FEATURE SPOTLIGHT : NEWBORN SCREENING AND GENETICS
Neonatal Abstinence Syndrome : To Screen or Not to Screen
By Kelsey Granger , MHS , specialist , Environmental Health
As public health continues to combat the opioid overdose epidemic , the impact on vulnerable populations must be considered . While Neonatal Abstinence Syndrome ( NAS ) symptoms are non-specific , they are caused by in utero exposure to opioids or other substances known to result in withdrawal . According to 2020 data from the Healthcare Cost and Utilization Project ( HCUP ) managed by the US Agency for Healthcare Research and Quality ( AHRQ ), one newborn with NAS is diagnosed every 24 minutes — about 59 diagnoses a day . While NAS impacts neonates across all demographic groups , a 2021 HCUP report found that neonates with NAS are significantly more likely to be non-Hispanic White , Medicaidbilled , residing in ZIP codes in the lowest quartile of median income and living in nonmetropolitan counties .
Raising the Alarm
The estimated rate of NAS increased 82 % between 2010 and 2017 . In response to these shocking data , and to address the role of laboratory data in NAS surveillance , APHL ’ s Overdose Biosurveillance Task Force ( OBTF ) convened a panel of experts across related disciplines including neonatology , obstetrics and gynecology , analytical chemistry , epidemiology and clinical and public health laboratory science . Lengthy debate among the experts around universal screening and the use of newborn screening dried blood spots ( NBS DBS ) in NAS surveillance resulted in a 2022 report which concluded that laboratory data has the potential to enhance NAS surveillance and provided the following recommendations :
1 . Laboratory testing is recommended for symptomatic neonates , not for screening of all newborns .
2 . Residual newborn dried blood spot specimen collected for the detection of diseases on the Recommended Uniform Screening Panel should not be used for NAS surveillance .
3 . Population-based research studies are recommended to determine the prevalence of in utero opioid exposure .
To track cases more easily , universal screening for NAS utilizing existing screening systems may seem appealing but ultimately may not be suitable . Immunoassay screening methods are accessible and possess rapid turnaround time that can quickly inform treatment decisions but come with challenges : only a recent drug exposure is detectable , sporadic drug use cannot be reliably detected , and this method is prone to false positive and false negative results , which can lead to inaccurate inflation or underestimation of NAS cases . As the opioid epidemic evolves , novel substances including fentanyl analogs have emerged , and may not be detectable using immunoassay . For definitive ( confirmatory ) results , toxicology testing using HPLC-MS / MS or HRMS is indicated .
Finding a Way Forward
NBS DBS tested according to the Recommended Uniform Screening Panel ( RUSP ) are a common feature of newborn screening programs across the US and may also appear an appealing specimen for universal NAS screening . However , APHL does not recommend the use of NBS DBS collected for the detection of diseases on the RUSP for NAS surveillance . Neonates present withdrawal symptoms 24 – 48 hours after birth , while conditions included in the RUSP otherwise go unrecognized without laboratory testing . Results from toxicology testing of dried blood spots may not be available for 5 – 7 days after birth and would not inform treatment in a timely manner . Inclusion of drug screening in NBS DBS could pose challenges to obtaining informed consent for critical NBS testing or could even deter birthing individuals who use drugs from choosing to give birth in a hospital .
While NAS occurs across racial groups , it is disproportionally concentrated among at-risk low-income , rural populations . Downstream impacts of universal screening methods are not without consequence and , if instituted without proper precaution or protection of the individual , can significantly negatively impact birthing individual and infant bonding through involvement of child protective services and subsequent legal challenges that can extend to future births without indication of drug use . In some states , these impacts can result in criminal prosecution of the birthing individual . The OBTF recommends that testing of symptomatic neonates be prioritized to best utilize laboratory and public health resources and minimize potential social and ethical implications of neonatal drug testing . g
20 LAB MATTERS Fall 2023
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