Jack and Katie Keenan thought the birth of their first child would be the most joyous moment of their lives. They knew they wanted children when they got married, and they felt fortunate to be pregnant within a year of their wedding. The pregnancy went smoothly, and 10 days before Katie’s due date, her water broke.
At the Greater Baltimore Medical Center, right before she delivered a healthy baby girl, Makenzie, Katie took various tests. One of them was a urine test, which had a surprising finding: It was positive for opioids.
This result raised alarms because babies born to mothers using opioids can develop neonatal abstinence syndrome (NAS), where the newborn experienceswithdrawal symptoms. That includes difficulty feeding, vomiting, fevers and seizures. Untreated NAS can be deadly.
But Katie vehemently denied using opioids. She didn’t take any pain medications or use illicit substances.
Upon questioning, she reported eating two “everything” bagels that contained poppy seeds. These aren’t opioids and wouldn’t cause NAS, but they can mimic morphine and codeine to trigger positive urine tests.
A photo of Makenzie Keenan, courtesy of the Keenan family.
Because Maryland, like most states, requires reporting positive drug testing, a social worker started an investigation and told them child protective services could get involved. Katie felt strongly about breastfeeding Makenzie, but a lactation consultant told her she wasn’t allowed to help.
Initially, Jack and Katie were told that the family could go home after two days. Then they learned that Makenzie would have to stay up to five days for observation and testing, and if the hospital became full, Katie might need to be discharged while the baby stayed.
“It was traumatic for us,” Jack told me. “The worst moment was when we realized that if we wanted to leave with our baby, we couldn’t.”
The Keenans’ story is not unique. Other women in Maryland, New York and Kentucky who ate food containing poppy seeds allege being shamed and denied bonding time with their infants. In one egregious case, a Pennsylvania woman who ate a salad containing poppy seeds had her newborn taken away to foster care for two months.
Stephen W. Patrick, the director of the Vanderbilt Center for Child Health Policy who recently served as senior adviser at the White House Office of National Drug Control Policy, described the urine toxicology screen as “problematic.” Not only can certain foods and medications cause false positives that can trigger mandatory reporting and investigations, but the test is also of limited utility because it only measures substance ingestion at one specific moment.
If the goal is to diagnose substance use to get treatment for moms and reduce risk to babies, what’s needed is a conversation with a trusted provider followed by prompt connection to addiction treatment.
“Child welfare agencies rely a ton on maternal toxicology testing, yet using a tox screen alone is not recommended by the American Academy of Pediatrics or the American College of Obstetricians and Gynecologists,” Patrick told me. Especially if it’s done without the mom’s permission or knowledge, testing could harm the clinician-patient relationship.
Still, given how serious NAS can be, is it so bad if some women are inaccurately flagged and their babies kept for observation?
Lauren Jansson, a pediatrician at Johns Hopkins who specializes in caring for babies born to women with opioid addiction, acknowledges the drawbacks of the urine test but notes that universal testing could catch more potential NAS cases. Plus, only testing those women deemed higher risk could be discriminatory. Black women and women from lower socioeconomic classes could be unfairly targeted, while opioid use in other groups could be missed.
Because some babies with NAS might not manifest symptoms for a few days, her hospital requires four days of observation for infants exposed to opioids during pregnancy to monitor for withdrawal. “Withdrawal can be deadly if undiagnosed and untreated,” Jansson said.
The hospital where Makenzie was born told me that its ultimate goal is to protect newborns and believes universal testing improves the health of babies. I have sympathy for this argument, but I also feel for the Keenans and other families who suffer trauma from false accusations. As with most policy decisions, there is a trade-off: How many families will endure unnecessary investigations for every child whose NAS diagnosis would have been missed if not for universal screenings? Is that ratio acceptable?
I don’t know, but I do think policies around mandatory urine drug screens should be reevaluated. Most states, including Maryland, do not require these tests, but many hospitals incorporate them into their labor and delivery protocol.
At the very least, there should be a concerted effort to ameliorate the risk of needless investigations. Pregnant women close to their due dates should be warned about substances that can trigger a false positive, including poppy seeds. And they need to explicitly give consent after being told what could happen if there is a positive result.
No family should have the joy of their child’s birth be turned into trauma. The health-care system must ensure that other families don’t suffer like the Keenans did.
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