What Should I Do When I'm Called To See A Drug-Exposed Child?

Patient Presentation
A 16-month-old male was brought to the emergency room after he was found in a home that a law enforcement officer had been called to about a domestic dispute.
The officer with the child stated that other officers had found the child unattended in a bedroom.
There was drug paraphernalia in another room, and equipment for possible drug manufacturing in the basement.
The parents were currently being held by law enforcement officers.
The child was brought in for an emergency evaluation and social services has been contacted and are coming to the emergency room.
There were no other children or adults on the premises, and no other information was available.
The pertinent physical exam showed a somewhat frightened male who said few words and was appropriately resistant during the examination.
He was dressed in a long-sleeved shirt and jeans appropriate for the weather which smelled of tobacco smoke.
His weight, height and head circumference were ~75-90% for age and his vital signs were appropriate for his age.
Pulse oximetry was 98% on room air. Pupils were 3-4 mm, equal, round and reactive to light.
Skin examination revealed a few different colored bruises on his shins, and two linear scratches on the dorsal surface of his left forearm.
His lungs were clear. His heart showed no murmurs and his neurological examination was normal.

The work-up included liver function tests, electrolytes, BUN, creatinine, complete blood count, and urinalysis. All were normal except for a hematocrit of 32%.
A skeletal survey was negative for fractures as was his eye examination by ophthalmology. Urine toxicology and a hair sample for illicit substances were sent to the pathology laboratory using chain of evidence procedures.
A lead level, urine and hair screening for illicit drugs were pending at discharge.
The child was also decontamined using soap and water and the clothes were given to the officer maintaining the chain of evidence.
The diagnosis of a child with potential exposure to illicit substances and neglect was made. Iron-deficiency anemia was diagnosed and the patient was begun on iron supplementation.
The patient’s clinical course at a one week follow-up appointment with the child maltreatment (child abuse) service showed that the child was in and would continue in emergency foster care for the foreseeable future.
The social worker said that the parents continued to be jailed on charges of manufacturing methamphetamine. The child had been adapting fairly well to the foster care family.
The follow-up on the laboratory testing showed a lead level of <10 mg/dl, and urine toxicology was positive for methamphetamine. The hair sample was pending.
The social worker said that his mother stated that he had received some care and vaccinations before his first birthday but no other specific information was available. The social worker would try to obtain medical records.
He was given one dose of Diphtheria-Tetanus-Acellular Pertussis, Inactivated Polio Virus, Haemophilus influenza B, Hepatitis B, Measles-Mumps-Rubella, Varicella, and Pneumococcal conjugate vaccines.
The child was referred for a full developmental, mental health and behavioral assessment. He was also referred to a local dentist and family medicine physician for his continued primary care.
He was to see the family medicine physician in 4-8 weeks to review his immunization records, re-evaluation of his anemia and the pending laboratory tests. He was to return to the child maltreatment service in 6 months.

Discussion

Methamphetamine use is increasing in the United States, especially in the rural Midwest.
Methamphetamine (slang names include: ice, glass, crystal, and tina) was first commercially introduced in the 1940s. The 1960′s saw skyrocketing illicit use.
Methamphetamine hydrochloride, meth’s free-based form, became widely available in the 1980s.
It comes as chunky white crystals that is often smoked, nasally inhaled or taken orally. It is hepatically and renally excreted with a half-life of ~10 hours.
Its affects include wakefulness and physical activity, decreased appetite. Chronic use can also cause psychotic behavior, hallucinations and stroke.

Methamphetamine is reported to be one of the most commonly made illegal drugs.
It commonly is manufactured from pseudoephedrine (found in over-the-counter decongestants) and anhydrous ammonia (used in farming fertilizers).
Laws regarding the control of the quantity of pseudoephedrine that can purchased have been or are being instituted in many states, and in some states have reduced the number of methamphetamine laboratories.

