Drug-Endangered Children

The term drug-endangered refers to children exposed to an environment where drugs are present. Exposure to illicit drugs, over-the-counter medications, prescription medications, and supplements can all endanger children. The potential for harm includes:

• prenatal drug exposure resulting in withdrawal symptoms at birth and risk for growth and developmental impairments

• exploratory ingestion of a substance by a child

• injury of a child in a drug-manufacturing environment

• neglect secondary to caregiver substance use rendering them unable to adequately provide for the child; parental substance misuse is a known risk factor for other forms of child maltreatment, including physical and sexual abuse

In this section, we discuss the evaluation and management of possible ingestion in the drug-endangered child. Prenatal drug exposure is covered in the Neonatal Care rotation guide.

Evaluation

A child undergoing medical evaluation for possible drug ingestion can present as completely asymptomatic or with a variety of clinical signs or symptoms, including vomiting, seizures, altered mental status, and acute respiratory failure. Drug ingestions may mimic other medical conditions and be included in the differential diagnosis for any child presenting with an impairment.

• Physical exam: A complete physical exam is warranted to assess for signs or symptoms of a toxic ingestion. This examination should take into account classic exam findings associated with various drug toxidromes (e.g., vital-sign changes, pupil size).

• Laboratory studies: All children for whom there is a concern for drug ingestion should undergo screening and confirmatory drug testing.

  • Screening drug tests typically result within a few hours, but the number of substances tested is limited and varies by institution. It is important to be familiar with the compounds that are included in your institution’s screening drug test. For example, fentanyl is not universally included on screening drug tests, and neither are newer forms of illicit substances, such as xylazine. Therefore, a negative drug screen may not rule out ingestion, and if clinical suspicion is high, additional confirmatory drug testing may be warranted. All positive results on drug screening tests are considered preliminary and require confirmatory testing.

  • Confirmatory drug tests test for a wide range of substances, including those tested for on the initial screening drug test, as well as synthetic drugs, prescribed medications, over-the-counter medications, and newer forms of illicit substances. Again, compounds tested may vary by institution. Confirmatory drug testing should be sent from the same sample as the initial screening test to minimize the possibility of false-negative results secondary to drug clearance. Confirmatory drug testing requires advanced diagnostic evaluation (e.g., spectroscopy) and results typically take several days.

  • Consultation with a toxicologist, if available, can aid in interpreting toxicology results.

  • Drug testing in the medical setting is usually by urine sample, but other testing modalities include hair, blood, saliva, and nails.

• Interventions: If clinical suspicion is high for a potential opioid exposure, do not delay administration of naloxone. A response to naloxone should raise suspicion for a toxic ingestion even when initial drug screening is pending or negative.

  • The opioid fentanyl is a frequent toxic ingestion seen in child maltreatment, and the opioid antagonist naloxone can be used for treatment.

  • However, fentanyl has been increasingly laced with xylazine, a tranquilizer often used in veterinary medicine. Unlike fentanyl, xylazine is an alpha-2 agonist and does not respond to naloxone.

Poison control should be contacted for guidance and reporting at 800-222-1222 (available 24 hours per day, 7 days a week, throughout the United States).

• Sibling evaluation: If a child tests positive for an illicit substance, all child household contacts should receive toxicology studies, even in the absence of clinical symptoms. Research is inconclusive as to the utility of further child maltreatment evaluation (i.e., skeletal surveys, in index cases and household contacts who test positive for illicit substances). If available, consultation with the hospital’s child protection team can help decide about further evaluation.

Reporting

In response to the rising rates of substance misuse in the United States, federal and state legislation have been amended to recognize drug-endangered children as suffering a form of child maltreatment, thereby necessitating a report to local child protective services. However, in regard to prenatal substance exposure, states vary on the approach to newborn drug testing, requirements to report, and whether reports generate a response from local child protective services. In states where prenatal drug exposure does generate a response from child protective services, this response has shifted to be more focused on providing treatment and support to caregivers experiencing substance use disorders.