Born an addict: Clues from umbilical cords

"We may already know the mom has an opioid dependency at delivery because most women disclose this to avoid risking withdrawal, but we also need to know what else is she taking that might affect the baby's central nervous system," says Karen Buchi, MD, president, Primary Children's Hospital Medical Staff and chief of the Division of General Pediatrics at the University of Utah.

Buchi points out these babies suffer from "drug exposure" as opposed to "addiction, "which is the behavior around drug dependency exhibited by the mother. As the baby is delivered -- when a mother is suspected of being high risk for drug use -- a member of the delivery team snips off six inches of the umbilical cord and sends it to ARUP Laboratories. Because umbilical cord tissue can be sent for testing immediately after birth, this specimen type offers logistical advantages over meconium, the traditional specimen for detecting drug-exposed newborns. As the second medical laboratory in the country to start offering cord testing (since August 2012), ARUP experts immediately begin analysis looking for more than 40 specific drugs and drug metabolites. The most common drug ARUP identifies is marijuana; the second most common drug class is opioids (e.g., heroin, prescription pain killers). Often there is a mix of illicit drugs and prescription drugs. According to a Utah Health Status Update released in July 2013, between 2009 and 2012, 1,476 Utah mothers were reported to have used illicit drugs. As a result, 29.5 percent of babies born to these mothers tested positive for illicit drugs at birth -- approximately 109 babies per year. "Utah is right up there with the rest of the nation in the rate of drug exposure among newborns," adds Buchi, citing that the U of U Hospital averages about one opioid-exposed newborn a month.

Each month, thousands of cord, and meconium, specimens arrive at ARUP from around the country. In Utah, the majority of cord specimens come from the Intermountain Medical Center while the University of Utah hospital still primarily sends ARUP meconium specimens. Though it varies based on the hospital, generally no consent from the mother is necessary for testing the infant if there is a medical reason to believe the child has been drug exposed in utero. Turning around results fast is crucial, because neonatal specialists need to identify and treat the symptoms to mitigate suffering and even possible death from withdrawals, before the typical 48-hour window closes when healthy mothers and their infants typically leave the hospital. While cord tissue testing can take up to 72 hours, for babies who exhibit signs of withdrawals or have mothers considered high-risk for drug use, the baby is frequently monitored longer. In this time period, the clinician can attain more information about the kinds of drugs in the baby's system and determine the best treatment.

"Sometimes babies are already in the throes of withdrawal symptoms but physicians can't determine what drugs they are dealing with until test results are available," says Gwen McMillin, PhD, DABCC, a medical director of the Clinical Toxicology Laboratories at ARUP. The Rough Road of Withdrawals for Newborns Known as neonatal abstinence syndrome, once the baby is born, and is no longer receiving drugs through the placenta from the mother, withdrawal symptoms begin. They can appear from one to ten days after birth, ranging from diarrhea, excessive or high-pitched crying, fever, seizures, hypersensitivity to light, touch, and sound, rapid breathing, trembling, hyperactive reflexes, to name a few. Some infants will carry the effects of their mothers' neonatal drug abuse for life, suffering longterm complications including brain damage and learning disabilities. Like any addict that immediately stops drug intake, a baby experiences the same physiological impact on the body and brain. In the case of a baby being exposed to opiates, if the opiate is not replaced, the baby can die. Affected newborns will spend their first months in a newborn intensive care unit; it can take more than a year for the effects of some drugs to wear off. Evidence reveals that these babies are more susceptible to drug addiction issues later.

"Ten years ago we were seeing significant prenatal methamphetamine use, now its opioids; the difference is the babies exposed to opioids have longer lengths of stay in the hospital because they go through physiological withdrawal," explains Buchi, who has helped set up a care process for the management of opioid-exposed newborns. "The symptoms of neonatal abstinence syndrome depend on the type of drug the mother used, how long it takes for the body to metabolize and eliminate the drug, how much of the drug she was taking and for how long," explains McMillin, adding that whether the baby was born full-term or premature can also be a variable. Whether a baby is addicted to stimulants or "downers" will result in different withdrawal symptoms and require different treatment. The American Medical Association estimated that in the United States approximately one infant, suffering from neonatal abstinence syndrome, was born every hour in 2009. "The work we're doing here is about the human condition; it is about the safety of children -- as the risk of child abuse and neglect increases in cases of maternal drug abuse," emphasizes McMillin, who has visited some of the babies in NICU, as well as testified in court when called to present evidence.

"This is also about getting mothers the care and support they need through rehab and social services so they can take care of their children." Why Is The Cord the Best Evidence of Drug Use? Traditionally meconium (an infant's first stool) has been tested for detecting the presence of drugs, forming in the second trimester, and absorbing over time. However, waiting for this first stool to pass may waste valuable time, or the mother may try to dispose of it secretly, or it may pass during a difficult delivery, as happens in 10 percent of cases. The samples may be too small or sent too late for viable testing. Hair was considered as a possible specimen, but many babies don't have enough hair to provide a sizable enough sample.

"About six years ago, we started looking for alternative specimens," recalls McMillin, considering the placenta, the vernix caseosa (a white, creamy, film covering the baby's skin during the last trimester), and the umbilical cord. The cord became the specimen of choice because of its practical size, easy transportability, and accessibility. "Every child comes into this world with one and it can be sent the minute the baby is born," points out McMillin. What makes the turn-around time quicker for the cord is there is no waiting to collect the specimen. About ARUP Laboratories Founded in 1984, ARUP Laboratories is a leading national reference laboratory and a nonprofit enterprise of the University of Utah and its Department of Pathology. ARUP offers more than 3,000 tests and test combinations, ranging from routine screening tests to esoteric molecular and genetic assays. ARUP serves clients across the United States, including many of the nation's top university teaching hospitals and children's hospitals, as well as multihospital groups, major commercial laboratories, group purchasing organizations, military and other government facilities, and major clinics. In addition, ARUP is a worldwide leader in innovative laboratory research and development, led by the efforts of the ARUP Institute for Clinical and Experimental Pathology®.