Increasing Awareness Is Needed Among Pediatric Hospitalists About Prenatal Substance Exposure: Policy, Advocacy, and Clinical Care

In this month’s Hospital Pediatrics, Lloyd Sieger et al evaluated a novel approach implemented in Connecticut to meet the requirements of the Child Abuse Prevention and Treatment Act (CAPTA).¹  CAPTA is a federal law that mandates notification by the states for pregnancies “affected by substance use” at the time of delivery, and in the case of such exposure, that a Plan of Safe Care be formulated.²  Plans of Safe Care (POSC) are blueprints for postbirth family care that “may address the immediate safety, health, and developmental needs of the affected infant…[as well as] the health and substance use disorder treatment needs of the affected parents or caregivers.”³  In 2019, Connecticut decided to decouple the federal notification requirement from a report to child protective services (CPS).⁴  The premise behind this strategy was the understanding that substance use during pregnancy does not necessarily constitute harm or neglect of a child, and therefore should not on its own constitute an indication for evaluation by CPS.⁵  Further consideration was given in this policy design to the inequitable consequences of CPS referral because of systemic racism and bias against people who use substances.⁶  These policy choices were made specifically with the intent of minimizing unnecessary referrals to CPS for substance exposure in pregnancy that does not rise to the level of concern for abuse or neglect. The findings of Lloyd Sieger et al’s study have significant relevance to pediatric hospitalists, specifically hospitalists who take care of newborns during their birth hospitalization. The pediatric hospital medicine community’s response to the growing number of newborns who are prenatally exposed to substances and medications to treat addiction can have an incredible influence on those children’s futures. Beyond managing neonatal withdrawal signs and symptoms, pediatric hospitalists’ awareness and involvement in the notification process can play a critical role in fostering healthy families and enhancing child well-being.

We are now beginning to learn about the outcomes of this state’s policy decisions in terms of the approach’s feasibility, acceptability, and efficacy, in part because of the authors’ work. Lloyd Sieger et al show that CT was able to successfully develop a new online portal to decouple CAPTA notification requirements from CPS reporting in the setting of prenatal substance exposure, diverting over half the cases of in utero substance exposure from CPS investigations. Yet, the data presented and our experience filling out the online portal highlight some important opportunities for ongoing improvement including: clinicians potentially misinterpreting the notification requirements, policy language that does not line up with medically preferred terminology for substance use disorder, and the formatting of the notification portal questions implicitly suggesting the need for toxicology testing at delivery to interpret risk of child harm. Additionally, the authors’ investigation of the impact of the policy with respect to type of prenatal substance exposure highlights that most diverted notifications involved cannabis exposure. Finally, they expose racial and ethnic disparities in prenatal POSC development and notifications that reflexed to reports to CPS among families of color.

∼1 in every 7 notifications submitted to the online system were dropped because of no evidence that the infant was prenatally exposed to substances. This number is substantial; further analysis of those excluded notifications would be helpful to understand what opportunities may exist for ongoing training for those responsible for submitting notifications.

For those notifications that include prenatal substance exposure, the notification reflexes to a CPS report if there is indication that an infant was exposed because of “maternal substance misuse.”⁷  This language and definition have no medical basis; the term “misuse” has been advised against within the addiction medicine literature because of lack of specificity and pejorative nature.⁸  Although this prompt has been further defined in the portal as “the harmful use of substances for nonmedical purposes,” this critical question may result in those without the training to make such a subjective determination filling out the notification and an unnecessary report to CPS being made.

Additionally, there is variability in who fills out the online form and how hospitals interpret the notification requirements. For example, at some institutions in Connecticut, the ordering of toxicology tests on newborns may in part be driven by the presence of the required question of whether “the child was tested for substances” in the CAPTA notification.⁹  Toxicology tests on newborns are commonly redundant to existing knowledge of substance use during pregnancy; there is strong concordance between positive toxicology results for pregnant patients and the same results for toxicology tests performed on the newborn after delivery.¹⁰  Thus, the inclusion of questions on toxicology tests on the newborn may be swaying providers to order them more frequently than they would for the purpose of guiding clinical care.

