Newborn Drug Testing - Meconium and Umbilical Cord Tissue

Exposure to maternal drug use during gestation may adversely affect neonatal development and may lead to acute adverse events, including neonatal abstinence syndrome (NAS) and infant mortality. Prenatal drug exposure may also contribute to long-term behavioral effects and developmental deficits.

  • Diagnosis
  • Background
  • Lab Tests
  • References
  • Related Topics
  • Videos

Indications for Testing

  • Detect prenatal exposure to drugs in meconium or umbilical cord tissue for infants
    • Born to mothers with high risk (eg, history of drug use, prostitution, sexually transmitted infection [STI])
    • Born to mothers with little or no prenatal care
    • Born to mothers with unexplained placental abruption or premature labor
    • Born with unexplained neurological complications
    • Born with unexpected intrauterine growth retardation
    • Who develop drug withdrawal symptoms (eg, neonatal abstinence syndrome [NAS])

Laboratory Testing

  • Umbilical cord tissue drug testing
    • Reflects drug exposure over approximately the last trimester of a full-term birth
    • Routine analysis includes qualitative detection by mass spectrometry for >30 prescription and illicit drugs (opioids, stimulants, sedative hypnotics) and qualitative screen for cannabinoids by immunoassay
    • Refer to ARUP's Drug Cut-Off Limits for Meconium and Umbilical Cord Tissue
      • Includes lowest concentration reported, drug class, and drug metabolites
  • Meconium drug testing
    • Reflects drug exposure over approximately the last trimester of a full-term birth
    • Routine analysis includes a qualitative screen for 9 drug classes – specimens that test positive for 1 or more drugs reflex to confirmatory testing by mass spectrometry
    • Directed (confirmation only) tests are available when only 1 drug class is of clinical interest or when quantity of meconium available for testing is very small (eg, <1 g)
    • Refer to ARUP's Drug Cut-Off Limits for Meconium and Umbilical Cord Tissue
      • Includes lowest concentration reported, drug class, and drug metabolites
  • Umbilical cord blood and infant urine drug testing
    • May be used for testing if meconium and tissue are not available
    • Only detects recent drug exposure
  • Maternal drug testing
    • May detect very recent drug use
    • Urine is the preferred specimen

Epidemiology

Prevalence – 400,000-440,000 infants (10-11% of all births) (The National Center on Substance Abuse and Child Welfare)

Pathophysiology

  • Umbilical cord tissue
    • Begins to form during ~fifth week of gestation
    • Passed during birth 
  • Meconium
    • Dark, tarry material passed from infant’s rectum in the first days after birth until milk- or formula-based stool appears
    • Begins to form during week 12-16 of gestation and is usually passed within first 3 days of birth
      • Passage may be delayed when infant is exposed to opioids or birth is premature
      • May also be expelled in utero or during birth

Clinical Presentation

  • Stimulants
    • Cocaine
      • Infant
        • Irritability and withdrawal at birth
        • Subarachnoid and intracerebral hemorrhage
        • Small infant head size
        • Reduced birth weight
        • Fetal death
        • May later manifest childhood behavioral disorders (eg, attention deficit hyperactivity disorder [ADHD])
      • Mother
        • Premature labor
        • Ruptured uterus, placental abruption
        • Adult behavioral disorders (eg, ADHD)
    • Amphetamines (particularly methamphetamine)
      • Infant
        • Effects similar to cocaine
        • Medical problems in early life
      • Mother
        • Effects similar to cocaine
        • Complications during pregnancy – reduced fetal growth, stillbirth, congenital anomalies
        • Increased rates of premature birth
  • Cannabinoid (marijuana)
    • Infant
      • No firm evidence for effects on attentional behavior or visual analysis/hypothesis testing
      • No effect on global intelligence quotient (IQ)
  •  Opioids, barbiturates, benzodiazepines
    • Infant and mother – withdrawal symptoms
      • Irritability
      • Tremors
      • Hyperactivity
      • Seizures

