Treatment Is Not a Safety Concern: Rethinking Automatic Child Protection Reports for Babies Exposed to Opioids Before Birth

What a Boston hospital's change in reporting practice (Khazanchi et al., 2026) and a review of every US state's "plan of safe care" rules (Lloyd Sieger et al., 2025) mean for families

In Massachusetts and some other US states, babies exposed to opioids before birth were automatically reported to child protective services, even when the parent was taking prescribed treatment. When one Boston hospital reported only specific safety concerns, reports fell by about half, with no detectable change in babies going home with a parent and no detectable difference in the drop between racial and ethnic groups. A national review found that state plans to support these families are often unclear.

Why this question matters to families

The days after a birth should be about getting to know a new baby. For parents who used opioids (strong pain-relieving drugs, a group that includes prescription painkillers, heroin and fentanyl) during pregnancy, including parents being treated for opioid use disorder (a medical condition in which a person has difficulty controlling opioid use), those days can also bring a visit from child protective services, or CPS, the state agency that investigates possible child abuse or neglect. This article looks at two studies that ask when such a report is really needed [1], and what states are supposed to offer these families [2].

How automatic reporting became routine

Since 2003, a US federal law called the Child Abuse Prevention and Treatment Act, or CAPTA, has required every state to make sure that CPS is "notified" about babies "affected by" substances before birth, and that each such baby has a "plan of safe care" [2]. A plan of safe care is meant to link the baby and family to health care and treatment, a purpose spelled out in a 2016 law. The federal law leaves the details to each state, and states, hospitals and doctors have understood it in very different ways [1][3]. Researchers reported that in 2019, 30 of the 50 states and Washington, DC (51 in all), had no written plan-of-safe-care policy at all [3][2].

In Massachusetts, a law dating from 1973 required a report when a baby had "physical dependence upon an addictive drug at birth". In practice, hospitals reported almost every baby exposed to substances, including babies whose parents were stable on methadone or buprenorphine, two medicines that treat opioid use disorder. Fewer than half of these reports were later confirmed by the state agency, according to the study authors [1].

Across the country, the rate at which newborns were reported to CPS because of substance exposure more than doubled between 2011 and 2019 [4]. Whether a baby was reported often depended on which hospital the baby was born in [5][6]. In one US county that screened all pregnant patients, Black newborns were four times as likely as white newborns to be reported, even though substance use had been identified at similar rates during prenatal care [7], although not every study found this [8].

There were also signs that reporting rules themselves were doing harm. Women who used substances during pregnancy and lived in states with mandatory reporting or child abuse rules for substance use started prenatal care later and were less likely to attend a check-up after the birth [9]. Mothers taking treatment medicines described being reported for following their doctor's advice as "unjust and stigmatizing", and some worried that staying on treatment could cost them custody of their baby [10][11]. That matters, because staying on these medicines longer during pregnancy is linked with a lower chance of overdose [12]. The American Academy of Pediatrics has called for a health-focused rather than punishment-focused response [13].

What the Boston hospital changed

In May 2021, Boston Medical Center, a teaching hospital that serves many families with limited resources, adopted a written guideline. It told staff to file a CPS report only when there was a specific safety concern, such as substance use disorder that was not being treated, a pattern of behaviour that put the baby at risk, or previous loss of custody of other children [1]. The guideline lists things that are not enough on their own to require a report, including taking prescribed treatment medicine during pregnancy, a baby showing withdrawal symptoms because of that medicine, or a baby needing medicine to treat those withdrawal symptoms. It also says drug tests on a baby should not be done without the parent's informed consent (agreement given after the reasons have been explained), and that a test result alone should never be the reason for a report.

An earlier look at the guideline's first two years, across 17 Massachusetts hospitals, had already shown that reports fell sharply [1][14]. The new study by Khazanchi and colleagues asked a harder question: did giving staff this judgement lead them to treat some families differently because of race or ethnicity?

