Review: Interpretation of drug presence in the hair of children

Forensic Science International 257 (2015) 458–472

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Forensic Science International journal homepage: www.elsevier.com/locate/forsciint

Review Article

Review: Interpretation of drug presence in the hair of children Xin Wang a,1, Olaf H. Drummer b,* a

Section of Forensic Chemistry, Department of Forensic Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Frederik V’s Vej 11, DK-2100 Copenhagen, Denmark b Victorian Institute of Forensic Medicine and Department of Forensic Medicine, Monash University, 65 Kavanagh Street, Southbank, VIC 3006, Australia

A R T I C L E I N F O

A B S T R A C T

Article history: Received 26 May 2015 Received in revised form 20 October 2015 Accepted 28 October 2015 Available online 10 November 2015

Hair analyses for drugs of abuse are being increasingly used in both clinical and forensic toxicology, including cases involving children exposed to a drug using environment. A review was conducted of peer-reviewed publications reporting hair concentrations of drugs in children published in the English language. Fifty-two publications were aggregated into three categories: results published on the newborn where hair was sampled at, or shortly after, birth that reflected in utero exposure and/or shortterm exposure from the mother’s breast milk, and publications in which children were either believed to have been exposed passively from drugs of abuse through their environment or by active exposure from accidental ingestion or deliberate administration by a caregiver. There was limited data for comparison of all three exposure routes. On average, cocaine, codeine, 6-AM and morphine showed higher concentrations in hair from in utero exposure compared to children exposed passively; however, there was considerable overlap in concentrations. Methamphetamine showed no significant difference between passive and in utero exposure, although there was only one study reporting hair concentrations from in utero exposure. There was no difference in concentrations for those cases exposed passively or actively for codeine and methadone. There was insufficient data for other drugs and other comparisons. Comparison data was confounded by the variability in extraction techniques employed as well as a variety of washing techniques, including studies that did not employ any decontamination technique. These data further illustrate the difficulties in interpreting hair concentrations in isolation of relevant contextual data, particularly in children. ß 2015 Elsevier Ireland Ltd. All rights reserved.

Keywords: Hair analysis Neonate hair Children hair Infants hair

Contents 1. 2. 3.

4.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . In utero and/or breast milk exposure in neonates 3.1. 3.2. Likely active exposure in children . . . . . . . . . . . . . Likely passive exposure in children . . . . . . . . . . . . 3.3. 3.4. Statistical comparisons . . . . . . . . . . . . . . . . . . . . . . Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1. General comments . . . . . . . . . . . . . . . . . . . . . . . . . Cocaine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2. Amphetamine-type stimulants. . . . . . . . . . . . . . . . 4.3. Heroin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4. Opiates and opioids . . . . . . . . . . . . . . . . . . . . . . . . 4.5. 4.6. Cannabis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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* Corresponding author. Tel.: +61 3 96844304; fax: +61 3 9682 7353. E-mail address: [email protected] (O.H. Drummer). 1 Training placement in the Department of Forensic Medicine, Monash University. http://dx.doi.org/10.1016/j.forsciint.2015.10.028 0379-0738/ß 2015 Elsevier Ireland Ltd. All rights reserved.

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X. Wang, O.H. Drummer / Forensic Science International 257 (2015) 458–472

4.7. Other drugs . Summary . . . 4.8. Acknowledgements References . . . . . . .

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1. Introduction Hair analysis is a routine test in many clinical and forensic toxicology laboratories for detecting past use of, or exposure to, drugs of abuse. Compared to urine, hair can be easily collected under close supervision to prevent manipulation with relatively little intrusion on privacy, and can be stored and transported at room temperature [1]. Hair is a keratinized specimen capable of storing compounds for as long as hair remains on a person. The detection time can be months compared to conventional matrices such as blood and urine that have detection times from hours to a few days [2,3]. Moreover, hair analysis through analyses of segments has been used to estimate an approximate exposure period [4,5]. Hence, the relative non-invasiveness of collection renders hair a potentially useful specimen to disclose past exposure to drugs. The mechanism of incorporation of drugs into hair appears to be complex, with three identified routes: transfer of drug from the blood in capillaries to the follicle; diffusion from sweat and sebum into the growing or maturing hair fiber; and external contamination from the environment [3,5–9]. In some cases, it is likely that a number of routes of incorporation apply, or it is not possible from the circumstances to determine which of the various routes exposure has occurred [10]. During the process of drug incorporation into hair, the color of hair is known to affect binding of some drugs particularly to eumelanin that is most abundant in black and brown hair [5,6,11,12]. Moreover, compared to adults, the hair of children is thinner and more porous, the ratio of anagen/catagen phases is not the same as those of adults, and the growth rate can be variable [13,14]. However, in children, particularly young children and infants, assumptions are made that the same mechanisms apply as for adults [15]. Differentiation between exposure due to intake or from the environment is quite difficult to discern. In addition, cases of proven in utero exposure or exposure from drug-using mothers through their breast milk should also be considered in neonates and children up to about 6–12 months of age. Increasing numbers of pregnant women are using illicit drugs with cannabis and cocaine; potentially exposing the child to numerous adverse health effects [16,17]. Hair testing for drugs has been used on children to provide extra information in child protection cases when exposure to drugs of abuse is suspected [18–22] and in cases where newborns may have been exposed to drugs in utero or through their mother’s breast milk [16,23– 26]. Therefore, identification of drugs in the hair of neonates can be useful to evaluate maternal and neonatal illicit drug exposure. Infants are at a higher risk for environmental exposure to drugs of abuse from caregivers who use drugs [27–29]. Higher concentrations of drugs have been found in infants and toddlers than older children [27,28,30]. Younger children spend most of their time indoors and stay with parents, therefore, the chance of passive exposure to drugs from smoke or from sweat/sebum from parents is greater. Moreover, children crawling on floors and putting contaminated objects in their mouths also poses a risk of exposure. The respiratory rate of infants and toddlers is higher than among older children, potentially leading to higher exposure to drugs from lung absorption [30,31].

