Case: An infant was dropped off in the emergency center by a family who expressed no intent to return. It was presumed that the infant was born the day before admission based on information gathered by the emergency center. However, no information was provided regarding the infant’s name or place of birth. The patient appeared well and was admitted to the newborn nursery. Vital signs were reassuring, including heart rate 142 beats per minute, respiratory rate 50 breaths per minute, rectal temperature 98.2°F, and pulse oximetry 100% on room air. The gestational age of the infant was estimated to be 39 weeks based on Ballard examination. Growth percentiles were appropriate for gestational age, including weight 3396 g (70%), length 49.5 cm (60%), and head circumference 34 cm (60%).
Question: What laws are in place regarding infant abandonment and what are our responsibilities as health care providers?
Discussion: The Baby Moses Law was created in an attempt to provide parents a way to safely relinquish custody of infants <61 days old and thereby prevent infants from being abandoned in unsafe locations. It allows a parent to voluntarily deliver a child <61 days of age to a designated emergency infant care (DEIC) provider without intent to return. Texas was the first state to enact this law in 1999 and most states have since adopted similar laws. Each state has slight variations in their law, particularly with regard to patient age and parental privacy. As long as the patient appears healthy, Texas state law does not require parents to provide DEIC providers with any information about the patient. Over the past decade, there has been a decrease in the number of abandoned infants in Texas and a larger percentage have been surrendered under the Baby Moses Law (Table 1). Infant abandonment is a complex social problem and requires coordination between social services, including DEIC providers, Child Protective Services, local jurisdiction, law enforcement, and the medical team. Hospital social services or case management should be consulted to assist with coordination of care. Law enforcement should submit information to the National Crime Information Center to check the registry for missing children.
Question: What infectious screening tests and treatments should be provided for abandoned infants?
Case Continuation: A complete blood cell count with differential (CBCd), blood culture, viral hepatitis panel, HIV screen, and syphilis screen were ordered, along with a blood type and direct Coombs. The CBCd was reassuring, with 13 000 white blood cells, 49% neutrophils, 43% lymphocytes, 3% monocytes, and 1% bands. The patient received the hepatitis B vaccination (HBV) and hepatitis B immunoglobulin (HBIG). The hepatitis panel demonstrated a positive hepatitis A virus immunoglobulin (Ig) G antibody suggestive of maternal immunity and negative hepatitis A virus IgM antibody, hepatitis B surface antigen, hepatitis B surface antibody, hepatitis B core IgG antibody, and hepatitis C antibody. Syphilis IgG, blood culture, and HIV-1 and -2 enzyme-linked immunosorbent assay were negative. HIV-1 RNA assay was negative at birth and repeat HIV-1 DNA polymerase chain reaction at ∼1 month of age was also negative.
Discussion: In the absence of maternal prenatal records, infant serology should be drawn for HIV, hepatitis B, hepatitis C, and syphilis. If the patient is presumed to be 1 to 2 days old, thought should be given to sepsis screening, particularly if the patient is symptomatic or appears to be premature on examination.1–3 Unless there are clinical findings concerning for rubella, infant screening is not useful.4 Abandoned infants with unknown vaccination records should receive the HBV. If the infant is estimated to be <7 days old and maternal hepatitis B surface antigen is unknown, HBIG also should be administered as soon as possible.5 Although erythromycin 0.5% ophthalmic ointment is most effective in preventing ophthalmia neonatorum if given in the first 4 hours of life, there may be marginal benefit up to 1 to 2 days of life.6
Perinatal HIV screening is one of the most time-sensitive dilemmas of the evaluation of abandoned infants. Chemoprophylaxis for HIV is effective only if started within 48 hours of birth, and initiation of prophylaxis outside the 48-hour window of time in a neonate who has an established HIV infection may contribute to antiretroviral resistance. Therefore, abandoned infants known to be <48 hours old should have urgent HIV screening. Outside this 48-hour window of time, HIV screening is recommended but less urgent. The National Perinatal HIV Hotline (1-888-448-8765) is a readily available resource for HIV evaluation in infants.7,8
