The substance-exposed child: Management

INTRODUCTION — The management of the substance-exposed child (SEC, also called the drug endangered child) will be discussed here.

The clinical features and diagnosis of the substance-exposed child, substance use in pregnancy, infants with prenatal substance use exposure, neonatal drug withdrawal, and medical child abuse, including maliciously giving medications or drugs to children to cause medical illness are covered separately:

●(See "The substance-exposed child: Clinical features and diagnosis".)

●(See "Substance use during pregnancy: Overview of selected drugs" and "Substance use during pregnancy: Screening and prenatal care".)

●(See "Prenatal substance exposure and neonatal abstinence syndrome (NAS): Clinical features and diagnosis".)

●(See "Prenatal substance exposure and neonatal abstinence syndrome (NAS): Management and outcomes".)

●(See "Medical child abuse (Munchausen syndrome by proxy)".)

APPROACH — Management of the substance-exposed child (SEC) varies by the type and acuity of exposure:

●Poisoned patients – For the SEC with findings of serious poisoning, initial management requires stabilization with support of airway, breathing, circulation, disability, and decontamination based upon the clinical findings ("toxidromes") that suggest the likely class of drug or substance exposure (table 1). (See 'Poisoned patients' below and "Approach to the child with occult toxic exposure", section on 'Management'.)

●Chemical exposure – The SEC who is discovered residing in or near clandestine illicit drug laboratories and who comes for evaluation within 72 hours is frequently asymptomatic. However, they may have occult contamination that requires decontamination. For these children, contamination consists of removal of the child's clothing, shoes, blankets and toys, and gentle showering or bathing with a mild soap and warm water. (See 'Decontamination' below.)

Although uncommon, the SEC may present with serious burns, inhalation injury, cold injury, or caustic ingestion that requires initial emergency measures including thorough chemical decontamination. (See "Topical chemical burns: Initial evaluation and management" and 'Patients with chemical exposure' below.)

●Impaired caregiver – When faced with an impaired caregiver, the clinician should intervene for the safety and well-being of the child but also engage the caregiver in a compassionate and nonjudgmental fashion. Toxicologic testing of the child is also warranted. (See "The substance-exposed child: Clinical features and diagnosis", section on 'Toxicology testing'.)

●Contaminated needle exposure – The SEC may have skin wounds caused by exposure to contaminated needles that require treatment for cellulitis, abscess, and identification and treatment of bloodborne pathogens. (See 'Contaminated needle exposure' below.)

●Reporting – All children suspected of substance exposure warrant urgent consultation with a social worker and, whenever available, involvement of a multidisciplinary child abuse team to assess for concomitant child abuse and, in many jurisdictions, reporting to Child Protective Services (CPS). Some regions also require involvement of law enforcement. Social work and clinical assessment of factors contributory to caregiver substance use is essential and complements community-based intervention programming and family supports to promote child health and safety. (See 'Reporting to child protective services' below and 'Providing family support' below.)

POISONED PATIENTS — For the SEC with findings of serious poisoning, initial management requires stabilization with support of airway, breathing, circulation, disability, and decontamination, and in patients with suspected opioid intoxication, presumptive administration of naloxone, as discussed separately and provided in the rapid overview table (table 2). (See "Approach to the child with occult toxic exposure", section on 'Management' and "Opioid intoxication in children and adolescents", section on 'Management of acute toxicity'.)

Toxidromes (groupings of physical findings such as vital signs, mental status, pupillary response, bowel sounds, and skin examination (table 1)) suggest the likely drug class causing poisoning and help to guide emergency management. For the SEC, common toxidromes include:

●Opioid poisoning – Findings include:

•Coma

•Respiratory depression progressing to apnea, bradycardia, hypotension, and hypothermia

•Miosis (often pinpoint pupils)

•Decreased muscle tone with hyporeflexia

●Sympathomimetic poisoning (methamphetamine or cocaine) – Findings include:

•Agitation/irritability which can progress to seizures

•Hyperthermia, tachycardia, tachypnea, and hypertension

•Dilated pupils

•Excessive sweating with cold, clammy skin

•Increased bowel sounds

Emergency management includes sedation with benzodiazepines, aggressive cooling measures (see "Heat stroke in children", section on 'Rapid cooling'), control of hypertension with benzodiazepines and (if necessary) rapidly-acting antihypertensive measures (see "Initial management of hypertensive emergencies and urgencies in children", section on 'Conditions with sympathetic overactivity'), and intravenous fluid therapy to maintain a urine output of 1 to 2 mL/kg per hour. (See "Methamphetamine: Acute intoxication", section on 'Pediatric exposure'.)

