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Dr. Jones: The epidemic of substance abuse in the U.S. includes moms and the babies they carry. Can a baby be born addicted? And how can we find out so we can provide better care for the newborns? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health, and this is The Scope.

Announcer: Covering all aspects of women's health, this is The Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: Whatever you breathe, eat, smoke, inject or put on your skin when you're pregnant goes to your baby. Knowing this, most moms-to-be are very careful about what they put in their bodies. But some moms just don't know the risks to the baby of the drugs they are taking. And some moms can't help themselves and put dangerous substances into themselves and their fetuses.

When a baby is born, the baby is separated physically from the mom, the cord is cut, and the umbilical cord, which is baby tissue, is discarded. If we obstetricians or pediatricians are worried about what the baby might have been exposed to, what can we do? Sometimes moms will tell us, sometimes they won't, and sometimes they don't know.

Today in The Scope studio we're talking to Dr. Gwen McMillin. She's a professor of pathology and the medical director of toxicology at ARUP, which is our big national testing lab. She'll tell us how we can use umbilical cords to help us take better care of newborns at risk.

Welcome, Dr. McMillin. When it comes to babies being exposed to drugs of abuse during pregnancy, what's the scope of the problem? Big? Little? One in a million?

Dr. McMillin: Unfortunately, the problem is actually growing, and some of that is the recognition of how harmful both drugs of abuse and prescription drugs can be to a mother and the unborn baby. I think the incidence is estimated at about 10% right now, so about 10% of babies are thought to have been exposed to dangerous compounds in utero, and I would say that that problem is growing in parallel with the national opioid epidemic that most people are aware of.

Dr. Jones: Wow, one in 10. One in 10.

Dr. McMillin: Yes.

Dr. Jones: We do 4,000 births at the University Hospital here a year. One in 10 makes a lot of babies exposed to drugs. Well, so how do we figure out if babies have been exposed? What kind of samples are used?

Dr. McMillin: So the traditional specimens that have been evaluated to identify drug exposed infants have been hair, which not every baby has.

Dr. Jones: I got a baldy for sure.

Dr. McMillin: And the meconium which is the first stool of the newborn, or baby poop maybe, that most of us are familiar with. And the challenge with meconium is that it may take several days to pass. We have to be very aware of those passages and scrape the meconium out of the diapers. That can require sometimes several days, several passages and lots of people involved. So there can be lots of problems or errors associated with that. It also will take more time to get results from the laboratory about what might be inside that meconium or hair.

So, a few years ago, we recognized that problem and investigated the possibility of using the umbilical cord tissue itself, which as you pointed out is typically discarded but is a lifeline to the baby. So we found that if we actually grind up that tissue we can detect drugs and drug metabolites or breakdown products in that cord to identify those drug exposed infants. And of course, that's logistically the best specimen possible because every child has a cord and it's available right at birth.

Dr. Jones: Right. And taking it, it's not like having to stick the baby for blood or wait around for the baby to poop. It's right there as soon as the baby is separated from the mom and we can send it to you. So, how do doctors access this? Can you ask for it? Or is it just a research plan? Or how is this happening right now?

Dr. McMillin: Well, ARUP laboratories has been offering this test clinically for about three and half years. There are now two other laboratories in the US that also offer this type of testing.

Dr. Jones: Were you first?

Dr. McMillin: We were actually second. But that's a tough race.

Dr. Jones: To be the best.

Dr. McMillin: To be the very best, yes.

Dr. Jones: Yes, to be fastest.

Dr. McMillin: Yes, yes, yes. And so we offered it as a clinical test to our clients, which are primarily hospitals, and we found that more and more hospitals are now making this a routine part of their practice so that they go ahead and collect cords for every baby and then store it to find out whether or not the baby starts to exhibit signs and symptoms of drug withdrawal or whether there are other risk factors that would suggest drug testing would make sense.

Dr. Jones: Right. But at sometimes we use it for moms who came in addicted to drugs, but changed their behaviors for themselves and for their babies and were completely clean for their pregnancy and it makes a big deal for them and the way the social services look at their mom if the moms cord is clean, the baby's cord is clean.

Dr. McMillin: Absolutely, absolutely. A cord that is negative for drugs or drug metabolites does not definitively say that mom abstained from drugs during pregnancy because, of course, no drug test is perfect and no drug test can pick up everything. But for the most part, yes, it's a way for moms to help validate that they did change their behavior and did what they thought was best for their child.

Dr. Jones: Right. So, in terms of the sample, does it reflect what happened in the last 12 hours or 72 hours? How long does the toxin, does the opioid, or whatever drug might be stay in the cord that you might be testing?