Infants may test positive for hepatitis B surface antigen for up to 1 to 2 weeks after receiving the HBV because of the antigen in the vaccine. Thus, a weakly positive hepatitis B surface antigen does not necessarily reflect actual hepatitis B infection.9 When maternal hepatitis B status is unknown, testing for hepatitis B surface antibody and antigen should take place at 9 to 18 months of age after maternal antibodies have diminished or 1 to 2 months after the completion of the HBV series. The first HBV should be administered as soon as possible, followed by the second dose at least 4 weeks after the first dose. The third dose should be given at 6 months of age or older and at least 2 months after the second dose and 4 months after the first dose.10 Although screening for hepatitis C is not routinely performed during prenatal care, mothers of abandoned infants may be at higher risk for this infection.11,12 Patients who test positive for hepatitis C antibodies should be retested at 9 to 18 months when maternal antibodies have waned or tested with hepatitis C virus RNA as early as 1 to 2 months of age to assess for active infection.13
A positive syphilis screening test should reflexively initiate a treponemal test (Treponema pallidum [TP]-particle agglutination, fluorescent treponemal antibody-absorption, TP-enzyme immunoassay, or microhemagglutination assay-TP). In cases of abandoned infants without documented maternal syphilis serology or treatment, the infant also should be evaluated with a CBCd, cerebrospinal fluid (CSF) studies including CSF VDRL test, and consultation with an infectious disease specialist to discuss penicillin treatment regimen and further studies, including chest radiograph, long-bone radiographs, eye examination, and liver function tests.14,15
Question: What features of routine newborn care should be provided for abandoned infants?
Case Continuation: It was unknown whether the patient was born at a hospital. Even if he had received routine care, there was no way to connect him to his newborn screen card, hearing screen, or administered medications. The patient was given intramuscular vitamin K and had a newborn screen drawn that was normal. He had an otoacoustic emissions hearing screen and passed in both ears. Blood type was A+ and direct Coombs was negative. Urine drug screen was negative and he never developed symptoms of withdrawal. He went home with an adoptive family and is growing and developing appropriately for age.
Discussion: One milligram of vitamin K given intramuscularly shortly after birth is routine practice for the care of neonates in the United States to prevent both classic and late-onset hemorrhagic disease of the newborn, also known as vitamin K deficiency bleeding (VKDB).16 Classic hemorrhagic disease of the newborn occurs from 1 to 7 days of life when a physiologic drop in vitamin K-dependent clotting factors occurs. This is thought to be due to poor vitamin K transfer across the placenta and a sterile gastrointestinal tract, not yet colonized with vitamin K–producing bacteria. It occurs in ∼2% of neonates who have not received vitamin K.17 Late-onset VKDB occurs from 2 weeks to 6 months of age. Risk factors include exclusive breastfeeding, as breast milk has low vitamin K content (1–4 μg/L), and cholestasis, which prevents the absorption of fat-soluble vitamins. The incidence in exclusively breastfeeding infants is 4.4 to 7.2/100 000.18
Abandoned neonates who are within the age range of classic VKDB (1–7 days) should be given 1 mg vitamin K intramuscularly because the risk of disease is reasonably high even for healthy children. The therapeutic index of vitamin K is relatively high, requiring 10 to 20 mg vitamin K to produce toxic effects, so abandoned neonates who may have already received vitamin K at birth will not be harmed by a repeat dose.19 The incidence of late-onset VKDB is low even within the at-risk population of exclusively breastfed infants. Most abandoned neonates and infants will be fed formula that contains vitamin K, 50 μg/L. Therefore, vitamin K may not be necessary in children older than 2 weeks.
All abandoned infants should have newborn screening performed unless the results from previous screens are available. Ideally, newborn screens should be sent between 24 and 48 hours of life and 7 to 14 days of life, as reference ranges are specified for these windows of time. Specimens can be sent for children up to 12 months of age; however, there may be higher false-positive or -negative results.