●Cannabis – In children, limited exposures to cannabis may result in changes in behavior (lethargy, euphoria, or irritability) and many of the common physiologic effects including (see "Cannabis (marijuana): Acute intoxication", section on 'Children'):

•Tachycardia with hypertension

•Conjunctival injection (red eye)

•Vomiting

•Nystagmus

•Ataxia

•Slurred speech in verbal children

In large overdoses (eg, ingestion of edible products, concentrated oils, or hashish), coma with apnea or depressed respirations can occur. Although uncommon, seizures have been reported. Treatment is supportive, as discussed separately. (See "Cannabis (marijuana): Acute intoxication", section on 'Children'.)

PATIENTS WITH CHEMICAL EXPOSURE — Children found residing in or near illicit drug manufacturing facilities are often asymptomatic but potentially exposed. Based upon chemicals commonly used in methamphetamine manufacturing, the SEC from these home laboratories are at risk for [1]:

●Chemical burns to the skin, eyes and mucous membranes – Emergency management includes endotracheal intubation for patients with respiratory compromise and/or copious irrigation of the eyes and skin (see "Topical chemical burns: Initial evaluation and management")

●Caustic ingestion – Emergency management includes ensuring no further oral intake and endoscopy in children with symptoms or a high-risk ingestion (eg, concentrated acid or alkali) (see "Caustic esophageal injury in children")

●Lung injury including hydrocarbon pneumonitis, caustic upper airway burns, and phosphine-induced ARDS – Emergency management includes humidified, supplemental oxygen, endotracheal intubation as needed for upper airway obstruction or respiratory failure, and ventilatory support (see "Acute hydrocarbon exposure: Clinical toxicity, evaluation, and diagnosis" and "Acute hydrocarbon exposure: Management")

●Cold injury caused by exposure to Freon or refrigerated anhydrous ammonia – Rewarming and consideration of time-limited treatments (eg, thrombolysis or prostacyclin therapy) for severe injury (see "Frostbite: Emergency care and prevention")

Decontamination — In the great majority of cases, the decontamination of chemical exposures consists of the following general steps:

●Ensure protection of rescuers and health care workers from exposure. Guidance from scene incident commanders (typically fire service) can assist with the type of chemicals likely to be encountered and the level of risk and appropriate personal protective equipment for hospital healthcare providers. (See "Topical chemical burns: Initial evaluation and management", section on 'Protection of clinicians' and "Chemical terrorism: Rapid recognition and initial medical management", section on 'Protection of providers'.)

●Remove all clothing and jewelry.

●Brush any dry chemicals off the patient; any suitable instrument may be used (eg, dry brush, towel).

●For serious cutaneous and/or eye exposures, perform copious irrigation with warm water at low pressure. (See "Topical chemical burns: Initial evaluation and management", section on 'Water irrigation'.)

For children removed from home drug laboratories but without signs or symptoms of serious poisoning or chemical exposure, decontamination is still necessary and consists of removal of the child's clothing, shoes, blankets, and toys, and gentle showering or bathing with a mild soap and warm water [2]. Decontamination may not be necessary if the SEC has been removed from the home production lab environment for 72 hours or greater [3].

CHILD OF AN IMPAIRED CAREGIVER — Concerns regarding risks posed to a child by an impaired caregiver should be addressed with compassion. Healthcare professionals should intervene with an impaired caregiver using a nonconfrontational approach [4]:

●Ensure that the conversation takes place in a confidential and safe environment.

●Emphasize that the purpose of any intervention is the safety and well-being of the child as well as support for the caretaker.