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470 470 471 471

Hence, interpretation of hair results should be treated cautiously as many other factors also influence the interpretation including personal hygiene and cosmetic treatments [6,23]. In order to determine if analysis of children’s hair can be used to differentiate between systemic exposure and merely external contamination in a drug-using environment, all published papers describing positive results in children’s hair were critically reviewed. 2. Methods Published peer-reviewed papers indexed in ‘‘PubMed’’, ‘‘Google Scholar’’ and the ‘‘TIAFT Bulletin’’ was conducted using search terms as ‘‘drugs of abuse’’ ‘‘hair’’ ‘‘children’’ ‘‘infants’’ up to March 2015. Articles were limited to the English language. Results of all identified papers are summarized in Table 1 by type of likely exposure to drugs of abuse; in utero or breast milk (category A, age range to 3 months); active ingestion (category B, older than 3 months to 16 years); and passive (environmental, older than 3 months to 16 years) exposure (category C). Cases classified in the active ingestion group may include the detection of other drugs that may have originated from likely passive exposure. Results were further separated into neonates (<3 months’ old), infants (3 months to 1 year) and older children (1–16 years), and by drug type. The focus on drug type was the common illicit drugs; heroin, methamphetamine (MA), amphetamine (AMP) and Ecstasy (MDMA or 3,4-methylenedioxymethamphetamine), cannabis, and cocaine (COC), as well as the narcotic analgesics (opiates and opioids) where sufficient publications were available; namely morphine, codeine, methadone and tramadol. The Table also summarizes the analytical validation parameters such as the extraction method, LOD and method of analyses. Statistical analysis was performed using software R 3.2.0 [32,33]. Results described in publications were categorized into the 3 main categories as described above and results visualized on Box and Whisker plots showing median, quartiles and outliers. The width of the ‘‘box’’ is proportional to the square root of the number of individual cases published for each category. In some publications, individual results were not presented, hence medians and ranges were shown. When this occurred this was shown in the figures. Newman–Keuls method was used for multiple comparisons between each category with results considered statistically significant when p < 0.05. 3. Results 3.1. In utero and/or breast milk exposure in neonates There were 15 peer-reviewed publications that provided data on drug concentrations in hair in babies under 1 month old (Table 1 for summary of all data) [10,15,16,23–26,34–41]. All these cases had proven in utero exposure and/or short-term exposure from breast milk with no suspicion of external contamination identified by the authors except one case [10] which probably caused through in utero exposure, breast milk and external contamination. In most of these cases [15,16,23–26,34–41], hair was sampled at delivery or within a few days after delivery which can exclude potential confounding by external exposure to drugs.

X. Wang, O.H. Drummer / Forensic Science International 257 (2015) 458–472

460

Table 1 Overview of publications for the detection of drugs of abuse in hair of children. Reference

In utero and/or GarciaBournissen et al. [25] Ursitti et al. [34] Sallee et al. [35] Katikaneni et al. [26]

GarciaBournissen et al. [25]

Katikaneni et al. [26]

Graham et al. [36]

Circumstances/type

breast milk exposure n = 1862 neonates (within the first day after delivery) clinical suspicious of in utero exposure to COC n = 182 neonates clinical suspicious of in utero exposure to COC n = 34 neonates (sampled at delivery) born to mothers urine-positive for COC n = 151 neonates (within the first 48 h after birth) born to mothers urine-positive for COC n = 98 mother–baby pairs (within the first day after delivery) who had at least one positive hair test for COC or BE n = 18 mother–baby pairs (within the first 48 h after birth) with mothers had positive hair analysis for COC n = 7 neonates with COC users mother during pregnancy

Joya et al, 2007 [10]

1-mo-breastfed child with heroin intoxication

Klein et al. [37]

Preterm neonate (hair sampled 3 weeks after birth), benzodiazepines detected in urine Gestational age 32-week neonate, mother admitted once-daily use 2–5 g COC and smoking about 20–40 cigarettes per day throughout pregnancy and use 0.5–1 g Hashish weekly during the first 3 months of pregnancy n = 2/17 mother–neonate pairs (sampled at delivery) with maternal drug addiction n = 2 neonates (sampled at delivery) with known in utero exposure to drugs n = 2 mother-neonate pairs (sampled at delivery) with maternal drug addiction

Potter et al, 1994 [38]

Vinner et al. [23] Kintz et al, 1993 [16] Vinner et al. [23]

Vinner et al. [23,39]

n = 10 mother–neonate pairs (sampled at delivery) with maternal drug addiction

Kintz et al. [40]

n = 9 neonates with known in utero exposure to heroin (sampled at delivery or 1–5 days after delivery) n = 57 neonates (sampled at delivery) with known in utero exposure to drugs

Kintz et al. [16]

Hair concentrations (ng/mg)

Hair decontamination method & comments

Extraction method for drugs

Analytical method and LOD

Positive rate 28.5% (n = 531) COC median 1.5 (<0.1–257) BE median 0.8 (<0.1–43)

No wash used

Methanol

GC–MS LOD 0.1 ng/mg

Positive rate 30% BE 4.4

No wash used

Methanol

RIA LOQ 0.25 ng/mg

Positive rate 85% BE mean 2.5 (0.7–5.4)

Washed in mild detergent

Hydrolyzed LLE

RIA Sensitivity 5 ng/mL

Positive rate 88% BE 0.1–23

Washed in mild detergent

Hydrolyzed LLE

RIA and confirmed by GC–MS Sensitivity 5 ng/mL

Neonates COC median 0.3 (<0.1–22) BE median <0.1 (0.1–23) Mothers COC median 3.6 (0.2–209) BE median 0.5 (<0.1–89) BE Neonates mean 2.9 (0–5.5) Mothers mean 9 (2.4–24)

No wash used

Methanol

GC–MS LOD 0.1 ng/mg

Washed in mild detergent

Hydrolyzed LLE

RIA and confirmed by GC–MS Sensitivity 5 ng/mL

Hair was washed repeatedly with a 1% solution of SDS, then rinsed repeatedly with water Washed hair (DCM)

0.1 mol/L HCl

RIA LOD 0.4 ng/mg

Methanol

GC–MS LOQ 0.02 ng/mg for COC and 0.01 ng/mg for others

Hair not washed unless obvious external contamination was suspected Washed hair (ethanol)

Methanol/5 M HCl (20:1)

RIA or ELISA and confirmed by GC–MS

NaOH

RIA and confirmed by MS LOQ 0.025 ng/mg for cocaine and 0.25 ng/mg for cotinine

Washed hair (DCM)

LLE

GC–MS LOD 0.1–10 ng/mg LOQ 0.2–12.5 ng/mg

Washed hair (DCM)

LLE

GC–MS LOD 0.05–0.63 ng/mg

NeonatesTHC <0.2 Cannabinol <0.2 & 0.25 Cannabidiol <0.2 MothersTHC mean 3 (<0.2–7) Cannabinol mean 2 (0.5–4) Cannabidiol mean 18.6 (<0.2–32) Neonates6-AM <2–29 Morphine <2–3 Codeine <2– 41 Mothers6-AM <2–33 Morphine <2–17 Codeine <2–28 Morphine 0.6–3.5