How the researchers studied it

The team used records from 17 Massachusetts hospitals that share information through a statewide quality improvement network. They included 3581 babies exposed to opioids before birth, born between 2017 and 2024; 475 of them were born at Boston Medical Center [1]. They compared how reporting changed at Boston Medical Center after the guideline with how it changed at the other 16 hospitals over the same years, which did not adopt the guideline (one hospital system that brought in a similar policy in April 2024 had its later births left out). Comparing "before and after" in both groups helps separate the effect of the guideline from other changes happening across the state at the same time.

What they found

Before the guideline, essentially every opioid-exposed baby at Boston Medical Center was reported to CPS: 301 of 302 babies. Afterwards, 100 of 173 babies were reported, or about 58 in every 100. At the other hospitals, about 94 in every 100 babies were reported both before and after [1]. The researchers estimated that 88 reports were avoided at Boston Medical Center, and that about 485 could have been avoided if all 17 hospitals had followed the same approach.

The biggest drop was for babies whose parents had taken only prescribed opioids, such as treatment medicines. Reports dropped less when the parent had also used cocaine, alcohol, amphetamines or sedatives called benzodiazepines, but not when the only other substance was cannabis or tobacco. The researchers found this pattern reassuring.

Two further findings matter most to families. First, the share of babies who went home with a parent did not change in a way the study could detect, although the authors say this result should be read with caution. Second, the study found no detectable difference in the drop in reports between families of different racial and ethnic backgrounds.

What states promise, and how hard it is to find

If fewer babies are reported to CPS, the plan of safe care becomes the main way families are connected to help. Lloyd Sieger and colleagues searched the laws and official reports of all 50 states and Washington, DC [2]. Every state except Illinois had some kind of plan-of-safe-care policy, but most were written only in internal agency manuals. Only 18 states had written the process into law or regulation. Even those laws said much more about which babies should get a plan than about who checks that the plan is followed, and five of the 18 did not address follow-up at all. States used 12 different names for the plan, and 35 of the 51 scored 3 or less on the researchers' accessibility scale, which runs from 0 to 6, which makes it hard for families and doctors to find out what the local rules are.

What this means for your family

If you are pregnant and taking methadone or buprenorphine, these studies support continuing your treatment and talking openly with your care team. Please do not stop a prescribed medicine on your own. It is reasonable to ask your hospital, before the birth, what its policy is on drug testing and on reporting, and to ask what a plan of safe care would include for your family. Doctors' groups have long said parents should know about testing and reporting in advance [13]. A good plan of safe care should be made with you, not about you: Connecticut's law, for example, says the plan is developed between the care team and the baby's mother [2]. If you are unsure what your state's rules are, your hospital social worker is a good person to ask, and it is fine to ask more than once. Knowing what to expect in advance can make the first days with your baby calmer. If your baby needs care for withdrawal, our articles on the Eat, Sleep, Console approach and newborn opioid withdrawal treatment explain what to expect.

What researchers are working on next

These studies have limits. The Boston results come from one hospital with specialised addiction and child-protection teams, only covered babies exposed to opioids, and followed families only until they left hospital [1]. The state review looked at written rules, which may not match what happens in practice [2]. Researchers now want to know whether babies stay safe and families stay in care over the longer term. Massachusetts passed a new law in December 2024 that ended automatic reporting for these babies and created a different way of notifying the state [1], and Connecticut has tried a similar route since 2019 [15][16], so both states will help answer that question.

The bottom line

When a hospital reported only real safety concerns rather than every opioid-exposed baby, about half as many families were reported, with no detectable effect on whether babies went home with a parent and no detectable difference in the drop between racial and ethnic groups [1]. The support that is supposed to follow, the plan of safe care, still needs clearer and more open rules in most states [2].

