Review: Interpretation of drug presence in the hair of children

Children victims of drug abuser parents: Hair testing as a forensic tool to assess exposure-A cohort of 37 cases from Spain

Hair testing is a useful tool to investigate suspected pediatric exposure to drugs of abuse. Newborns and young children are at high risk of exposure to drugs of abuse from parents or caregivers who consumed these substances, a fact prosecuted by Spanish authorities as child abuse. A retrospective study based on a cohort of 37 cases classified using several parameters, which involve children under 12 years old, were analyzed at the Drugs Laboratory of the National Institute of Toxicology and Forensic Sciences (Madrid, Spain) between 2009 and 2021. Hair samples were tested for the presence of opiates, cocaine, ketamine, amphetamines, methadone, and cannabis using a gas chromatography-mass spectrometry (GC-MS) method. A 59% of the studied children had ages in the range of 1-3 years old, and in 81% of cases, victims required hospitalization. In 81% of cases (n = 30), hair was submitted only or in combination with other samples, and these were classified in four categories according to analyzed samples: A (only hair), B (hair and blood), C (hair and urine), and D (hair, blood, and urine). The 93.3% of these cases (n = 28) showed a positive result of cannabinoids (THC and CBN in hair and THC-COOH in urine; 71.4% n = 20), cocaine and metabolites (benzoylecgonine and cocaethylene; 46.4% n = 13), opiates (morphine and 6-acetylmorphine), and amphetamines (MDMA and MDMA; 3.10% n = 1). Hair analysis matched positive results in cases where urine screening test was carried out previously (n = 24) and in those cases where blood and/or urine were also submitted (35.6% n = 11). As a conclusion, hair analysis was confirmed as a useful tool to detect previous exposure to acute poisoning events in children.

Hair testing applied to the assessment of in utero exposure to drugs: Critical analysis of 51 cases of the University Hospital of Verona

The work discusses the results of hair and urine testing performed in 51 cases of suspected in utero drug exposure handled at the University Hospital of Verona from 2016 to 2022. On the day of birth or the day after birth, urine from mother and newborn (UM and UN) and hair from mother (HM), newborn (HN) and father (HF), if possible, were collected. Urine underwent immunoassay and GC-MS analysis, whereas hair underwent LC-MS/MS and GC-MS/MS analysis. In 50 out of 51 cases, HM and/or HN were available. In 92% of them, hair testing resulted in a positive, often (>50% cases) for more than one class of substance. The most detected substances were cocaine, opiates, methadone and cannabinoids. Maternal segmental analysis showed a prevalent decreasing concentration trend during pregnancy in case of positivity for one class of substances, whereas, as expected, a neatly prevalent increasing trend in the case of positivity for more than one class of substances. In nine cases, HF was also available, resulting in all being positive, usually for the same classes of substances identified in HM, thus questioning parental responsibility. In 33 cases, urine samples from the mother or newborn were also collected. Of them, 27 cases (82%) tested positive, showing peri-partum drug consumption and then confirming the severity of the addiction. Hair testing showed to be a reliable diagnostic tool to investigate in utero drug exposure because of the possibility of obtaining a complete picture of maternal addictive behaviour and family background, thanks to segmental maternal hair analysis and father hair testing.

Fetal exposure to organic contaminants revealed by infant hair: A preliminary study in south China

Fetal exposure to multiple organic contaminants (OCs) is a public concern because of the adverse effects of OCs on early life development. Infant hair has the potential to be used as an alternative matrix to identify susceptible fetuses, owing to its reliability, sensitivity, and advantages associated with sampling, handling, and ethics. However, the applicability of infant hair for assessing in utero exposure to OCs is still limited. In this study, 57 infant hair samples were collected in Guangzhou, South China, to evaluate the levels and compositions of typical OCs in the fetus. Most of the target OCs were detected in infant hair, with medians of 144 μg/g, 17.7 μg/g, 192 ng/g, 46.9 ng/g, and 1.36 ng/g for phthalate esters (PAEs), alternative plasticizers (APs), organophosphorus flame retardants (OPFRs), polybrominated diphenyl ethers (PBDEs), and organochlorine pesticides (OCPs), respectively. Meanwhile, paired maternal hair (0-9 cm from the scalp) was collected to examine the associations between maternal and infant hair for individual compounds. Low-brominated PBDEs tended to deposit in infant hair, with median concentrations approximately two times higher than those in maternal samples. Levels of PBDEs and 4,4'-dichlorodiphenyldichloroethylene (p,p'-DDE) in paired maternal and infant hair showed strong positive correlations (p < 0.05), while most plasticizers (PAEs and APs) were poorly correlated between paired hair samples. Exposure sources were responsible for the variation in correlation between OC levels in the paired infant and maternal samples. Crude relationships between fetal exposure to OCs and birth size were examined using the Bayesian kernel machine regression (BKMR) model. BDE-28 was found to be adversely associated with the birth size. This study provides referential information for evaluating in utero exposure to OCs and their health risks based on infant hair.