●Discuss concerns regarding the risk to the child caused by the caretaker's impairment (eg, the caregiver is not safe to operative a motor vehicle) in a compassionate and nonjudgmental manner.

●Assist the individual in finding resources to address the situation (eg, family member or trusted friend to provide transportation and child care until the caregiver is no longer impaired).

●If the caregiver is amenable, help them identify resources to address their substance use problem in collaboration with their primary care provider. When feasible, identifying the drug or substance causing caregiver impairment is helpful to attempt to link them to additional family or community-based supports such as substance use disorder treatment services. (See "Substance use disorders: Clinical assessment".)

Permission for medical care may be complicated in circumstances where caregiver impairment is obvious; routine, non-urgent medical care should be postponed if appropriate consent cannot be assured [4].

Appropriate next action steps involve determination of safe disposition for the child from the clinic or hospital setting. Potential actions include [4]:

●Arranging alternate forms of transportation for the child (eg, calling a taxi)

●Contacting another family member

●Providing temporary emergency childcare

If no appropriate caregiver can be identified, consultation with Child Protective Services (CPS) is warranted.

Concerns for obvious or suspected caregiver impairment may also interfere with safe hospital care. Healthcare professionals can request that obviously impaired caregivers voluntarily leave the bedside until intoxication symptoms abate. If the caregiver refuses, then the clinician should involve in-house resources (eg, security and social work) and law enforcement, as needed, to remove the caregiver followed by CPS reporting, especially if the caregiver's actions are impeding emergency care. In these situations, notification of hospital administration and risk management is also necessary.  

CONTAMINATED NEEDLE EXPOSURE — Children exposed to contaminated needles should be assessed for skin wounds. Skin infections should receive appropriate antibiotic therapy (algorithm 1). Abscesses warrant management, as described in the algorithm (algorithm 2) and separately. (See "Skin and soft tissue infections in children >28 days: Evaluation and management" and "Techniques for skin abscess drainage".)

Children with contaminated needle exposure also require screening for and follow-up counseling and treatment, as needed for the following pathogens:

●Human immunodeficiency virus (see "Screening and diagnostic testing for HIV infection", section on 'Possible HIV exposure')

●Hepatitis B (see "Hepatitis B virus: Screening and diagnosis in adults")

●Hepatitis C (see "Hepatitis C virus infection in children")

●Tetanus prophylaxis (table 3)

MANDATED REPORTING AND FAMILY SUPPORT — Reporting a child with substance exposure to Child Protective Services (CPS) and initiation of multidisciplinary and community-based family support, including substance use treatment for caregivers, are essential to stop substance exposure and provide a safe environment for the child.

Reporting to child protective services — All children suspected of substance exposure warrant urgent consultation with a social worker, involvement of a multidisciplinary child abuse team to assess for concomitant child abuse whenever available, and in many jurisdictions, reporting to CPS. Some regions also require involvement of law enforcement.

Abuse or neglect considerations specific to the substance-exposed child (SEC) include:

●Failure to protect the child from harmful substance exposure

●Permitting or encouraging substance use

●Serious disregard of caregiver responsibility for the health and welfare of the child because of personal substance use

●Exposures resulting from direct actions of the caregiver such as drug manufacturing

The SEC may also be a victim of physical, sexual, emotional abuse, or neglect. (See "The substance-exposed child: Clinical features and diagnosis", section on 'Signs of child abuse'.)

Children suspected of substance exposure benefit from evaluation by a social worker and a multidisciplinary child abuse team if available. In many jurisdictions, reporting substance exposure to CPS and, if a separate report is required, law enforcement is also required. (See "Child abuse: Social and medicolegal issues", section on 'Reporting suspected abuse'.)

Child health and/or safety concerns prompting toxicological testing for a SEC should be well documented in the medical record including [5,6]:

●Documentation of SEC reporting to CPS and, if separate reporting is required, law enforcement

●Positive toxicological test results with interpretation

●Notification of primary caregivers/legal guardian and CPS of positive toxicology test results

The healthcare professional should retain a copy of all legal documents received (including warrants for legal blood draws or subpoenas for toxicological test results). Chain of custody procedures should be followed for any evidentiary specimen collection, such as legal blood draws, based on local jurisdictional policies and procedures. Any necessary interventions performed at the bedside if the caregiver was suspected to be impaired should be well documented.