Washed hair (DCM)

LLE

GC–MS LOD 0.1–10 ng/mg LOQ 0.2–12.5 ng/mg

Washed hair (DCM)

LLE

GC–MS LOD 0.1–10 ng/mg LOQ 0.2–12.5 ng/mg

Washed hair (DCM)

LLE

GC–MS

n = 34 Nicotine 0.2–11.8 n = 9 Morphine 0.6–3.5 n = 8 Diazepam 3.4–17.6 n = 3 Oxazepam 0.8–32 n = 1 AMP 1.2

Washed hair (DCM)

LLE

GC–MS LOD 0.05–0.63 ng/mg

Positive rate 100% BE mean 5.4 (0.2–27.5)

ChildCOC 17.5 BE 2.2 Morphine 2.4 6-AM 8 Codeine 0.4 ParentsCOC 2.5–12 BE 1.7–5.5 Morphine 0.2–6.4 6-AM 0.6–8 Codeine 0.05–1.8 COC BE (results not given)

Neonates BE undetectable Nicotine 3.0 Cotinine 0.1 MothersBE 0.8–3 Nicotine 6.5–23 Cotinine 0.2–0.4

NeonatesCOC <2 & 18 EME <2 MothersCOC 36 & 84 EME 3&8 BE 0.71–2.5

X. Wang, O.H. Drummer / Forensic Science International 257 (2015) 458–472

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Table 1 (Continued ) Reference

Circumstances/type

Hair concentrations (ng/mg)

Hair decontamination method & comments

Extraction method for drugs

Analytical method and LOD

GarciaBournissen et al. [24,41] Su et al. [15]

n = 11 mother–neonate pairs with mothers were positive for MA (within the first day after delivery) Neonate (several days after delivery) with general hypotonia, the mother abused ketamine during late pregnancy

MA Neonates median 1.6 (0– 23) Mothers median 1.8 (0.1– 52) Only one neonate was 0

Hair not washed unless obvious external contamination was suspected Washed hair (solvent not given)

Methanol

ELISA and confirmed by GC– MS

SPE

GC–MS LOD 10–20 pg/mg LOQ 20–50 pg/mg

Proven active exposure of at least one drug Taguchi et al. 2-yr-girl with seizures, [43] unconsciousness and high fever (length 0–15 cm) Papaseit et al. A 13-mo-infant with [44] methadone withdrawal syndrome Kintz et al. [45]

Tournel et al. [46]

Kintz et al. [45]

Chadderton et al. [47]

Kintz et al. [20]

Strano-Rossi et al. [49]

5-mo-girl repetitive sedation by methadone and subsequent death, blood concentration for methadone (142 ng/mL) 11-mo-infant died from ‘‘methadone poisoning’’, lethal concentration of methadone in blood and gastric content, the mother used methadone during pregnancy and breastfeeding periods 14-mo-girl repetitive sedation by methadone and subsequent death, blood concentration for methadone (1071 ng/mL) and EDDP (148 ng/mL) 14-mo-child died, lethal methadone (0.3 mg/mL) and EDDP found in blood and 4yr-sibling Unconscious boy (age unknown) sent to hospital, methadone detected in a body fluid 2-yr-child died of methadone overdose. Hair analysis tested if single or multiple doses was given 16-mo-child suspected of being given methadone by parents, methadone detected in a body fluid Child (age unknown) suspected of being given methadone over period of time, methadone detected in a body fluid Child (age unknown) admitted to hospital after allegedly drinking some of her mother’s methadone 3-yr-child died of methadone overdose, both parents under methadone therapy 5-yr-child exposure to heroin; symptoms respiratory arrest, scarce cardiac activity, hypothermia, cyanosis, miosis, and total unconsciousness; also on therapeutic phenobarbital

Ketamine 0.14 Norketamine 0.06

ChildCOC 6–76 BE 2–36 MotherCOC 0.3 BE negative

Washed (ethanol)

Methanol

RIA LOD 0.025–0.25 ng/mg

Methadone 3 Heroin 0.7 COC 17 BE 0.6

Hair washing treatment not given; possibly passive exposure to COC from COC users Washed (DCM)

–

GC–MS

LLE

GC–MS

ChildMethadone:0.9–1.8 EDDP: 0.15–0.6 MotherMethadone: 2.8–11.7 EDDP 0.1–2

Washed (DCM)

LLE

UPLC–MS/MS 0.1 ng/mg

Methadone 1.9 EDDP 0.8

Washed (DCM)

LLE

GC–MS

14-mo siblingMethadone 0.7–1 EDDP <0.1 4-yrsiblingMethadone 0.3–0.4 EDDP <0.1 Methadone 0.05–0.08 EDDP <0.01

Washed (DCM)

LLE

LC–MS/MS LOQ 10 pg/mg

Washed (DCM)

LLE

LC–MS/MS LOD 2 pg/mg LOQ 10 pg/mg

Washed (3 Tween 80, 0.1%, 3 water, once acetone)

Hydrolyzed SPE

GC–MS LOD 0.1 ng/mg for morphine and 0.2 ng/mg for 6-AM LOQ 0.2–5 ng/mg

Methadone 1–21 EDDP <0.2– 5.2

Methadone 0.5–0.6 EDDP <0.01

Methadone 0.13–0.15 EDDP 0.02

Methadone 0.07–0.09 EDDP 0.01–0.03

Methadone 0.06–0.13 EDDP 0.02–0.03

Methadone 0.4–0.8 EDDP 0.04–0.06 6-AM 0.2–0.6 Morphine 0.1– 0.3 Phenobarbital 23–38

X. Wang, O.H. Drummer / Forensic Science International 257 (2015) 458–472

462 Table 1 (Continued ) Reference

Circumstances/type

Hair concentrations (ng/mg)

Hair decontamination method & comments

Extraction method for drugs

Analytical method and LOD

Gaillard et al. [84]

2-yr and 3-yr-boys died of cyanide and carbon monoxide poison following administration by parents 3 children (12–16-yr) repeated administration by mother of Feminax (contains paracetamol, codeine, caffeine, and scopolamine) 9-yr-child in a kidnap and false imprisonment; 20  1 cm section; repeated exposure

Phenobarbital 1.2 & 1.5

Washed (2 hot water, 2 DCM)

SPE

HPLC-PDA and GC–MS

Scopolamine 0.0003–0.0011 Codeine 0.09–0.5

Washed (DCM)