Evidence for the transfer of methadone and EDDP by sweat to children's hair

In cases where there is a question as to whether children have come into contact with drugs, examinations of their scalp hair are frequently carried out. Positive test results are often discussed in the forensic community due to the various possible modes via which drugs and their metabolites can be incorporated into the hair. These include drug uptake by the child (e.g. oral ingestion or inhalation), but also contamination of hair via contact with the sweat from drug users. In this study, the possibility of methadone and its metabolite EDDP being incorporated into children’s hair by contact with sweat from persons undergoing opiate maintenance therapy (methadone) was examined. The transfer of methadone and EDDP via sweat from methadone patients (n = 15) to children’s hair was simulated by close skin contact of drug-free children’s hair, encased in mesh-pouches, for 5 days. Sweat-collecting patches (hereafter referred to as ‘sweat patches’) were applied to the test persons’ skin. One strand of hair and one sweat patch were collected daily from each patient. Analyses were performed using GC–MS/MS (hair) and LC–MS/MS (serum, sweat patches). After 4 days of skin contact, methadone was detectable in the formerly drug-free hair strands in all 15 study participants. EDDP was detectable in 34 of 75 hair strands, with the maximum number of positive results (11 EDDP-positive hair strands) being detected after 5 days. These results show that transfer of methadone and EDDP to drug-free hair is possible through close skin contact with individuals taking part in methadone substitution programmes. A correlation between serum concentration, sweat concentration and substance concentration in hair strands could not be demonstrated, but a tendency towards higher concentrations due to longer contact time is clearly evident.

Findings of illicit drugs in hair of children at different ages

Hair is a preferred material to detect exposure or use of illegal drugs in children. In the present study, we investigated a total of 387 hair samples for commonly applied illegal drugs of children up to 16 years. Analysis was by liquid chromatography/mass spectrometry with LOQs of 0.01 ng/mg hair for all analytes except tetrahydrocannabinol carboxylic acid with an LOQ of 0.1 pg/mg hair. Results were firstly compared with our in-house statics on results from adults' hair, and secondly to literature data. We started from the assumption that drug concentrations decrease with increasing age.Results were assigned to 4 different age groups (< 1 year, 1-< 6 years, 6-< 14 years, 14-16 years). As expected, higher results were obtained in age groups 1 and 2. The lowest concentrations were present in age group 3, whereas an increase could be observed in group 4 except heroin. In babies, positive results may be due to in utero exposure, breast milk feeding, and a close physical contact. All drugs under investigation such as cannabinoids, cocaine, amphetamines, and opiates have been detected in breast milk as well as in skin excretions such as sebum, sweat and cutaneous cells. For most drugs, average concentrations in children hair were lower than in adult hair when compared with our in-house statistics. Interestingly, the increase of cannabinoids, cocaine, and amphetamines concentrations in adolescents' hair points to a deliberate use of these drugs possibly in addition to passive exposure. This observation shows that age groups 1 and 4 are most vulnerable if caregivers or parents are drug users, even if the sources of positive drug findings differ.