References

  1. Khazanchi R, Schiff DM, Egan E, et al. Discretionary Child Protective Services Reporting for Infants With Prenatal Opioid Exposure. Pediatrics. 2026;158(3):e2025075126. doi:10.1542/peds.2025-075126 ↩
  2. Lloyd Sieger M, Andraka-Christou B, Loch SF, Stein BD, Bouskill K, Patrick SW. A Policy Scan on Plans of Safe Care for Infants With Prenatal Substance Exposure. Hosp Pediatr. 2025;15(12):1039-1047. doi:10.1542/hpeds.2025-008536 ↩
  3. Lloyd MH, Luczak S, Lew S. Planning for safe care or widening the net?: A review and analysis of 51 states’ CAPTA policies addressing substance-exposed infants. Children and Youth Services Review. 2019;99:343-354. doi:10.1016/j.childyouth.2019.01.042 ↩
  4. Rebbe R, Sieger ML, Reddy J, Prindle J. U.S. State rates of newborns reported to child protection at birth for prenatal substance exposure. Int J Drug Policy. 2024;130:104527. doi:10.1016/j.drugpo.2024.104527 ↩
  5. Rebbe R, Mienko JA, Brown E, Rowhani-Rahbar A. Hospital Variation in Child Protection Reports of Substance Exposed Infants. J Pediatr. 2019;208:141-147.e2. doi:10.1016/j.jpeds.2018.12.065 ↩
  6. Reddy J, Halpern CT, Schiff DM, et al. Prenatal Substance Exposure and Multilevel Predictors of Child Protection System Reporting. J Pediatr. 2025;282:114546. doi:10.1016/j.jpeds.2025.114546 ↩
  7. Roberts SC, Nuru-Jeter A. Universal screening for alcohol and drug use and racial disparities in child protective services reporting. J Behav Health Serv Res. 2012;39(1):3-16. doi:10.1007/s11414-011-9247-x ↩
  8. Putnam-Hornstein E, Prindle JJ, Leventhal JM. Prenatal Substance Exposure and Reporting of Child Maltreatment by Race and Ethnicity. Pediatrics. 2016;138(3):e20161273. doi:10.1542/peds.2016-1273 ↩
  9. Austin AE, Naumann RB, Simmons E. Association of State Child Abuse Policies and Mandated Reporting Policies With Prenatal and Postpartum Care Among Women Who Engaged in Substance Use During Pregnancy. JAMA Pediatr. 2022;176(11):1123-1130. doi:10.1001/jamapediatrics.2022.3396 ↩
  10. Schiff DM, Work EC, Muftu S, et al. "You have to take this medication, but then you get punished for taking it:" lack of agency, choice, and fear of medications to treat opioid use disorder across the perinatal period. J Subst Abuse Treat. 2022;139:108765. doi:10.1016/j.jsat.2022.108765 ↩
  11. Work EC, Muftu S, MacMillan KDL, et al. Prescribed and Penalized: The Detrimental Impact of Mandated Reporting for Prenatal Utilization of Medication for Opioid Use Disorder. Matern Child Health J. 2023;27(Suppl 1):104-112. doi:10.1007/s10995-023-03672-x ↩
  12. Krans EE, Kim JY, Chen Q, et al. Outcomes associated with the use of medications for opioid use disorder during pregnancy. Addiction. 2021;116(12):3504-3514. doi:10.1111/add.15582 ↩
  13. Patrick SW, Schiff DM. A Public Health Response to Opioid Use in Pregnancy. Pediatrics. 2017;139(3):e20164070. doi:10.1542/peds.2016-4070 ↩
  14. Khazanchi R, Wachman EM, Schiff DM, Modest A, Saia KA, Hsu HE. Mandatory Child Protective Services Reporting for Substance-Exposed Newborns and Peripartum Outcomes: A Difference-in-Differences Analysis. JAMA Pediatr. 2024;178(7):719-722. doi:10.1001/jamapediatrics.2024.0903 ↩
  15. Sieger ML, Nichols C, Chen S, Sienna M, Sanders M. Novel Implementation of State Reporting Policy for Substance-Exposed Infants. Hosp Pediatr. 2022;12(10):841-848. doi:10.1542/hpeds.2022-006562 ↩
  16. Sieger ML, Godoy L, Moore TE, et al. Connecticut's Novel Prenatal Substance Exposure Policy Is Associated With Declining CPS Reports And Foster Placements. Health Aff (Millwood). 2025;44(7):821-829. doi:10.1377/hlthaff.2024.01160 ↩