LLE

UPLC–MS/MS LOD 0.08 pg/mg LOQ 0.2 pg/mg

Amitriptyline 0.007–0.3 Nortriptyline 0.007–0.3 Temazepam 0.002–0.03 Tramadol 0.06–2 Dihydrocodeine 0.01–0.09 Amitriptyline 1.8 Nortriptyline 0.04 Bromazepam 0.74

Washed (DCM)

LLE

LC–MS/MS LOD 0.005–0.03 ng/mg LOQ 0.01–0.1 ng/mg

Washed (no technique given)

Hydrolyzed SPE

LC–MS/MS

Washed (DCM); proven repeated active exposure

LLE

LC–MS/MS LOQ 10 pg/mg

Tramadol 0.2–2.3 O-desmethyl-tramadol 0.03– 0.2

Washed (DCM)

LLE

LC–MS/MS LOD 0.03 ng/mg LOQ 0.1 ng/mg

Alprazolam 0.002–0.005

Washed (DCM)

LLE

LC–MS/MS LOD 0.4 png/mg LOQ 2 pg/mg

Trimeprazine 0.13

Washed (DCM)

LLE

LC–MS/MS LOD 2 png/mg LOQ 10 pg/mg

Diphenhydramine 0.033– 0.039

Washed (DCM); proven active exposure

LLE

Clozapine (levels not given)

Decontamination treatment not declared

LC–MS/MS LOD 2 png/mg LOQ 10 pg/mg GC–MS

Opiates (levels not given)

Washing not conducted unless obvious external contamination was suspected

Methanol/5 M HCl (20:1)

RIA or ELISA and confirmed by GC–MS

Amitriptyline 0.5–1.4 Nortriptyline 1.3–4

Washed (DCM)

Methanol

LC–MS/MS LOD 0.005 ng/mg LOQ 0.0075 ng/mg

COC median 3 (1.3–4.6) BE median 0.5 (0.4–0.5) Mother negative

Washed (DCM), likely ingestion Ecstasy, possible passive exposure to COC and/or breast milk Washed (diethyl ether)

Hydrolyzed LLE

GC–MS LOQ 0.04–0.26

LLE

RIA or HPLC or GC–MS

Kintz et al. [56]

Chadderton and Kintz [50]

Gaillard et al. [53]

Chadderton et al. [47]

Kintz [51]

Kintz et al. [13,54]

Kintz et al. [52]

Kintz et al. [55] Bartsch et al. [21]

Klein et al. [37]

1-mo-baby autopsied 8 months after death, amitriptyline and nortriptyline found in liver and CSF Two children (age 7 and 12yr) were given amitriptyline for 6 months 3-yr-child, symptom pale, floppy and lethargic; tramadol positive in urine 8-mo-girl died at home. Tramadol and Odesmethyltramadol detected in femoral blood of child; mother used tramadol during pregnancy 12-yr-old girl claimed to have been assaulted and during the last 3 months of the period of the offense she was given Xanax 7-yr-boy observed drowsiness, ataxia, sedation, muscular weakness, marked somnolence. Sedated by stepmother 13-yr-girl observed drowsiness, ataxia, sedation, muscular weakness, marked somnolence. Sedated by stepmother 9-yr-girl involved in a DFC sedated by diphenhydramine 18-mo-girl unconsciousness, apathy, arterial hypotension, muscle relaxation, dyspnea, hair analysis 10 months after death; active administration by mother 1-mo-baby given an Indian herbal remedy that contained codeine

Possible active exposure of at least one drug Alibe et al. 6-mo-baby with generalized [85] hypotonia or hypertonia, paleness, cheeks flush, chewing and systematized movement; likely repeated exposure Garcia-Algar 11-mo, breast-fed, et al. [29] generalized seizures, high urinary levels of MDMA (12 mg/L) and MDA (1 mg/L) Staub [48] 2½-yr-child with unconscious and high fever, codeine, morphine and 6-AM detected in urine; hair sampled 2 months later

Amitriptyline 0.2–1.1 Nortriptyline 0.4–2 Tramadol 1.5–2.25

Trimeprazine 0.02–0.3

6-AM (levels not given)

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463

Table 1 (Continued ) Reference

Circumstances/type

Hair concentrations (ng/mg)

Hair decontamination method & comments

Extraction method for drugs

Analytical method and LOD

Fucci et al. [2]

A 3-yr-boy with drowsiness, urine positive for opiate

6-AM 5.0 Morphine >0.2

No wash used

Hydrolyzed LLE

GC–MS LOD 0.1 ng/mg LOQ 0.2 ng/mg

Positive rate 50% BE mean 6 (4.3–7.8)

Hair was washed repeatedly with a 1% solution of SDS, then rinsed repeatedly with water Hair was washed repeatedly with a 1% solution of SDS, then rinsed repeatedly with water Washed hair (methanol)

0.1 mol/L HCl

RIA LOD 0.4 ng/mg

0.1 mol/L HCl

RIA LOD 0.4 ng/mg

–

IA Cut-off 0.5 ng/mg

Washed hair (methanol)

Hydrolyzed LLE

GC–MS Cut-off 0.5 and 1 ng/mg

Children positive rate 92% COC mean 2.4 (0–14.4) BE mean 0.7 (0–5.4) Mothers COC mean 2.4 (0–12.2) BE mean 0.4 (0–1.9)

Washed hair (ethanol & phosphate buffer)

LLE

GC–MS LOD 0.05 ng/mg

COC median Infant 2.6 (0–38), caregiver 5 (0.3–69) A 1.7 (0–75), caregiver 1.8 (0.2–14) B 0 (0–2), caregiver 11 (0.3– 19) BE median Infant 0.12 (0–7), caregiver 0.14 (0–7) A 0.2 (0–1.8), caregiver 0.2 (0–2.7) B 0 (0–0.2), caregiver 0.5 (0– 1) Positive rate 25–28% COC median 0.3–1.6 BE median 0.2–0.8 6-AM 0.3–0.4 Morphine 0.15–0.25 Codeine median 0.17–0.4 Children Positive rate 23% COC median 1.6 (0.3–6) BE median 0.9 (0.2–1.4) Parents COC median 1 (0.3–24) BE 0.8 (0.3–2.7) 20% COC median 0.54 (0.15– 3.8) BE median 0.2 (0.07–0.55) 11% THC median 0.16 (0.05– 0.5) 3.5% Codeine median 0.2 (0.1–0.3) 0.9% Methadone 2.1 0.9% 6-AM 0.4 Morphine 0.15 THCA-A median 0.1 (0–1) THC median 0.01 (0–0.25)

No wash employed

Methanol

RIA and confirmed by GC–MS LOD 0.1 ng/mg

Washed Hair (DCM)