Dr. McMillin: The actual detection limits vary a little bit based on the stability of the drug at physiological temperatures.

Dr. Jones: Well, that sounds like lab speak but I get it.

Dr. McMillin: Okay. So, yes. At physiological temperatures, which are warm. . .

Dr. Jones: Well, thank you.

Dr. McMillin: Some drugs don't stick around very long and breakdown, and so some drugs are hard to detect after a period of time when they're incubated, basically, by the mom and the baby. But research has been done thus far suggests that the umbilical cord tissue can detect drugs that are used during approximately the last trimester of a full-term birth. We can also pick up drugs that are administered during labor and delivery sometimes and that's because of contamination of the cord with mom's blood, but sometimes that's informative as well.

Dr. Jones: Right, and unless we have records of that?

Dr. McMillin: Yes.

Dr. Jones: So you know or you can ask the record . . .

Dr. McMillin: That's correct.

Dr. Jones: That the mom got during labor. Well, this is all important for us to take care of babies and to take care of moms. I think when babies are born and suffering symptoms that look like drug withdrawal, we need to have the tools to provide the best specific care for the newborn, and ARUP laboratories have given us new tools to help the babies and we'll try to create a better world for moms. And thanks for joining us and thank you, Gwen, for joining us on The Scope.

Dr. McMillin: Thank you for the opportunity.

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Dr. Jones: Ten years ago, our clinics were filled with moms doing meth when they were pregnant and it broke my heart, but times have changed and drugs have changed, and we're going to talk about the drugs we unfortunately send to our babies when we're pregnant today on The Scope. This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health, and this is The Scope.

Announcer: Covering all aspects of women's health, this is The Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: So, as we think about the drug epidemics that we're facing now in this country, we think about heroin, and we think about opioids, but I grew up in the era of cocaine, not personally, of course, and so clearly there have been some changes, and it's important because babies that are exposed to these drugs in utero withdraw differently, and some drugs last much longer. So we need to know what's available to the moms, what are moms taking these days, so that we can best take care of the baby. So today in The Scope Studio, we're talking with Dr. Gwen McMillin who is Professor of Pathology and Medical Director of Toxicology at ARUP Laboratories, which is our big national testing lab.

Thanks for joining us, Dr. McMillin.

Dr. McMillin: Happy to be here.

Dr. Jones: So tell me a little bit. You and I are of an age where we've seen things come and go in popularity in the drug business, but what have you been seeing in laboratories from substances that came with the baby after the baby was born? What were babies exposed to?

Dr. McMillin: Well, you're right. Drug use patterns have changed over time, and they are also geographically distributed, so some drugs are more popular in some parts of the country than others.

Dr. Jones: Can you give me an example of that?

Dr. McMillin: So I know that in San Diego, California, for example, methamphetamine was a very, very large problem. That has somewhat abated, and now I would say cannabis or THC-containing products are probably a much bigger problem.

Dr. Jones: Okay. So how about here in Utah? Have you seen a change over the last handful of years? I know we have . . . when people come, women who are pregnant come into our clinic, and we always ask about drugs that they might be using, I think things have changed, if they'll tell us.

Dr. McMillin: Definitely. The opioid epidemic that is affecting many people in this nation has also affected people in Utah, and a larger number of pregnant women are using prescription opioids like oxycodone or hydrocodone. If those moms are treated during pregnancy, then sometimes the drug is switched to one that may be safer, such as buprenorphine. Buprenorphine has recently been accepted as probably the safest opioid replacement for pregnant women.

Dr. Jones: And is it safer for the baby?

Dr. McMillin: It seems to be. There are studies that have shown that the likelihood of a withdrawal syndrome and the severity of that withdrawal syndrome seems to be less with a buprenorphine-exposed baby than with a methadone-exposed baby, or certainly with heroin and the prescription opioids like oxycodone and hydrocodone.

Dr. Jones: So there are reasons for mothers to be truthful.

Dr. McMillin: Absolutely.

Dr. Jones: We've done a Scope on being truthful to your doctor. Be truthful about what they're taking so they might actually have some changes made in the way they're cared for during their pregnancy that might help them and their baby, and it's also important for them to know what the consequences might be for them. So what are we seeing if about 1 in 10 -- that's a big number -- 1 in 10 babies are exposed to drugs of abuse or drugs in this state which might be abused, because it's certainly legal in Colorado in terms of cannabis? So what kinds of things were you seeing in ARUP? ARUP has samples from all over the country, right?

Dr. McMillin: Correct, yes. We receive roughly 50,000 specimens a day from all 50 states.