Specific interpretation of hair concentrations in 2 fatal metformin intoxication cases

Hair analysis is very useful for toxicological investigations since, by providing a wider detection window, it gives the possibility to perform a retrospective study on the historical consumption of a substance. Unfortunately, there are no data available for hair concentrations in metformin-related deaths. In this study, the authors present 2 cases of fatal metformin intoxication in which, for the first time, hair analysis was performed using a specific GC-MS/MS method. Metformin was tested positive in femoral blood (112.3 mg/L and 64.7 mg/L respectively) and cardiac blood (226.9 and 203.2 mg/L) of the two subjects. For case 1, other samples were also tested positive, including vitreous humor (31.1 mg/L) and gastric contents (773.5 mg/L). In case 2, metformin was measured at 844.9 mg/L in urine. Metformin hair concentrations were 28.3-44.8 and 22.5 ng/mg for both cases, respectively. The concentrations found in the 2 fatal cases are clearly higher than those obtained in a previous study with subjects under treatment (0.3-3.8 ng/mg) or those found in 3 post-mortem cases where metformin death was excluded (0.6-1.4 ng/mg). Excessive sweating during the agonal phase due to fatal hypoglycemia could explain these elevated concentrations as sweat can have contaminated the hair.

Extent of In Utero Transfer of Tenofovir From Mother to Fetus: A Paired Analysis of Hair Specimens Collected at Birth From a Cohort in the United States

Understanding in utero transfer of antiretrovirals is critical for interpreting safety. Hair levels measure cumulative exposure. We measured tenofovir (TFV) concentrations in hair at delivery among women living with human immunodeficiency virus receiving TFV disoproxil fumarate-based treatment and their infants, using liquid chromatography-tandem mass spectrometry. Among 103 mother-infant pairs, the mean log10 ratio of infant-to-maternal TFV levels was 1.08 (95% confidence interval, .97-1.20). TFV transfer was 60% lower from mothers who had preterm compared with term deliveries and 42% lower from mothers who had cesarean compared with vaginal deliveries. Like prior studies assessing transfer via short-term measures (plasma, cord blood, amniotic fluid), we found high cumulative transfer using hair.

UPLC–MS/MS simultaneous determination of methamphetamine, amphetamine, morphine, monoacetylmorphine, ketamine, norketamine, MDMA, and MDA in hair

Hair is a stable specimen and has a longer detection window (from weeks to months) than blood and urine. Through the analysis of hair, the long-term information of the drug use of the identified person could be explored. Our work is to establish an ultra-performance liquid chromatography–tandem mass spectroscopy (UPLC–MS/MS) method for simultaneous determination of methamphetamine, amphetamine, morphine, monoacetylmorphine, ketamine, norketamine, 3,4-methylenedioxymethamphetamine (MDMA), and 3,4-methylenedioxyamphetamine (MDA) in hair. Methoxyphenamine was used as an internal standard. The chromatographic separation was performed on a UPLC ethylene bridged hybrid (BEH) C18 (2.1 mm × 50 mm, 1.7 μm) column using a mobile phase of acetonitrile–water with 10 mmol/L ammonium acetate solution which containing 0.05% ammonium hydroxide. The multiple reaction monitoring in positive electrospray ionization was used for quantitative determination. The intra-day and inter-day precisions (relative standard deviation [RSD]) were below 15%. The accuracy ranged between 85.5% and 110.4%, the average recovery rate was above 72.9%, and the matrix effect ranged between 92.7% and 109.2%. Standard curves were in the range of 0.05–5.0 ng/mg, and the correlation coefficients were greater than 0.995. The established UPLC–MS/MS method was applied to analyze the hair samples successfully.

Positive findings of ethyl glucuronide in hair of young children from families with addiction background

AIMS

Small children are expected to be abstinent from alcohol, and children's hair is frequently used as the blank matrix for calibration of the alcohol consumption marker ethyl glucuronide (EtG). The basal EtG concentrations of total abstainers were described to be 0.3-2.1 pg/mg (Pirro et al. 2013). It is examined whether this assumption is valid for children from families with addiction background.

METHODS

In a social support system for families with drug and/or alcohol addicted parents, 161 hair samples from 126 children (age 1-14 years, hair segment 0-3 cm) were analyzed for EtG by a validated LC-MS/MS method (LOD 0.56 pg/mg, LLOQ 2.3 pg/mg). For comparison, ethyl palmitate (EtPa) was measured and hair samples from parents were included. EtG ≥ 3 pg/mg was considered as an alarming result for children.