SPE and extracted with acidic aqueous buffer

GC–MS and UPLC–MS/MS LOQ 0.05–0.2 ng/mg

Washed Hair (DCM)

SPE

GC-MS LOQ 0.2 ng/mg

Washed hair (methanol & diethyl ether)

Extracted with basic aqueous buffer

IA and confirmed UPLC–MS/ MS LOQ 0.05–0.1 ng/mg

Washed hair (water & acetone)

1. Methanolic extraction 2. Hydrolyzed and LLE

LC–MS/MS and GC–MS LOQ 2.5–20 pg/mg

Likely passive exposure Graham et al. n = 4 infants (2.5–3.5-mo) [36] with COC users mother during pregnancy Graham et al. [36]

n = 3 toddler (2–3-yr) with COC users mother during pregnancy

Negative

Papaseit et al. [58]

2-yr-child presenting with neonatal withdrawal syndrome; 0–3 cm and >3 cm segments

Di Giorgio et al. [59]

6-yr-boy with general distress, living with COC smoker parents. COC and metabolites were detected in urine Hair from COC-using mothers (n = 16) and their children (n = 24) (1–14-yr). No breast feeding. Urine testing in children was negative for virtually all children n = 8 infants (3-mo–1-yr) n = 6 children A (1–6-yr) n = 5 children B (6–16-yr)

Child BE 1.9 & 7 Cannabis 0.3–0.7 Parents BE 6.4–13 Cannabis 0.3–0.9 COC 16 BE 0.6

Smith et al. [60]

GarciaBournissen et al. [27]

Pichini et al. [61]

n = 391 children (1–14-yr)

Joya et al. [62]

n = 90 children (<5-yr) in an urban pediatric emergency department without symptoms suggestive of drug exposure

Pichini et al. [18]

n = 114 (24-mo–10-yr)

Moosman et al. [64]

n = 41 (7-om–12-yr)

n = 5 (2–3-yr) n = 5 (4–12-yr)

THCA-A 0.1–0.65 THC 0–0.07 THCA-A 0.02–0.5 THC 0–0.1

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464 Table 1 (Continued ) Reference

Circumstances/type

Hair concentrations (ng/mg)

Hair decontamination method & comments

Extraction method for drugs

Analytical method and LOD

Uhl et al. [65]

2-yr-child living with cannabis smoking father

THCA 0.00003–0.00007

SPE

GC–MS/MS LOQ 0.1 pg/mg

Kintz [51]

9-mo-boy died in bed and mother smoked cannabis during pregnancy n = 149 (1–14-yr) living with parents substituted by methadone and/or suspected for abuse of illegal drugs

THC 0.2–0.9

Washed hair (SPE acetonitrile & hydrochloric acid) Washed (DCM)

LLE

Positive rate 76.5% n = 28 Methadone 0.007–2.2 n = 11 EDDP 0.01–0.07 n = 44 6-AM 0.01–11.2 n = 73 COC up to 17.8 n = 6 AMP 0.025–3.3 n = 1 MDMA 0.06 n = 55 THC 0.01–0.7 n = 35 CBN 0.007–0.5 n = 17 CBD 0.03–0.13 n = 15 Morphine 0.01–1.32 n = 4 Codeine 0.006–0.24 Methadone 0.3–1.6 EDDP <0.01–0.2

Washed hair (water & acetone)

Extracted with a mixture of methanol/ acetonitrile/ 2 mM of ammonium formate (25:25:50, v/v/ v), LLQ and SPE

LC–MS/MS LOD 0.03 ng/mg LOQ 0.1 ng/mg LC–QTOF/MS, LC–MS/MS and GC–MS LOD 0.000038–0.005 ng/mg LOQ 0.00018–0.007 ng/mg

Washed (DCM)

LLE

MDMA 8.6

Hair not washed unless obvious external contamination was suspected

Methanol/5 M HCl (20:1)

Hair not washed unless obvious external contamination was suspected

Methanol

ELISA and confirmed by GC–MS

MA 0.3–4.5 AMP 0.1 MDMA 0.1–0.25 Positive rate 78% 75% MA median 1.4 (0.1–22.0) 55% AMP median 0.1 (0.025–1.2) 12% MDMA median 0.25 (0.1–2.3) 73% MA mean 7 (0.1–131) 65% AMP mean 0.4 (0.02–4.8) Positive rate 45% for MA Positive rate 15% for AMP

Washed hair (isopropanol)

Digested with proprietary solution

LC–MS/MS LOQ 0.02–0.1 ng/mg

Washed hair (methanol)

SPE

No wash employed

Methanol

LC–MS/MS LOQ 0.1 mg/mg ELISA and GC–MS Cut-off 5–100 pg/mg

MA positive rate 62% COC positive rate 22% THC positive rate 8% Benzodiazepines positive rate 7% (levels not given) Carbamazepine 0.15–0.4

No wash employed

–

–

Wash (DCM); source not proven but thought to be passive

LLE

LC–MS/MS LOQ 10 pg/mg

Pragst et al. [57]

Kintz [51]

GarciaBournissen et al. [80]

GarciaBournissen et al. [24,41]

Castaneto et al. [28]

11-mo-girl often sedated and mother used methadone during pregnancy 14-mo-child in a family house had been used to manufacture MDMA, normal development, no clinical signs of exposure 8-yr-child in a family house had been used to manufacture MDMA, normal development, no clinical signs of exposure n = 19 children <3-mo (median age 1.4 days)

n = 13 Children (3-mo–16-yr) (median age 1.2-yr) 3 infants (<12-mo) among n = 89 n = 89 children (1-mo–18-yr), environmentally exposed to household MA intake

Bassindale [63] Farst et al. [30]

Mecham [79]

Kintz [14]

n = 52 (2-mo–15-yr) from MA laboratories n = 107 children (<12-yr) suspicion of having been exposed to the manufacture of MA n = 132 children (20-d–16-yr) exposed to chemicals at methamphetamine laboratories

21-mo-child custody case

LC–MS/MS LOD 0.03 ng/mg LOQ 0.1 ng/mg GC–MS LOD 0.2 ng/mg

MDMA 1.4

MA Median 0.9 (0.2–23)

MA Median 2.5 (0.1–28)

AMP = amphetamine, MA = methamphetamine, MDMA = 3,4-methylenedioxymethamphetamine, HMMA = 4-hydroxy-3-methoxymethamphetamine, MDA = 3,4-methylenedioxyamphetamine, Cocaine = COC, BE = benzoylecgonine, DFC = drug-facilitated crime, CSF = cerebrospinal fluid, DCM = dichloromethane, 6-AM 6-acetylmorphine, EME = ecgonine methyl ester, SDS = sodium dodecyl sulphate, THC = D9-Tetrahydrocannabinol, THCA = 11-nor-D9-tetrahydrocannabinol-9-carboxylic acid, CBN = cannabinol, CBD = cannabidiol, mo = months, yr = years, d = day, radioimmunoassay = RIA, ELISA = enzyme linked immunosorbent assay, PDA = photodiode-array UV detection, immunoassay = IA, SPE = solid-phase extraction, LLE = liquid liquid extraction, LOD = limit of detection, LOQ = limit of quantification.

