EPSDT Care for Kids Newsletter

Every year, Iowa welcomes an average of 38,000 newborns. On the basis of known rates of drug use, we would expect 7-8 percent, or about 2800 infants, to have been exposed to drugs in utero. With an appropriate screening program, health care providers would identify about 1,200 of these newborns, and then refer them for evaluation and services.

In Iowa in 2005, however, as a result of inadequate screening and testing, only 537 newborns were confirmed as having been exposed to drugs in utero. Infants who have been exposed to drugs but who remain unidentified will be discharged to homes in which mothers are likely to continue to use drugs. Often these infants face continuing exposure to drugs and to the chaotic lifestyle and lack of nurturing so often associated with drug use.

Some states, such as California and Virginia, have mandated maternal and neonatal drug screening protocols for hospitals. Other states, such as Arizona, Washington, and Indiana, have developed a statewide consensus on perinatal screening for drugs, and established education programs in all birthing hospitals. In addition to statewide efforts, many individual hospitals, often in urban areas, have developed structured screening and testing protocols. State, community, and individual hospital efforts have continued to grow in response to our increasing awareness of the extent of perinatal drug exposure.

In Iowa, health care professionals have long recognized the need for programs to identify perinatal drug exposure. Some Iowa hospitals have developed and implemented protocols to guide medical staff in screening mothers and newborns for specific high-risk factors.

Parallel to this, Iowa code encourages health professionals to perform perinatal screening and testing for drugs when risk factors are recognized and documented. However, Iowa code leaves the specific definition of these risk factors to the discretion of the clinician. In addition, Iowa has not mandated that birthing hospitals develop screening and testing protocols. As a result, tremendous variation exists among Iowa birthing hospitals regarding perinatal drug screening. Most community hospitals do no screening at all. Some do randomized screening, such as testing every 15^th or 20^th infant. Often, whether a mother is screened, tested, or exempted depends on the personal perceptions of the medical staff.

A study conducted in Iowa birthing hospitals found that hospitals using a structured screening or testing protocol test twice as many infants as hospitals that have no protocol. At hospitals that use a screening protocol, the rate of positive test results – infants identified as having been exposed to illicit drugs in utero -- is almost five times higher than in hospitals without such a protocol. But less than half of the infants born in Iowa are delivered in hospitals that use a structured protocol for screening and testing.

Even hospitals that use protocols often provide no specific training, which reduces the effectiveness of screening and testing. In one urban hospital in Iowa, and despite the availability of a structured protocol, almost one-third of eligible infants were not screened because staff did not follow the protocol.

As a result of growing concern about perinatal drug exposure, a statewide collaboration came together and developed a targeted, risk-based perinatal drug screening, testing, and intervention protocol to be adopted by every birthing hospital in Iowa. This protocol is now available online (see Resources).

Participants in this collaboration include:

Iowa Department of Public Health
Iowa Perinatal Care Association
Iowa Hospital Association
American Academy of Pediatrics, Iowa Chapter
Drug Endangered Children Alliance of Iowa
Iowa Child Protection Council

Iowa Child Protection Centers and programs, including the University of Iowa Children’s Hospital in Iowa City, Blank Children’s Hospital in Des Moines, St. Luke’s Hospital in Cedar Rapids, Mercy Hospital in Sioux City, and Davenport Child Abuse Task Force.
Many other professional organizations working with newborns, children, and women

The Perinatal Care Program Advisory Council of the Iowa Department of Public Health has approved a screening protocol (see Perinatal Illicit Drug Exposure Risk Assessment Tool), and this is now included in the State Perinatal Care Clinical Guidelines. Members of the Perinatal Care Program staff are currently disseminating this protocol to birthing hospitals around the state. It calls for screening for perinatal drug exposure to be performed in the prenatal clinic, labor and delivery unit, and newborn nursery unit or NICU, and for services to be provided to both the mother and the newborn.

Prenatal clinics play a key role in identifying perinatal drug use, and in offering the mother the opportunity for testing and intervention. Prenatal clinic staff should screen mothers when they first visit the prenatal clinic. If the initial screening is negative, staff should verify abstinence from illicit drug use at every subsequent visit.

Mothers who are reluctant to abstain from drug use may not be willing to disclose addiction, and may refuse to give consent for testing and intervention. When that happens, hospitals need to have a system in place to ensure that information about the status of this at-risk mother and child is communicated from the prenatal clinic to the labor and delivery unit and to the newborn nursery or NICU.

Implementing a standard protocol allows health care providers to identify most drug exposed newborns and provide treatment or referral for treatment. Such a protocol also allows providers to link the mother to the services she needs to become the parent she wants and deserves to be.