Detection

  • Timely detection of in utero drug exposure is critical for effective management of withdrawal syndromes and long-term needs (social and medical) of exposed infants
    • Actual time window for detecting exposure with meconium or umbilical cord tissue is unknown and is drug dependent, but is thought to represent approximately the last trimester of a full-term birth
  • Detection of drugs depends on
    • Extent of maternal drug use
    • Drug stability
    • Deposition of drug analytes in meconium and umbilical cord tissue
    • Performance of the analytical method
  • Drugs administered to the mother during labor and delivery may be detected in meconium and umbilical cord
  • Drugs administered to the newborn after birth can be detected in meconium if the meconium is collected after drug administration
  • Concentrations of drugs in meconium are much higher than concentrations of drugs in umbilical cord tissue; cutoff concentrations were established to harmonize positivity rates between the 2 specimen types for most drugs
  • Umbilical cord tissue testing may be preferable to meconium testing due to
    • Ease of collection of a larger volume of specimen
    • Relatively fast turnaround time if specimen is sent to laboratory on day of birth
    • Reflex/confirmation testing not performed
  • Meconium or umbilical cord tissue testing is preferred over urine for testing of infants
    • Urine testing indicates drug use over the previous 1-10 days, depending on the drug
    • Meconium may be contaminated by urine; umbilical cord tissue may be contaminated by maternal blood
    • Deposition of drugs in umbilical cord tissue is not well studied but appears consistent across the length of the cord
    • It is preferred that all meconium voids be collected to maximize the potential for drug detection
    • Umbilical cord tissue can be sent to laboratory immediately after birth
    • Umbilical cord tissue avoids detection of drugs administered directly to newborn after birth

 

Tests generally appear in the order most useful for common clinical situations. Click on number for test-specific information in the ARUP Laboratory Test Directory.

Drug Detection Panel, Umbilical Cord Tissue, Qualitative 2006621
Method: Qualitative Liquid Chromatography/Tandem Mass Spectrometry/Enzyme-Linked Immunosorbent Assay

Limitations 

Pattern and frequency of drug(s) used by the mother cannot be determined by this test

A negative result does not exclude the possibility that a mother used drugs during pregnancy

Detection of drugs in umbilical cord tissue depends on extent of maternal drug use as well as drug stability, unique characteristics of drug deposition in umbilical cord tissue, and performance of the analytical method

Concentrations of drugs and metabolites in cord tissue are generally lower than those found in meconium

Marijuana metabolites (eg, THC) are detected by immunoassay and are not confirmed

Test results are qualitative; quantitative results are not provided

Drugs of Abuse Panel, Meconium - Screen with Reflex to Confirmation/Quantitation 0092516
Method: Qualitative Enzyme-Linked Immunosorbent Assay/Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Limitations 

A negative result does not exclude the possibility that a mother used drugs during pregnancy

Detection of drug use depends on quantity and quality of the specimen tested as well as pattern and frequency of drug(s) used by mother

Although not likely, drugs administered during labor and delivery may be detected in meconium

General References

Adrian M, Van Truong M, Osazuwa T. Measuring levels of comorbidity in drug user* emergency patients treated in Ontario hospitals. Subst Use Misuse. 2007; 42(2-3): 199-224. PubMed

Araojo R, McCune S, Feibus K. Substance abuse in pregnant women: making improved detection a good clinical outcome. Clin Pharmacol Ther. 2008; 83(4): 520-2. PubMed

de Castro A, Jones HE, Johnson RE, Gray TR, Shakleya DM, Huestis MA. Methadone, cocaine, opiates, and metabolite disposition in umbilical cord and correlations to maternal methadone dose and neonatal outcomes. Ther Drug Monit. 2011; 33(4): 443-52. PubMed

Gareri J, Klein J, Koren G. Drugs of abuse testing in meconium. Clin Chim Acta. 2006; 366(1-2): 101-11. PubMed

Lozano J, Garcia-Algar O, Vall O, de la Torre R, Scaravelli G, Pichini S. Biological matrices for the evaluation of in utero exposure to drugs of abuse. Ther Drug Monit. 2007; 29(6): 711-34. PubMed

Marcellus L. Is meconium screening appropriate for universal use? Science and ethics say no. Adv Neonatal Care. 2007; 7(4): 207-14. PubMed