The most commonly encountered drugs in these cases were COC [10,16,23,25,26,34–38], heroin [10,16,23,39,40] and MA [24,41]. Ketamine [15], cannabis [23] and two different benzodiazepines [16] concentrations were also reported in one published paper each.

These papers clearly showed that the hair of newborn babies showed evidence of exposure from drug-using mothers (Table 1). The positive rate of hair analysis from neonates born to mothers suspected of COC abuse was around 30% [25,34]. The hair analysis positive rate was above 85% [35] for neonates born to mothers

X. Wang, O.H. Drummer / Forensic Science International 257 (2015) 458–472

positive for COC in urine. COC concentrations in the hair of neonates was reported in 4 publications detecting COC with concentrations ranging from the limit of detection (LOD), or cutoff, to 257 ng/mg, with most reports showing concentrations less than 25 ng/mg [10,23,25,37]. One report describing the highest COC concentrations in maternal hair (209 ng/mg) result did not use a hair decontamination step, hence these results may have been artificially high from surface contamination which could also have skewed the overall group results to the high end [25]. Benzoylecgonine (BE) was reported as also being present (range up to 43 ng/mg) in some of these publications and most of the other 6 publications which only reported the presence of BE [16,26,34–36,38]. The median concentration of BE in neonates was almost four times lower compared with COC (2.5 vs. 9.8 ng/mg). The extent of exposure of neonates to COC from drug-using mothers in utero was variable. However, a correlation was found between maternal COC and BE concentrations in hair and neonatal drugs concentrations in hair [25]. Of the 98 mother–neonate pairs, median COC concentration in the hair of mothers was 10-fold higher, and median BE concentrations 4-fold higher than the neonates [25]. Another publication that studied 18 mother–baby pairs reported similar conclusions [26]. There was one case where BE only (0.8–3 ng/mg) was found in the hair of the mother who had admitted to once daily use of COC, but neither COC nor BE were detected in the hair of the baby at a gestational age of 32 weeks [38]. There were 4 publications reporting of gestational heroin exposure by analysis of neonates’ hair [16,23,39,40]. Concentrations of the metabolite morphine in the hair ranged from 0.6 to 3.5 ng/mg (4 publications), while codeine was reported in one of these publications with concentration ranging from 0.4 to 41 ng/ mg. The principal metabolite of heroin, 6-acetylmorphine (6-AM) was detected in neonates of heroin-using mothers with hair concentrations up to 29 ng/mg. The corresponding concentrations of 6-AM in mothers were very similar to their babies. There was one case reporting COC and 6-AM in the hair of a 1-month-old breastfed baby with acute heroin intoxication through either breast milk or passive exposure [10]. The parents were both COC and heroin users. Hair COC concentrations in the child (17.5 ng/ mg) and his father (11.8 ng/mg) were higher than in the mother (2.5–4.4 ng/mg). 6-AM also showed a higher hair concentration in the child and the father (both are 8 ng/mg) than in the mother (0.6–0.8 ng/mg). Segmental hair analysis suggested that it is likely that more than one possible routes of exposures could have occurred. Ketamine (0.14 ng/mg) were also detected in one case from their mother’s use of ketamine earlier during pregnancy [15]. In 2 publications, MA was reported in the hair of neonates of mothers using this drug with concentrations up to 23 ng/mg [24,41]. Concentrations in the hair of these mothers were not dissimilar to their children. In another publication, a hair concentration of AMP at 1.2 ng/mg in the neonate probably resulted from maternal use of MA [16]. Two neonates sampled at birth had THC (<0.2 ng/mg) in their hair, while the mother had a mean concentration of 3 ng/mg [23]. Cannabinol and cannabidiol were also detected. Kintz [42] proposed that if the ratio concentration of the proximal segment to the concentration of the distal segment is lower than 0.5, 100% in utero contribution was considered to the final interpretation. However, the age of children should be less than 1-year old and the length of hair should be able to achieve suitable segmentation. 3.2. Likely active exposure in children There were 18 publications outlining hair concentrations of children exposed directly to drugs, either by accidental ingestion of

465

a tablet by the child or administration by a caregiver or another person. Another 4 publications suggested active exposure even though details were lacking to confirm the most likely source (Table 1). These were labeled as possible active exposure and were not included in the statistical calculations or the figures unless the results were confirmed by the analysis of blood or urine. COC was involved in 3 cases [29,43,44], although two of these may not necessarily have involved direct ingestion of COC. One child was being breastfed at 11 months old but had high urine levels of MDMA and MDA [29] and another (13-month-old infant) probably involved administration of methadone [44]. Both children were exposed to COC smoke. In one case [43], a 2-year old girl was admitted to hospital with seizures and high fever who became unconscious following suspected administration of COC. She had hair COC concentrations of 6–76 ng/mg throughout her 15 cm length hair, whereas her mother had a hair COC concentration of 0.3 ng/mg. The highest concentration (76 ng/mg) was at 6– 7 cm from root end whereas the first 1-cm segment had a concentration of 7.6 ng/mg. There were no reported cases showing hair concentrations of children who had been given amphetamines; however, there were several in which opioids were involved. The most common opioid was methadone with several reports where methadone was given to children of varying ages although these tended to be under 2 years of age [20,44–47]. In one case, segmental hair analysis (5 cm in 4 segments) was performed on a 5-month-old child [45] with concentrations of methadone and EDDP of 1–2.3 ng/mg and <0.2 ng/mg in the first 3 cm (from the root) and 21 ng/mg and 5.2 ng/mg in the distal segment (4–5 cm), suggesting in utero exposure. Most cases reported methadone and EDDP concentrations in the range of 0.05–3 (median 0.4) and <0.01–0.8 (median 0.04) ng/mg hair, respectively. Of the 12 cases reporting methadone exposure, 6 children died of suspected methadone poisoning with hair concentrations of methadone in the range of 0.4–2.3 ng/mg [20,45–47]. However, the concentrations of methadone across all segments were consistently low could be indicative of external contamination; it is possible that methadone could have derived from the environment including sweat of caregivers or body fluids at the post mortem. The homogenous low concentrations could also possibly be because the methadone administration was acute or the deaths were caused by other causes [20]. Six children who survived methadone exposure had hair concentrations of methadone ranging from 0.05 to 3 ng/mg [20,44,47]. One publication reported a 2½-year-old child admitted to hospital following a suspected overdose of codeine, although 6-AM was detected in hair taken 2 months later (level not given) [48]. Another case reported coercive administration of heroin to a 5year-old child [49]. 6-AM and morphine were detected in hair in the range of 0.2–0.6 ng/mg and 0.1–0.3 ng/mg, respectively. The hair of a 3-year-old child positive for opiate in urine had a head hair morphine concentration of >0.2 ng/mg and a higher level of 6-AM (5 ng/mg). Even 2 months later, 6-AM was still at 2.9 ng/ mg in whole-length (about 4 cm) hair [2]. Tramadol was involved in 3 cases with the concentration ranging from 0.06 to 2.3 ng/mg and only one case reported the presence of metabolite O-desmethyl-tramadol in several segments in the concentration range 0.03–0.2 ng/mg [47,50,51]. Two children that were sedated by their stepmother with trimeprazine gave hair concentrations ranging from 0.02 to 0.3 g/ mg analyzed 2 months after the likely administration [52]. Trimeprazine was detected in whole-length hair of one child following suspicion of repeated exposure during the previous 5 months. Trimeprazine was present in the first 6 cm (from the root) and negative in the next 3 cm in the other child’s hair.