Detection of any substance at any level on toxicological testing performed for a suspected SEC warrants thorough scrutiny and careful expert interpretation (see "The substance-exposed child: Clinical features and diagnosis", section on 'Interpretation of results'). Reporting substance exposures to CPS has historically been subject to variability, and limited evidence suggests that illicit drug exposures are more commonly reported compared with other types of exposures such as prescription drug, ethanol, and over-the-counter drug exposures [7].

Neither healthcare professionals nor child welfare agency professionals should rely solely on a positive or negative toxicology test to determine substance exposure. Test results should be interpreted within the broader context of home environment and caregiver safety [8,9]. Concerns for co-occurring physical, sexual, emotional abuse or neglect victimization should also be reported to CPS and/or law enforcement as required by regional reporting statutes. A toxicology resource guide provides additional information for healthcare professionals, social work, and the multidisciplinary child abuse team to utilize when communicating to child welfare investigators about clinical toxidromes, testing methods, and result interpretation [8].

Healthcare professional perceptions of the home environment, particularly if caregivers report substance use or provide details regarding the substance ingested, may inappropriately dissuade reporting, particularly in cases of marijuana exposures traditionally perceived as lower risk compared with other illicit substances and also legal in some jurisdictions. Marijuana has been associated with child maltreatment risk [10,11]. Regardless of legality or jurisdiction, the healthcare professional should determine impact to the child, specifically whether marijuana use is impeding caregiving, by assessing when and where caregivers are using marijuana, location and supervision of the children when this is happening, safe storage of any edible products, and reason for use [12].

Reporting to CPS may be appropriate even in jurisdictions where marijuana is legal to fully ascertain child safety risk. For example, exposure to psychoactive substances like illicit marijuana recreationally used by caregivers may result in harmful toxicity symptoms for the child and reflects risk of harm to the child, particularly if caregivers engage in poly-substance use. This situation may only be ascertained during a CPS investigation, and caregivers may need referrals to substance use disorder treatment services that can be facilitated by child welfare involvement. Reporting therefore provides an opportunity to intervene on behalf of the child potentially at risk [13]. Fear of punitive repercussions should not dissuade healthcare professionals from reporting. While circumstances may suggest that substance exposure occurred unintentionally, further assessment by CPS and/or law enforcement personnel is typically necessary outside of the healthcare encounter to determine whether jurisdictional criteria for supervisory neglect are met.

Providing family support — Families affected by substance use commonly face multiple other psychosocial adversities (mental illness, poverty, and family violence) that must be comprehensively addressed to ensure a healthy and nurturing environment for a child [2]. Social work and clinical assessment of factors contributory to caregiver substance use is paramount, with implementation of appropriate, responsive, community-based intervention programming and family supports to promote child health and safety. Thus, referrals for mental health assessments, trauma-focused therapy, and/or other community-based supportive programming should be facilitated during the SEC evaluation [2,14].

SUMMARY AND RECOMMENDATIONS

●Terminology – The "substance-exposed child" (SEC, also called the "drug-endangered child") refers to infants and children harmed or at risk of harm due to exposure to harmful drugs or other substances and/or an unsafe home environment related to parent or caregiver substance use. (See "The substance-exposed child: Clinical features and diagnosis", section on 'Terminology'.)

●Approach – Management of the SEC varies by the type and acuity of exposure. Most SECs are asymptomatic at the time of evaluation. For the SEC with findings of serious poisoning, initial management requires stabilization with support of airway, breathing, circulation, disability, and decontamination, as discussed separately. (See 'Poisoned patients' above and "Approach to the child with occult toxic exposure", section on 'Management'.)

