Just under 2,100 Pennsylvania newborns whose mothers had Medicaid were diagnosed with narcotics withdrawal syndrome last year, but only 972 infants were reported to county child welfare authorities as having been exposed to drugs in the womb.
In 2015, the first year the state broke out data for those substance-exposed newborns, 707 infants were reported to child welfare as being exposed to narcotics, but 2,350 babies were diagnosed with withdrawal from narcotics, known as neonatal abstinence syndrome, according to the statistics from the state Department of Human Services.
Yet no gap should exist between the number of babies diagnosed and those reported to child welfare agencies, since all cases of infants who were exposed to legal or illegal narcotics must be reported to those government agencies under the 2003 U.S. Child Abuse Protection and Treatment Act, known as CAPTA. Before infants are sent home with their parents who might be struggling with drug addiction themselves, the county agencies are required to assess the home environment and create a safe-care plan, including services to drug-dependent parents.
But Pennsylvania's interpretation of the federal law has led to confusion among health care providers about when child protective services should be notified, according to county officials and child advocates.
The Pennsylvania Department of Human Services interpreted the federal mandate to apply only to babies whose mothers took illegal drugs or misused prescription drugs during pregnancy. As a result, health care providers aren't required to report drug-exposed babies born to mothers who were legally prescribed narcotics — like oxycodone or heroin —replacement drugs like methadone — if they took them as directed under medical supervision.
The full extent of the number of drug-exposed newborns in Pennsylvania is unknown because the only data collected is on those covered by Medicaid, the federal health insurance program for the poor and disabled. No agency collects newborn-exposure data on the privately insured.
State interpretation
The prescribed-narcotics exception in Pennsylvania law was intended to reduce the social stigma surrounding parental substance abuse, which discourages pregnant women from entering drug treatment, said Cathleen Palm, founder and executive director of the Center for Children's Justice in Berks County. But the exception created unanticipated consequences, she added.
“It takes the eyes off the baby because you don’t want to punish the mom. But you need to focus on mom and baby. Sometimes parents with a drug history don’t need child welfare in their lives, but if you don’t check, you don’t know,” Palm said. “You’ve really diminished the commitment to the baby in an attempt, rightfully, to not judge the actions of the mom.”
The conflict between the state and federal laws also means some health care providers report all newborn narcotic exposures and others only report exposure to illegal drugs, as evidenced by discrepancies in the numbers reported on the local and state levels, child welfare officials and advocates say.
The number of drug-exposed births at St. Mary Medical Center increased from 185 in 2014 to 270 of the 2,291 Middletown hospital's births last year, officials said. St. Mary reports all drug-exposed births to child welfare, whether the drug the mother used was legal or illegal.
State hospital discharge records show only 93 newborns were reported as being exposed to “illegal” drugs at all three Bucks County hospitals with maternity units during fiscal year 2014-15, the most recent year available. St. Mary didn't have fiscal year data available for drug-exposed births, but a hospital official said the state discharge data was inaccurate.
"In some situations, we can discern between babies born with exposure to legal versus illegal drugs, however, our ability to draw that distinction relies on the mom's health history and a drug screen of the baby, " Dr. Carrie Hufnal, interim director of St. Mary's Neonatal Intensive Care Unit. "A drug screen in and of itself will only reflect exposure to opiates but will not tell us if the exposure is related to prescription or street drug use."
Bucks County Children and Youth received 209 hospital referrals under CAPTA for babies born to county residents last year, up from 129 in 2015. The first six months of this year, the agency received 112 referrals, according to agency director Lynne Kallus-Rainey. But she suspects that there are more births that should have been reported.
"We know not all (drug-exposed) babies are being reported,” Kallus-Rainey said. “We are not totally able to access when, and why, some get reported, while others don't
In Montgomery County, Abington Hospital-Jefferson Health has seen its drug-exposed births increase from 31 to 93 between the 2012-13 and 2015-16 fiscal years. The hospital also reports all drug-exposed births involving prescribed and illegal drugs, but doesn't differentiate between exposures to legal or illegal narcotics, an official said.
Montgomery County Children and Youth Director Laurie O'Connor acknowledged the 114 CAPTA referrals it received from area hospitals last year may not represent all drug-exposed newborns born to county residents, because referrals for drug-exposed infants under age 1 without any hospital record of newborn exposure are classified differently. “It may be suspected that the child was born drug-affected, given the mother’s history of addiction, but without completion of testing by the hospital (at birth) there is only speculation,” O’Connor said.
Palm suspects confusion over the reporting law coupled with a lack of understanding about prenatal drug exposure and its prevalence is responsible for the divergence in reporting.
"No one has really been paying attention to this issue," she said. “There is a big bucket of kids that we may not know if they were prenatally exposed to drugs, so all the provisions of law and the safety mechanism for them may never get triggered.”
State vs. local laws
The state's CAPTA interpretation became legally binding in 2015, when the Pennsylvania Child Protective Services Law was amended. However, Congress updated the federal law in 2016 to clarify that health care providers must refer all cases of drug-exposed infants to child welfare agencies, regardless of whether the exposure was to legal or illegal drugs.
The Pennsylvania Department of Human Services was supposed to submit a plan to the federal government to bring the state into compliance or risk losing child welfare service funding by June 30, but it recently received an extension. The state agency has assembled a group to develop recommendations for lawmakers to amend Pennsylvania's law to bring the state into compliance with the infrastructure and guidance necessary, according to state Rep. Katharine Watson, R-144, of Warrington. As chairwoman of the House Children and Youth Committee, she gets updates from the group.
DHS said there is no timeline to fix the law and Watson acknowledged the state law is failing some babies.
“I’m very much worried about that,” she said. “I have a problem that we knowingly are sending babies home with people who aren’t ready to take care of them.”
Complicating the situation is the fact that not all infants born exposed to drugs will develop withdrawal symptoms, neonatal doctors said. And while symptoms typically appear within 24 hours after birth, they can appear up to 10 days later — long after most infants leave the hospital.
Health care providers say the growing number of pregnant and parenting women who secretly misuse legally prescribed or illegally obtained narcotics complicates their ability to identify drug-exposed newborns.
This year, Abington Hospital-Jefferson Health anticipates delivering 120 drug-exposed babies, said Dr. Joel Sorosky, chairman of the OB-GYN department. Three-quarters of them will be born to privately insured women taking prescribed opioids for pain-related issues — a number that has tripled over the last four years. Some of these women don't tell their obstetrician about the drug use because they don't believe they're drug-dependent, Sorosky said, and most are unaware the fetus can become dependent on opioids in as little as two weeks.
Dr. Joel Sorosky, head of the OB/GYN Department at Abington Hospital-Jefferson Health, talks about the drug-exposed babies delivered at the hospital.
Area hospitals also are seeing pregnant heroin users who self-medicate with opioids like methadone or suboxone they obtained illegally, believing it's healthier for the baby and a way to stay under government radar, health workers and drug treatment specialists said.
If a pregnant woman discloses dependence early, hospitals can connect the family with alternative pain management or drug treatment providers, Sorosky said. At a minimum, neonatal staff can prepare for observation and, if needed, medical intervention, if the infant experiences withdrawal, he said.
"The challenge comes when we are caught unaware and the baby withdrawals," Sorosky said. "Sometimes, the significant other is just as surprised and it creates an adversarial relationship (between the parents). We can avoid that by knowing early on and have a chance to treat the mother and help the baby.”
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