Child Welfare Reports of Infants with Neonatal Abstinence Syndrome: Implications for Data Collection and Provider Training

Background/Purpose:  Recent media reports have suggested that there may be a rising number of infants who are withdrawing from opioids at birth, and that they are coming to the attention of the child welfare system. A recent federal report indicated that at least 11 states have reported as much as a 50% increase in reports of infants to the child welfare system due to their caregiver’s substance use.  However, there are few reports that have focused on opioids specifically, raising the question of whether there has been a rise in the numbers of infants with neonatal abstinence syndrome (NAS) reported to the child welfare system that can be documented. The purpose of this study is to examine the trend in the number and percentage of infants reported to the child welfare system with NAS from 2004 to 2014, and determine whether the trend is distinct from the trend in the percentage of infants reported with fetal alcohol spectrum disorder (FASD).  We hypothesize that there is a statistically significant rise in NAS reports during the study period and that the trend will be distinct from the FASD report trend.

Methods:  National Child Abuse & Neglect Data System (NCANDS) data on reports of infants (aged < 1 year) between 2004 and 2014 were analyzed.  Given inconsistencies in the reporting across states and time, the sample included data from 10 states to ensure data quality for interpretations.  We examined the trend over time in the percentage of NAS and FASD cases reported to child welfare using a Generalized Estimating Equations (GEE) model approach to account for nested data, clustered by State. Substance Type and Year were repeated variables.   

Results:  The number of reports of infants with NAS in the 10 state sample was the lowest at 3,073 in 2009 and highest at 4,806 in 2014. The average percentage of reported cases of NAS rose from 4.72% in 2004 to 9.19% in 2014.  GEE model results indicated a significant main effect of Substance Type (p = .015) and Year (p = 0.009), demonstrating that averaged over time, the percentage of NAS reports was greater than the percentage of FASD reports and averaged over substance type, the percentage of substance-related reports increased over time. Additionally, there was a significant Substance Type × Year interaction (p=0.011), which showed increases in NAS reports, but not FASD reports.

Conclusion/Implications:  NAS reports increased significantly during the decade long study period, most pronounced between 2010 and 2014, while the trend for FASD reports did not show significant change.  Although recent efforts to curb prescribing and other means of supply have been implemented, it remains to be seen whether the large rise will continue or be ameliorated by these public health initiatives.  In the meantime, it is imperative that states report high quality data to NCANDS in order to support continued surveillance efforts.  Practitioners working in health care facilities and with child welfare agencies need to be trained to appropriately assess the needs of infants with NAS and their families.