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau; 2014.

Cuypers E, Flanagan RJ. The interpretation of hair analysis for drugs and drug metabolites. Clin Toxicol (Phila). 56(2):90-100; 2018.

Dolan K, Rouen D, Kimber J. An overview of the use of urine, hair, sweat and saliva to detect drug use. Drug Alcohol Rev. 23(2):213-7; 2004.

Farst K, Reading Meyer JA, Mac Bird T, James L, Robbins JM. Hair drug testing of children suspected of exposure to the manufacture of methamphetamine. J Forensic Leg Med. 18(3):110-4; 2011.

Farst K, BB Bolden. Substance-exposed infants and children: forensic approach. Clin Pediatr Emerg Med. 13(3): 221-8; 2012.

Felitti VJ, RF Anda, D Nordenberg, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) study. Am J Prev Med. 14(4):245-58; 1998.

Hayek SN, Wibbenmeyer LA, Kealey LD, et al. The efficacy of hair and urine toxicology screening on the detection of child abuse by burning. J Burn Care Res. 30(4):587-92; 2009.

Hoffman RJ. Testing for drugs of abuse (DOA). In: UpToDate, Traub SJ (Ed). (Accessed on March 3, 2017).

Kellogg ND, AAP Committee on Child Abuse and Neglect. Evaluation of suspected child physical abuse. Pediatrics. 119(6):1232-41; 2007.

Kintz P. Hair analysis in forensic toxicology: an updated review with a special focus on pitfalls. Curr Pharm Des. 23(36):5480-6; 2017.

Kintz P, Ameline A, Eibel A, et al. Interpretation of cannabis findings in the hair of very young children: mission impossible. Curr Pharm Biotechnol. 18(10):791-5; 2017.

Klein J, Karaskov T, Koren G. Clinical applications of hair testing for drugs of abuse – the Canadian experience. Forensic Sci Int. 107(1-3):281-8; 2000.

Levy S, Siqueira LM, Committee on Substance Abuse, et al. Testing for drugs of abuse in children and adolescents. Pediatrics. 133(6):e1798-1807; 2014.

Lewis D, Moore C, Morrissey P, Leikin J. Determination of drug exposure using hair: application to child protective cases. Forensic Sci Int. 84(1-3):123-8; 1997.

Lustbader AS, Mayes LC, McGee BA, Jatlow P, Roberts WL. Incidence of passive exposure to crack/cocaine and clinical findings in infants seen in an outpatient service. Pediatrics.102(1):e5; 1998.

Oral R, Bayman L, Assad A, et al. Illicit Drug Exposure in Patients Evaluated for Alleged Child Abuse and Neglect. Pediatr Emer Care. 27(6):490-5; 2011.

Petska HW, Porada K, Nugent M, Simpson P, Sheets LK. Occult drug exposure in young children evaluated for physical abuse: An opportunity for intervention. Child Abuse Negl. 88:412-419; 2019.

Rosenberg NM, Meert KL, Knazik SR, Yee H, Kauffman RE. Occult cocaine exposure in children. Am J Dis Child. 145(12):1430–2; 1991.

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Shannon M, Lacouture PG, Roa J, Woolf A. Cocaine exposure among children seen at a pediatric hospital. Pediatrics. 83(3):337–41; 1989.

Stauffer SL, Wood SM, Krasowski MD. Diagnostic yield of hair and urine toxicology testing in potential child abuse cases. J Forensic Leg Med. 33:61-7; 2015.

Wang X, Drummer OH. Review: interpretation of drug presence in the hair of children. Forensic Sci Int. 257:458-72; 2015.

Wells K. Substance abuse and child maltreatment. Pediatr Clin North Am. 56(2):345-62; 2009.

Wennig R. Potential problems with the interpretation of hair analysis results. Forensic Sci Int. 107(1-3):5-12; 2000.

Yin S. Malicious use of pharmaceuticals in children. J Pediatr. 157(5):832-6; 2010.

Thank you to Dr. Lynn Sheets for additional slide content.

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