With respect to the types of prenatal exposure, Lloyd Sieger et al identified cannabis as the primary substance in 79% of notifications; when it was the only substance, it was much more likely to be associated with diversion away from a CPS referral. As recreational cannabis becomes increasingly legal across the country (as it became in CT in 2021, at the very end of the period investigated by this study), the notification portal offers an alternate approach to care for mother-infant dyads impacted by prenatal cannabis use that better reflects our current understanding of its potential for harm to children and families.¹¹  CPS programs across the country remain understaffed and underfunded¹² ; reducing the number of families reported to CPS for cannabis use at a level not thought to be impacting the ability to parent frees up needed resources which can be focused on children who are experiencing harm.

The state of Connecticut designed their notification system to collect information about not only birthing parent race and ethnicity but also the race and ethnicity of the person completing the notification in order to be able to stratify their results and evaluate for racial disproportionality and bias in the system. The authors found that although 13% of all babies born in Connecticut during the study time frame were Black, they represented 22% of all CAPTA notifications, suggesting Black non-Hispanic mother-infant dyads are overrepresented in the notifications made, despite all available evidence affirming that substance use rates are the same across patient groups when separated by race.¹³  Further, Lloyd Sieger et al identified an overrepresentation of Black non-Hispanic mother-infant dyads having a notification reflex to a report because of a lack of POSC being completed. Stratifying data by key demographics including race and ethnicity is a critical first step that all states adopting CAPTA notification systems should perform to assess for disparities.¹⁴  Now that data from CT has highlighted the persistence of racial disparities within the notification system, hospital-based clinical teams must reexamine policies and guidelines that could be contributing to these biases, including specifically evaluating hospital guidelines for toxicology testing at delivery and how POSC documents are completed. Further review of this reporter-level race and ethnicity data that is collected in the portal but not reported in this manuscript will be beneficial to understanding potential explanations for disparities identified.

As states develop and improve their approaches to CAPTA notification, two additional design considerations in the Connecticut approach are noteworthy. First, the online portal in Connecticut was developed and is managed by the state’s CPS agency. Other states, such as Rhode Island, have developed a dual track notification and reporting system in which the notification is submitted through their Department of Health to completely avoid involvement with CPS when no child safety risks were identified.¹⁵  Given the well-documented avoidance of prenatal care among women who perceive punitive responses to substance use in pregnancy, establishing systems that meet federal requirements but preserve patient trust and are felt to be nonpunitive are essential.¹⁶  Additionally, one potential limitation of the intentionally anonymous design in Connecticut is the inability to study the efficacy of this novel design to meet one of its intended goals: to reduce unnecessary reports to CPS while minimizing child harm. A critical question of how many mother-infant dyads that were initially diverted through the notification system that subsequently resulted in future child abuse or neglect is not possible to evaluate with a truly anonymous notification system. How do we balance the real harm that is caused by unnecessary CPS involvement with the potential for future harm for another child that did not have risks identified at delivery?

In our own practices, we have seen how powerful and impactful it can be to grapple with these difficult questions alongside clinicians caring for parents and infants across the perinatal continuum. To ensure notifications are filled out correctly and toxicology testing is used primarily to inform clinical management, hospital teams could consider implementing a multidisciplinary “family safety huddle” before potential CPS referrals, which would bring together care team members for the birthing person and the infant, review case details, ensure POSC is completed, and review any concerns for infant safety. As states continue to develop and refine their own approaches to CAPTA notification requirements, establishing trusting cross-disciplinary collaboratives with public health practitioners, policy makers, child protective services, and researchers will be needed to further evaluate different policy approaches. Newborn hospitalists, as the first point of contact with families after delivery, have an essential role in these discussions to ensure our policies achieve their intended aims to equitably improve care for families impacted by substance use.