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Benzodiazepines have also been used to sedate children and their presence has been detected in several cases [13,50,53,54]. These included alprazolam (0.002–0.005 ng/mg) [13,54], bromazepam (0.7 ng/mg) [53] and temazepam (0.002–0.03 ng/mg) [50]. Diphenhydramine (33–39 pg/mg) [55] and scopolamine (0.3– 1.1 pg/mg) were also reported in the hair of children exposed to active ingestion of detected drugs [56].

The hair of children also tested positive to THC when exposed to families using cannabis. Hair THC concentrations have ranged up to 0.7 ng/mg [18,57,64]. THC was detected (0.2–0.9 ng/mg) in the hair of a 9-month-old child death in which the mother had smoked cannabis during her pregnancy [51]. The acid precursor to THC (THCA-A) was also detected in many of these children with levels up to 1 ng/mg [64,65].

3.3. Likely passive exposure in children

3.4. Statistical comparisons

There were 20 publications where positive hair results in children were suspected as having been entirely caused by passive exposure from the environment (Table 1). There were 8 publications [18,27,57–62] reporting hair concentrations in children in COC-using homes. The hair of these children had COC concentrations of up to 75 ng/mg, together with BE. In one study of 16 children from 1 to 14 years old living in a COC-using environment the mean hair concentration of COC was 2.4 ng/mg, the same as their COC-using mothers. BE showed a similar mean and range. BE/COC ratio was in the range of 0–0.7, with a median concentration of 0.14 ng/mg [60]. Hair samples collected from children of various ages (n = 391, 1–14 years) exposed passively to drugs were analyzed for the presence of opiates, COC, amphetamines and cannabis using mass spectrometry [61]. The positive rate ranged from 25% to 28% of children; predominately COC. Median COC and BE concentrations ranged from 0.3 to 1.6 and 0.2 to 0.8 ng/mg. THC and MDMA were also detected in some of the children. Similarly, children living in a facility where MA was manufactured had hair concentrations of up to 131 ng/mg, with a mean of 1.4 and 7 ng/mg, from two studies of 89 and 52 exposed children [28,63].

Published data was compared through the use of Box and Whisker plots to enable a more ready visualization of hair concentrations deriving from in utero/breast milk exposure to likely passive and active exposures. These are shown in Figs. 1–3. Table 2 summarizes the medians and ranges for selected drugs by likely exposure route. Fig. 1 shows the distribution of COC and BE between the in utero exposure, active exposure and passive exposure groups. In some cases, hair concentrations of COC and BE from in utero exposure were higher than those from passive exposure. Since there was only one case of active exposure, no conclusions can be made from this case even though the concentrations from several segments were higher than those seen in the passively exposed group. The statistical comparison by Newman–Keuls test shows that there were no significant differences between hair concentrations of COC and BE in utero exposure and passive exposure groups (p = 0.15). The distribution of morphine, codeine and 6-AM between the in utero exposure, active exposure and passive exposure to heroin or codeine were shown in Fig. 2. The morphine, codeine and 6-AM showed much higher hair concentrations in utero compared to both active and passive exposure (Fig. 2). However, no differences

Fig. 1. Box and Whisker Plots showing median, quartile and ranges for hair concentrations in children positive to cocaine (COC) and its metabolite benzoylecgonine (BE) in circumstances of in utero (A), likely active (B) and likely passive exposures (C).

X. Wang, O.H. Drummer / Forensic Science International 257 (2015) 458–472

467

Fig. 2. Box and Whisker Plots showing median, quartile and ranges for hair concentrations in children positive to methadone or tramadol in circumstances of in utero (A), likely active (B) and likely passive (C) exposures.

Fig. 3. Box and Whisker Plots showing median, quartile and ranges for hair concentrations in children positive to morphine, 6-AM or codeine in circumstances of in utero (A), likely active (B) and likely passive (C) exposures.

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468

Table 2 Comparison of drug concentrations in hair for different drug incorporation routes. Compounds

MA AMP MDMA Methadone EDDP Tramadol Cocaine BE Morphine 6-AM Codeine

In utero exposure

Likely active exposure

Likely passive exposure

No. cases

Median and range (ng/mg)

No. cases

Median and range (ng/mg)

No. cases

Median and range (ng/mg)

11 1 0 0 0 0 534 643 13 3 8

0–23 1.2 – – – – 9.8 (0–257) 2.5 (<0.1–43) 2.4 (1.7–3.5) 9 (<2–29) 8.7 (0.4–41)

0 0 0 12 11 3 1 1 2 2 1

– – – 0.44 (0.05–21) 0.04 (<0.01–5) 0.06–2.3 25 (6–76) 13 (2–36) 0.2 (0.1–0.3) 0.45 (0.2–5) 0.3 (0.09–0.5)

137 89 15 20 12 0 194 193 14 24 14

0.1–131 0.02–4.8 0.06–8.6 0.38 (0.007–2.2) 0.01 (0–0.2) – 0.6 (0–75) 0.2 (0–7) 0.1 (0.01–1.3) 0.36 (0.01–11) 0.17 (0.006–0.44)

[24,41] [16]