RESULTS AND DISCUSSION

EtG concentrations between 3.0 and 42.6 pg/mg (mean 9.55 pg/mg, median 6.40 pg/mg) were measured for 25 samples (15.5%, age 22 × 1-5 years, 3 × 9-11 years). Elevated EtPa (0.15-0.46 ng/mg) was found in 6 samples and cocaethylene (0.02-0.07 ng/mg) was detected in 5 samples with high cocaine findings. Hair results of one or both parents indicated drug abuse in 12 from 14 cases (85.7%) if both parents were tested.

CONCLUSION

Although accidental or voluntary intake of alcoholic beverages cannot be excluded, the external contamination of children's hair by EtG-containing wine and sweat or urine of the alcohol abusing parents is assumed to be the most probable explanation for the positive EtG results in hair of 1-5-year-old children.

Interpreting γ-hydroxybutyrate concentrations for clinical and forensic purposes

INTRODUCTION

γ-Hydroxybutyric acid is an endogenous substance, a therapeutic agent, and a recreational drug of abuse. This psychoactive substance acts as a depressant of the central nervous system and is commonly encountered in clinical and forensic practice, including impaired drivers, poisoned patients, and drug-related intoxication deaths.

OBJECTIVE

The aim of this review is to assist clinical and forensic practitioners with the interpretation of γ-hydroxybutyric acid concentrations in blood, urine, and alternative biological specimens from living and deceased persons.

METHODS

The information sources used to prepare this review were PubMed, Scopus, and Web-of-Science. These databases were searched using keywords γ-hydroxybutyrate (GHB), blood, urine, alternative specimens, non-conventional biological matrices, saliva, oral fluid, sweat, hair, vitreous humor (VH), brain, cerebrospinal fluid (CSF), dried blood spots (DBS), breast milk, and various combinations thereof. The resulting 4228 references were screened to exclude duplicates, which left 1980 articles for further consideration. These publications were carefully evaluated by taking into account the main aims of the review and 143 scientific papers were considered relevant. Analytical methods: The analytical methods used to determine γ-hydroxybutyric acid in blood and other biological specimens make use of gas- or liquid-chromatography coupled to mass spectrometry. These hyphenated techniques are accurate, precise, and specific for their intended purposes and the lower limit of quantitation in blood and other specimens is 0.5 mg/L or less. Human pharmacokinetics: GHB is rapidly absorbed from the gut and distributes into the total body water compartment. Only a small fraction of the dose (1-2%) is excreted unchanged in the urine. The plasma elimination half-life of γ-hydroxybutyric acid is short, being only about 0.5-0.9 h, which requires timely sampling of blood and other biological specimens for clinical and forensic analysis. Endogenous concentrations of GHB in blood: GHB is both an endogenous metabolite and a drug of abuse, which complicates interpretation of the laboratory results of analysis. Moreover, the concentrations of GHB in blood and other specimens tend to increase after sampling, especially in autopsy cases. This requires the use of practical "cut-off" concentrations to avoid reporting false positive results. These cut-offs are different for different biological specimen types. Concentrations of GHB in clinical and forensic practice: As a recreational drug GHB is predominantly used by young males (94%) with a mean age of 27.1 years. The mean (median) and range of concentrations in blood from apprehended drivers was 90 mg/L (82 mg/L) and 8-600 mg/L, respectively. The concentration distributions in blood taken from living and deceased persons overlapped, although the mean (median) and range of concentrations were higher in intoxication deaths; 640 mg/L (280 mg/L) and 30-9200 mg/L, respectively. Analysis of GHB in alternative specimens: All biological fluids and tissue containing water are suitable for the analysis of GHB. Examples of alternative specimens discussed in this review are CSF, saliva, hair strands, breast milk, DBS, VH, and brain tissue.

CONCLUSIONS

Body fluids for the analysis of GHB must be obtained as quickly as possible after a poisoned patient is admitted to hospital or after a person is arrested for a drug-related crime to enhance chances of detecting the drug. The sampling of urine lengthens the window of detection by 3-4 h compared with blood samples, but with longer delays between last intake of GHB and obtaining specimens, hair strands, and/or nails might be the only option. In postmortem toxicology, the concentrations of drugs tend to be more stable in bladder urine, VH, and CSF compared with blood, because these sampling sites are protected from the spread of bacteria from the gut. Accordingly, the relationship between blood and urine concentrations of GHB furnishes useful information when drug intoxication deaths are investigated.