Dr. Jones: Wow! But that's not 50 baby specimens?

Dr. McMillin: No, no, not that many baby specimens, but we are doing thousands a month of umbilical cord tissue and meconium testing.

Dr. Jones: Okay, specifically to test to see if the baby's been exposed?

Dr. McMillin: Yes.

Dr. Jones: So what are you finding?

Dr. McMillin: So the most common drugs that we are finding are cannabis, as you might expect, so THC-containing drugs, and opioids. And, of the opioids, we do see quite a bit of buprenorphine, methadone, oxycodone, hydrocodone, and then some fentanyl, or meperidine, and sometimes heroin.

Dr. Jones: Wow! So, in terms of cannabis, let's talk of that a little bit, I think because it's legal, people think it won't have any effects on their pregnancy, or it's safe. We know that alcohol, which is legal, is not good for babies, and women largely abstain from alcohol. We know that nicotine, which is legal, is bad for babies, but I'm not sure we've got the word out so much on marijuana.

Dr. McMillin: Right. It is a controversial topic that's the subject of extensive research in many places. I'm aware of quite a bit of research going on in Colorado, for example, right now where mothers are queried about their cannabis use patterns during pregnancy, and both meconium and umbilical cord tissue are tested to help us understand what the extent of the deposition of these different cannabis compounds looks like and what that might mean to babies.

Dr. Jones: Well, so we don't necessarily want to feed these drugs to our babies when they're in our tummies, because then when they are removed from us, we're not going to . . . it's hard to smoke a joint when you're just a newborn. I couldn't get my kid to blow his nose until he was two. It just was too hard for him. We don't want to deliver these drugs to our babies through breast milk. Do you ever test breast milk?

Dr. McMillin: We actually do not test breast milk, and that's because it varies during a feeding, and so to do a good job, one would have to collect all of the breast milk from a feeding, mix it up and then test a portion of that, and even that is just a snapshot based on what mom was doing just prior to the collection, so it's not very informative. But we do use the results of the umbilical cord and meconium testing to help counsel a mother on whether she should be breastfeeding or not, and that's because we know that the THC-type compounds actually concentrate . . .

Dr. Jones: That's the marijuana kinds of compounds.

Dr. McMillin: Yes, the psychoactive compounds in marijuana tend to concentrate in the breast milk, and so maybe several-fold higher in concentration in the breast milk than they are in the blood, which, of course, would potentially expose the baby to a dangerous amount of these drugs.

Dr. Jones: Well, we know that some of the withdrawal symptoms are different, so babies withdrawing from methamphetamines might behave a little bit differently than babies withdrawing from opioids, but some babies withdraw for a long time. It takes a long time for them to get over that. Can you talk to that at all?

Dr. McMillin: Well, yes. Unfortunately, most babies don't get exposed to just one drug, so usually if a mother is using drugs during pregnancy, she's likely to use multiple drugs, and the withdrawal symptoms will look different for exposures to multiple drugs in combination. The timing, as you mentioned, is also variable because, for the withdrawal symptoms to be precipitated, the drug actually has to be eliminated sufficiently that the baby's body needs that drug or wants that drug, and will respond in such a way to solicit that drug.

Dr. Jones: Okay, so let's put it in common terms. If a baby wants the drug, what will the baby be doing? So what does a baby do when it wants its breast milk drug? It cries, it gets irritable, it wags its head around looking for a breast. So what do babies do when they're looking for their marijuana drug or their . . .?

Dr. McMillin: Irritability is a major sign and symptom. There's some well-characterized cries, shrieks, if you will, that suggest a baby is needing drug. There may be seizures which, of course, are really scary. And so, yeah, the baby will get very restless, their vital signs will ramp, so heart rate, temperature, and, you know, it's a pretty characteristic syndrome that . . .

Dr. Jones: That makes it really hard for a new mom, who is having her own sleep disturbances, and may not be at the top of her game, to have a baby who's really hard to soothe, because the breast isn't going to be enough to soothe that baby.

Dr. McMillin: Right. So the ideal scenario is that that these babies who are going through drug withdrawals get identified in the hospital before they go home so they can get appropriate treatment. And, in fact, many of these babies are admitted to neonatal intensive care units and treated with things like morphine, or phenobarbital, or melatonin to help them curb the need, and then they're weaned over days to weeks so that they can go home safely.

Dr. Jones: So what we want is the best for our moms, we want the best for our babies to be, and our best when our babies are born. So, to paraphrase Grace Slick, some pills, some drugs make you larger and some drugs make you small, but the ones you take when you're pregnant should be nothing at all. But thank you, all, for joining us on The Scope.

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