Race and Screening for Drugs of Abuse in the NICU Setting

Race and Screening for Drugs of Abuse in the NICU Setting

Infant Race Affects Application of Clinical Guidelines When Screening for Drugs of Abuse in Newborns
Marc A. Ellsworth, BS, Timothy P. Stevens, MD, MPH, Carl T. D'Angio, MD
PEDIATRICS Vol. 125 No. 6 June 2010, pp. e1379-e1385 (doi:10.1542/peds.2008-3525)
Pubmed Citation; Pediatrics Citation

BACKGROUND Screening for illicit drugs in newborns has privacy, social, and legal risks for families of the infants. Established drug-screening criteria may be applied in a manner that considers nonproven risk factors such as race in addition to evidence-based factors.

OBJECTIVE The goal of this study was to determine if race was used as a criterion for screening infants for intrauterine cocaine exposure. We hypothesized that infants of black mothers would be more likely to be screened regardless of whether they met the standard criteria for screening of our institution's NICU.

METHODS We used the electronic medical records of newborn infants and their mothers to determine which mother-infant pairs had documented evidence of meeting the criteria for screening infants for prenatal exposure to illicit drugs set forth in the guidelines of our NICU. We then assessed the rates of drug screening to determine the strongest predictors of whether an infant would be screened.

RESULTS We assessed 2121 mother-infant pairs. Infants born to black mothers were more likely than those born to white mothers to have screening performed whether they met screening criteria (35.1% vs 12.9%; P < .001) or did not (5.3% vs 1.2%; P < .001). In a logistic regression analysis, black race remained independently associated (odds ratio: 2.17 [95% confidence interval: 1.25–3.79]) with drug screening even when we controlled for our standard screening criteria and income, insurance status, and maternal education.

CONCLUSION Providers seemed to have used race, in addition to recognized risk criteria, as a factor in deciding whether to screen an infant for maternal illicit drug use.

DISCUSSION - This is a thought-provoking study about how clinical decision-making might be guided by other factors, including preconceived notions about race. Equitable care in healthcare is not a new discussion and certainly much has been written about disparities in outcomes as well. The Institute of Health report - Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare has a wealth of information on this very issue. In addition, the recently released VON e-book has an entire section dedicated to the discussion of disparities in the NICU.

This particular study outlined above found that for those mother-infant pairs that met screening criteria, 20.7% of the infants were actually screened and infants born to black mothers were threefold more likely to be screened than those infants born to white mothers if they met the screening criteria. Additionally, among pairs that did not meet screening criteria, infants born to black mothers were four times more likely to be screened than those born to white mothers.

Thinking about how care is provided in our own units- how many times do we make assumptions that are not based in evidence as it relates to our families? Do we unknowingly apply different standards based on perceptions and not by clear guidelines? How do we avoid this and provide care that is equitable to all in every circumstance? Having an established, objective and evidence-based screening protocol seems reasonable, but how do we ensure it's applied equally?