The concentrations of bioelements in the hair samples of Jordanian children who stutter

OBJECTIVES

This study investigates the levels of 15 bioelements (calcium, copper, chromium, sodium, iron, magnesium, manganese, zinc, cobalt, selenium, molybdenum, vanadium, potassium, boron, and lithium) in the hair species of Jordanian stutterer.

METHODS

The subjects of the study included 25 cases of stuttering, and 25 normal children (age and sex matched). The severity of stuttering (low, moderate, and severe) were assessed using Stuttering Severity Instrument, Fourth edition (SSI-4). Hair samples of subjects were cut, washed, dried, physically degraded, hydrolyzed, and analyzed by Inductively Coupled Plasma Mass Spectrometry (ICP-MS).

RESULTS

Results indicated that the levels of bioelements (Calcium, Copper, Chromium, Magnesium, Manganese, Cobalt, Selenium, Molybdenum, Vanadium, Boron, and Lithium) were significantly lesser in the hair samples of stuttering group than the control group.

CONCLUSION

The findings of the current study could support the use of biochemical analyses as diagnostic biomarker for stuttering.

High risk of misinterpreting hair analysis results for children tested for methadone

The major problem after testing the hair of a child for drugs is the interpretation of the findings. In 2016, the laboratory received several hair specimens with the request to verify if there was any evidence of previous methadone exposure by the donor of the sample. Case 1 was a child admitted to the Emergency Unit for intense sedation and breathing difficulties. Cases 2-4 involved children found dead at home. In all cases, methadone and EDDP, its metabolite, were found in blood. After decontamination, the hair was analysed with LC-MS/MS for methadone and EDDP. The LOQ for both drugs was 10pg/mg. Concentrations were in the range 60-1590 and <10-220pg/mg for methadone and EDDP, respectively. In all of the cases, segmental analysis revealed approximately the same amount of drug along the hair lock. As a consequence, contamination was considered as an issue and interpretation of the results was a challenge that deserves particular attention. It must be considered that the amount of hair from children, available for analysis, can be low, particularly when several drugs have to be tested. This has consequences on the limit of quantitation and the identification of the metabolite(s). It must be also noted that hair from children is finer and more porous in comparison with adult (risk of higher contamination by sweat versus adults). It is very difficult to put any window of detection when testing for drugs in young children as hair growing is asynchronous. It is even more complicated as it has been demonstrated that drugs can be incorporated during pregnancy in the hair of the foetus, which will contribute to the positive findings after delivery. Several weeks or months after delivery, identification of a drug in hair can indicate: 1, in-utero exposure, or 2, exposure after delivery, or 3, a mix of both situations. Whereas the detection of drugs in a child's hair unambiguously shows drug handling in the environment of the child, it is difficult to distinguish between systemic incorporation into hair after ingestion or inhalation and external deposition into hair from smoke, dust, or contaminated surfaces. However, the interpretation of hair results with respect to systemic or only external exposure is particularly important in case of children for a realistic assessment of the toxic health risk. Practising scientists have the responsibility to inform the child protection authorities, courts, etc about these limitations.

The analysis of 132 novel psychoactive substances in human hair using a single step extraction by tandem LC/MS

A rapid LC-MS/MS method for the targeted screening of 132 NPS in hair is described. Drugs include cathinones and synthetic cannabinoids, as well as amphetamine-type stimulants, piperazines and other hallucinogenic compounds. This method utilizes hair pulverization in acidified methanol followed by analysis using liquid chromatography coupled with tandem MS. The limit of detection varied from 0.001 to 0.1ng/mg hair among the various analytes. The method was validated in terms of sensitivity, selectivity, repeatability and stability. The limit of reporting was set at 0.1ng/mg of hair. The method was successfully applied to 23 medico-legal cases where NPS were detected in blood or where NPS use was suspected. The identified NPS included acetyl fentanyl, 25C-NBOMe, MDPV, PB-22 and AB-FUBINACA, allowing hair to be used where historical or retrospective information on use of NPS is sought. This technique has proven to be efficient for the one step extraction from hair of different classes of NPS in routine toxicological investigations; from unstable and volatile compounds, such as most of the cathinones, to hydrophobic compounds such as synthetic cannabinoids.