The exact mechanism of methamphetamine’s effects is unknown, but the ‘highs’ are most likely due to dopamine and other neurotransmitters in the central nervous system.
Long-term pharmacological effects of methamphetamine are also not well known and there is the possibility of developing chronic psychiatric illnesses such as depression and schizophrenia, or other illnesses such as a Parkinson-like syndrome.

Learning Point
Initial evaluation for potential exposure to illicit substances includes:

  • Assessment and treatment for life-threatening findings
  • Decontamination of child with soap and water. Give clothing to law enforcement officials maintaining the chain of evidence
  • Obtain medical history from available sources, e.g. parents, social worker, law enforcement officials, emergency medical technicians, etc.
  • Complete physical examination emphasizing general appearance, affect, neurologic, respiratory and skin examinations
  • Laboratory and other evaluations
    • Urine and hair specimens for toxicology screening. Ask laboratory to report all positive results. Maintain the chain of evidence
    • Liver function tests
    • Electrolytes, BUN, creatinine
    • Complete blood count
    • Lead level
    • Urinalysis including dipstick for blood
    • Skeletal survey for children < 2 years and older child with indicators of skeletal injury
    • Ophthalmological evaluation
    • Head computed tomography or magnetic resonance imaging if ophthalmological or neurological examination are abnormal, or if the child is less than 1 year of age
    • Consider oxygen saturation, carboxyhemoglobin, chest radiograph or pulmonary function tests if child has respiratory abnormalities
    • Consider complete metabolic panel and creatinine phosphokinase and coagulation studies if bleeding or battering appears to have occurred
    • Consider HIV testing if history of parental drug abuse or other concerning history
  • Call Poison Control Center if clinically indicated (800-222-1222)
  • Call social worker, Department of Human Services for social service evaluation and management
  • Call law enforcement officials for evidence management
  • Follow-up with child maltreatment clinic within few days

Initial follow-up

  • Obtain interval history and past medical history
  • Complete physical examination
  • Check laboratory evaluation already completed and status of those tests, order any missing tests
  • Consider hepatitis screening (for B and C) if liver function tests are abnormal, tuberculosis screening, and nutritional assessment for lack of normal growth if concerns in history or physical examination
  • Referral for complete developmental, behavioral and mental health assessment
  • Referral for dental care
  • Referral for primary care including to follow-up missing immunizations
  • Obtain release of medical records

Long term follow-up (at 6 and12)

  • Obtain interval history and past medical history
  • Evaluate medical records
  • Repeat abnormal tests until they normalize or are otherwise evaluated
  • Monitor primary care including immunizations, screening tests and anticipatory guidance

Questions for Further Discussion
1. How do you maintain the chain of evidence of specimens?
2. Is a positive neonatal drug screen evidence of child abuse and/or neglect?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed – Street Drugs or PubMed – Child Abuse.

Information prescriptions for patients can be found at MedlinePlus for these topics: Child Abuse and <a href="Drug Abuse
and at Pediatric Common Questions, Quick Answers for this topic: Child Abuse

To view current news articles on this topic check Google News.

American Academy of Pediatrics Policy Statement. Neonatal Drug Withdrawal. Pediatrics 1998:101;1079-1088. Available from the Internet at: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;101/6/1079 (rev. 6/6/1998, cited 8/20/2006).

Child Protection Clinical Protocols. Medical Assessment Protocol for Children Exposed to Illicit Substances. University of Iowa. Available from the Internet at: http://forms.uihc.uiowa.edu/pdf/abuseforms/index.htm (rev. 12/2003, cited 8/20/06).

American Academy of Pediatrics. Active Immunization, In Pickering LD, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2006;28.

Gettig JP, Grady SE, Nowosadzka I. Methamphetamine: putting the brakes on speed. J Sch Nurs. 2006 Apr;22(2):66-73. Available from the Internet at: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16563028&query_hl=5&itool=pubmed_docsum (rev. 4/2006, cited 8/20/2006).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competency performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
    16. Learning of students and other health care professionals is facilitated.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Professionalism
    21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.

  • Systems Based Practice
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Authors
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Resmiye Oral, MD
    Clinical Assistant Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    September 18, 2006