Toxidromes (groupings of physical findings such as vital signs, mental status, pupillary response, bowel sounds, and skin examination (table 1)) suggest the likely drug class causing poisoning and help to guide emergency management. For the SEC, common substances and initial treatment include:

•Opioid poisoning – Treatment as provided in the rapid overview (table 2). (See "Opioid intoxication in children and adolescents", section on 'Management of acute toxicity'.)

•Sympathomimetic poisoning (eg, methamphetamine or cocaine) – Supportive care including:

-Sedation with benzodiazepines,

-For patients with hyperthermia, aggressive cooling measures (see "Heat stroke in children", section on 'Rapid cooling'),

-Control of hypertension with benzodiazepines and (if necessary) rapidly-acting antihypertensive measures (see "Initial management of hypertensive emergencies and urgencies in children", section on 'Conditions with sympathetic overactivity')

-Intravenous fluid therapy to maintain a urine output of 1 to 2 mL/kg per hour (see "Methamphetamine: Acute intoxication", section on 'Pediatric exposure')

•Cannabis intoxication – Supportive care as needed for coma with respiratory depression and/or seizures. (See "Cannabis (marijuana): Acute intoxication", section on 'Children'.)

●Chemical exposure – Based upon chemicals commonly used in methamphetamine manufacturing, the SEC from these home laboratories are at risk for:

•Chemical burns to the skin, eyes and mucous membranes (see "Topical chemical burns: Initial evaluation and management")

•Caustic ingestion (see "Caustic esophageal injury in children")

•Lung injury including hydrocarbon pneumonitis (algorithm 3), caustic upper airway burns, and phosphine-induced ARDS (see "Acute hydrocarbon exposure: Management")

•Cold injury caused by exposure to Freon or refrigerated anhydrous ammonia (see "Frostbite: Emergency care and prevention")

●Decontamination – For patients with signs and symptoms of serious chemical exposure, the decontamination of these exposures consists of the following general steps:

•Ensure protection of rescuers and health care workers from exposure. Guidance from scene incident commanders (typically fire service can assist with the type of chemicals likely to be encountered and the level of risk to hospital healthcare providers.) (See "Topical chemical burns: Initial evaluation and management", section on 'Protection of clinicians' and "Chemical terrorism: Rapid recognition and initial medical management", section on 'Protection of providers'.)

•Remove all clothing and jewelry.

•Brush any dry chemicals off the patient; any suitable instrument may be used (eg, dry brush, towel).

•For cutaneous and eye exposures, perform copious irrigation with warm water at low pressure. (See "Topical chemical burns: Initial evaluation and management", section on 'Water irrigation'.)

For children removed from home drug laboratories but without signs or symptoms of serious chemical exposure, decontamination is still necessary and consists of removal of the child's clothing, shoes, blankets and toys, and gentle showering or bathing with a mild soap and warm water. Decontamination may not be necessary if the SEC has been removed from the home production lab environment for 72 hours or greater.

●Contaminated needle exposure – Children exposed to unsafe drug paraphernalia, including contaminated needles or syringes, should be assessed for skin wounds and, as needed, receive treatment for cellulitis or abscess. Children with contaminated needle exposure also require screening for and follow-up counseling and treatment, as needed, for human immunodeficiency virus, and hepatitis B, hepatitis C as well as tetanus prophylaxis. (See 'Contaminated needle exposure' above.)

●Child of an impaired caregiver – When faced with an impaired caregiver, the clinician should intervene for the safety and well-being of the child but also engage the caregiver in a compassionate and nonjudgmental fashion. Toxicologic testing of the child is warranted. (See 'Child of an impaired caregiver' above and "The substance-exposed child: Clinical features and diagnosis", section on 'Toxicology testing'.)

●Reporting – All children suspected of substance exposure warrant urgent consultation with a social worker and, whenever available, involvement of a multidisciplinary child abuse team. In many jurisdictions, reporting substance exposure to Child Protective Services (CPS) and, if a separate report is required, law enforcement is also required. (See "Child abuse: Social and medicolegal issues", section on 'Reporting suspected abuse'.)

●Family support – Social work and clinical assessment of factors contributory to caregiver substance use is essential and complements community-based intervention programming and family supports to promote child health and safety. (See 'Providing family support' above.)