All abandoned infants should have either an otoacoustic emissions or auditory brainstem response hearing screen unless the results of a previous hearing screen are available. Early detection of hearing deficits allows for early intervention and ideally prevents delays in child development.
Blood glucose screening should be performed in infants thought to be <24 hours old who are preterm, small for gestational age, or large for gestational age based on Ballard examination and growth percentiles. Also, patients of any age who have symptoms of hypoglycemia should have their blood sugar checked. Management of hypoglycemia should be continued based on nursery protocol.20
Infants should be screened for jaundice on examination at initial evaluation. Because the infant’s exact age will likely be unknown, the neonatal bilirubin nomograms will be less useful. Therefore, risk factors, including prematurity based on Ballard examination and direct Coombs, will be the primary tools used to decide on jaundice follow-up and initiation of phototherapy.21
Drug screening is appropriate in abandoned neonates both for medical decision-making and legal purposes. Ideally, a urine drug screen, as well as an additional test that reflects exposure over the course of the pregnancy, should be used and may include meconium, neonatal hair, or umbilical cord specimens.22 Drug screening becomes particularly important in infants who screen positive for opiates because they should be observed for withdrawal symptoms. Positive drug screens also may have significant legal implications if parents are prosecuted or attempt to regain custody of the infant.
Conclusions: Abandoned infants <61 days old are a unique population that requires extra medical attention in addition to routine newborn care. The medical evaluation of an abandoned infant poses a challenge to health care professionals because they are rarely encountered, and although medical literature is rich with guidelines for routine prenatal and neonatal care, discussions in the context of infant abandonment are sparse. This article provides health care professionals an organized approach to the medical evaluation of abandoned infants (Table 2). Further research should investigate the diagnoses made in cases of abandoned infants, as well as factors leading to infant abandonment. This information could provide greater clarity of the risks associated with infant abandonment.
Dr Mongkolrattanothai is currently affiliated with Children’s Hospital Los Angeles, Los Angeles, California and Dr Scott is currently affiliated with Cook Children’s Hospital, Fort Worth, Texas.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
- complete blood cell count with differential
- cerebrospinal fluid
- designated emergency infant care
- hepatitis B immunoglobulin
- hepatitis B vaccination
- Treponema pallidum
- vitamin K deficiency bleeding
- Jordan HT,
- Farley MM,
- Craig A,
- et al
- Stoll BJ,
- Hansen NI,
- Sánchez PJ,
- et al
- 4.↵American Academy of Pediatrics. Rubella. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book:2012 Report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012:629–634.
- 5.↵American Academy of Pediatrics. Hepatitis B. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book:2012 Report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012:369–390.
- 7.↵American Academy of Pediatrics. Human immunodeficiency virus infection. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book:2012 Report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012:418–439.
- 8.↵Department of Health and Human Services. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. p. H6–H25. Available at: http://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultandAdolescentGL.pdf. Accessed July 9, 2013.
- Mast EE,
- Margolis HS,
- Fiore AE,
- et al
- 12.↵American Association for the Study of Liver Diseases. Recommendations for testing, managing, and treating hepatitis C. Available at: hcvguidelines.org. Accessed September 10, 2014.
- 13.↵American Academy of Pediatrics. Hepatitis C. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book:2012 Report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012:391–395.
- 15.↵American Academy of Pediatrics. Syphilis. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book:2012 Report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012:690–703.
- 16.↵American Academy of Pediatrics, Committee on Fetus and Newborn. Controversies concerning vitamin K and the newborn. Pediatrics. 2003;112(1 pt 1):191–192.
- Maheshwari A,
- Carlo W
- Tschudy M,
- Arcara K
- 20.↵Adamkin DH; Committee on Fetus and Newborn. Postnatal glucose homeostasis in late-preterm and term infants. Pediatrics. 2011;127(3):575–579.
- 21.↵American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 2004;114(1):297–316.
- Olitsky S,
- Hug D,
- Plummer L,
- Stass-Isern M
- Kemper AR,
- Mahle WT,
- Martin GR,
- et al
- 27.American Academy of Pediatrics. Tetanus. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book:2012 Report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012:707–712.
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