Moller M, Gareri J, Koren G. A review of substance abuse monitoring in a social services context: a primer for child protection workers. Can J Clin Pharmacol. 2010; 17(1): e177-93. PubMed

Rayburn WF. Maternal and fetal effects from substance use. Clin Perinatol. 2007; 34(4): 559-71, vi. PubMed

References from the ARUP Institute for Clinical and Experimental Pathology®

Barakauskas VE, Davis R, Krasowski MD, McMillin GA. Unresolved discrepancies between cannabinoid test results for infant urine. Clin Chem. 2012; 58(9): 1364-7. PubMed

Chittamma A, Marin SJ, Williams JA, Clark C, McMillin GA. Detection of in utero marijuana exposure by GC-MS, ultra-sensitive ELISA and LC-TOF-MS using umbilical cord tissue. J Anal Toxicol. 2013; 37(7): 391-4. PubMed

Coles R, Clements TT, Nelson GJ, McMillin GA, Urry FM. Simultaneous analysis of the Delta9-THC metabolites 11-nor-9-carboxy-Delta9-THC and 11-hydroxy-Delta9-THC in meconium by GC-MS. J Anal Toxicol. 2005; 29(6): 522-7. PubMed

Coles R, Kushnir MM, Nelson GJ, McMillin GA, Urry FM. Simultaneous determination of codeine, morphine, hydrocodone, hydromorphone, oxycodone, and 6-acetylmorphine in urine, serum, plasma, whole blood, and meconium by LC-MS-MS. J Anal Toxicol. 2007; 31(1): 1-14. PubMed

Marin SJ, Christensen RD, Baer VL, Clark CJ, McMillin GA. Nicotine and metabolites in paired umbilical cord tissue and meconium specimens. Ther Drug Monit. 2011; 33(1): 80-5. PubMed

Marin SJ, Coles R, Merrell M, McMillin GA. Quantitation of benzodiazepines in urine, serum, plasma, and meconium by LC-MS-MS. J Anal Toxicol. 2008; 32(7): 491-8. PubMed

Marin SJ, Coles R, Urry FM, McMillin GA. Confirmation of cannabinoids in meconium using two-dimensional gas chromatography with mass spectrometry detection. J Chromatogr B Analyt Technol Biomed Life Sci. 2007; 858(1-2): 59-64. PubMed

Marin SJ, Keith L, Merrell M, McMillin GA. Comparison of drugs of abuse detection in meconium by EMIT II and ELISA. J Anal Toxicol. 2009; 33(3): 148-54. PubMed

Marin SJ, Keith L, Merrell M, McMillin GA. Evaluation of a new ELISA kit for the detection of benzodiazepines in meconium. J Anal Toxicol. 2009; 33(3): 177-81. PubMed

Marin SJ, McMillin GA. Quantitation of Total Buprenorphine and Norbuprenorphine in Meconium by LC-MS/MS. Methods Mol Biol. 2016; 1383: 59-68. PubMed

Marin SJ, Moore C, McMillin GA. Cross-reactivity of phentermine with an immunoassay designed to detect amphetamine in a meconium specimen. Clin Chem. 2009; 55(3): 589-90. PubMed

Marin SJ, Roberts M, Wood M, McMillin GA. Sensitive UPLC-MS-MS assay for 21 benzodiazepine drugs and metabolites, zolpidem and zopiclone in serum or plasma. J Anal Toxicol. 2012; 36(7): 472-6. PubMed

McMillin GA, Wood KE, Strathmann FG, Krasowski MD. Patterns of drugs and drug metabolites observed in meconium: What do they mean? Ther Drug Monit. 2015; 37(5): 568-80. PubMed

Wood KE, Krasowski MD, Strathmann FG, McMillin GA. Meconium drug testing in multiple births in the USA. J Anal Toxicol. 2014; 38(7): 397-403. PubMed

Wood KE, Sinclair LL, Rysgaard CD, Strathmann FG, McMillin GA, Krasowski MD. Retrospective analysis of the diagnostic yield of newborn drug testing. BMC Pregnancy Childbirth. 2014; 14: 250. PubMed

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Last Update: October 2017