[10,23,25] [10,16,23,25,26,34–36] [10,23,39,40] [10,23,39] [10,23,39]

[20,45–47] [20,45–47] [42,47,50] [70] [70] [2,49] [2,49] [55]

[24,28,41,63] [28,57,63] [28,42,57] [18,42,57] [18,42,57] [18,27,57,59–62] [16,18,27,57–62] [18,57,61] [18,57,61] [18,57,61]

Note: When more than one segment was analyzed in a case, the number of cases was counted as one case.

were found when comparing concentrations of these compounds from likely active exposure and passive exposures, although there were only very few cases of likely active exposures (n = 2 morphine, n = 1 codeine and n = 2 6-AM). In contrast, methadone hair concentrations were not distinguishable when concentrations obtained from likely passive and active groups were compared (Fig. 3). There were 3 cases involving tramadol but these were all likely active exposures. The concentration range for the 5 publications reporting hair levels of MA in children are shown in Fig. 4. One derived from in utero exposure paired with the mothers’ hair that had no decontamination procedure, and four cases involving likely passive exposure in situations where children were living in ‘‘meth’’ labs all of which were decontaminated. There was no obvious difference in the hair concentrations of MA, although again a wide range of concentrations were reported.

4. Discussion 4.1. General comments Hair grows in a cycle consists of the anagen (active growing), catagen (transition) and telogen (resting) phase [5,66]. Hair follicle buds begin around 10th week of the development and the entire scalp is covered on the human fetus with anagen phase hair by the 20th week. The initial catagen/telogen phase associated with the first cycle of these follicles occurs between the 24th and 28th weeks of development [67]. After delivery, hair grows asynchronously during the first 3–4 months and hair loss will be observed during the first 6 months. The normal rate of hair growth (1 cm/ month such as adults) starts from one year after delivery [42]. Therefore, it is hard to define the detection window in the hair of infants who were in utero exposure. Graham et al. [36] reported

Fig. 4. Box and Whisker Plots showing median, quartile and ranges for the five publications describing hair results in children positive to methamphetamine (MA).

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that all seven neonates, two of four infants (2.5- to 3.5-month-old) and none of three children (1–3 years old), of admitted cocaine users during pregnancy by hair analysis. Moreover, the older the children are, the more external contamination could occur. Most drugs of abuse are capable of crossing the placenta to incorporate in the hair of the fetus in the case of maternal consumption. Therefore, hair analysis of neonates reflects exposure during the third trimester of gestation [36,68,69]. Incorporation of drugs from amniotic fluid is not considered as an issue with neonate hair in the context of the diagnosis of intrauterine drug exposure [9,34]. However, the interpretation of hair results with respect to systemic or only external exposure is particularly important in case of children for realistic assessment of the toxic health risk [14]. However, the disadvantage of hair testing for neonates is that many newborns are born with hair of varying lengths and the amount of neonatal hair is often insufficient for analysis, or no hair at all is present on the scalp. In utero exposure to drugs of abuse can cause neonates to suffer from a withdrawal syndrome after birth [39] as well as have adverse consequences for the development of the fetus leading to stillbirths, premature births [40] and mental, physical and neurocognitive deficiencies of children during later stages in life [9,69]. Hence, determination of maternal drug use history is helpful to manage withdrawal symptoms and aid the mother in caring for her newborn child [69]. There were surprising differences in the distribution of hair concentrations across the three main exposure mechanisms depending on which drug was detected. 4.2. Cocaine Almost all children positive for COC and BE were from likely passive exposure or from exposure in utero. The concentrations of COC and BE in the hair of children were in the range of 0–75 ng/mg and 0–7 ng/mg, respectively with medians of 0.6 and 0.2 ng/mg. There were overall differences in the median of reported hair concentrations for COC with 9.8 ng/mg for in utero exposure and 0.6 ng/mg for likely passive exposure although the ranges were very wide in both groups. The one actively exposed case was much higher at 25 ng/mg across several segments [70]. It should not be assumed that this case is necessarily representative of any other future case in which a child had exposure to clinically significant dose(s) of drug. By way of comparison, cocaine concentrations in the hair of adult cocaine users ranges up to over 200 ng/mg; however, median concentrations in adult Caucasians reporting use of the drug daily, 2–4 times weekly or 1–2 times monthly, were 40, 19 and 4 ng/mg, respectively. Adults of African descent showed corresponding median COC concentrations of 61, 33 and 15 ng/mg [71]. The measurement of the hydrolytic metabolite BE did not seem to assist the interpretation of active versus passive exposure since concentrations were always a variable fraction of COC. For example, the one paper presenting in utero exposure had a mean BE/COC ratio of 0.5 [25], several papers describing likely passive exposure with BE/COC gave ratios ranging from 0.03 to 1.6 [18,27,29,44,57,59–62] and only one publication with possible active exposure in 2-year old showing ratios of 0.25–0.98 [43]. Meanwhile BE/COC ratio 0.05 together with the presence of 0.05 ng/mg BE and 0.5 ng/mg COC was proposed as one criteria for a positive COC hair test [72]. BE/COC ratios ranging from 0.03 to 1.6 in the passive exposure group were in agreement with this criteria. In adult users of cocaine, the mean BE/COC ratio is about 14% in Caucasians and 12% in persons of African descent, although individual ratios showed substantial variation as reflected by high coefficient of variations of almost 50% of actual concentrations [71].

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The routes of administration for COC are diverse, with the most common routes snorting or inhalation of crack COC smoke, but also there are other routes such as oral, smoking, intravenous or even rectal [58]. Since the detection time of COC is short in blood (few hours) and urine (few days), hair has proven a common specimen to determine exposure. Washing steps are applied to minimize the possibility of external contamination causing false positive results, providing the wash is also analyzed [3,73]. However, washing is not usually able to discriminate between active exposure and external contamination [74,75]. COC and BE were found in the hair in high concentrations from in vitro experiments when hair is artificially exposed to manual contamination after one day of exposure (and after several weeks) irrespective of the washing procedure used [75,76], meanwhile BE/ratios were higher than 0.05. Therefore, the use of BE/COC ratio is unlikely to be useful to discriminate active users from contaminated (so-called passively exposed) subjects. The variation in uptake and/or retention of drugs in hair is also demonstrated by nearly identical concentrations of COC in hair of monozygotic twins while dizygotic twins had a large concentration variability [69]. While the presence of non-hydrolytic metabolites such as cocaethylene and norcocaine (NOR) can be used to confirm active exposure to drugs of abuse. However, these metabolites may also be present in the COC itself [77,78]. Pragst et al. [57] gave additional information of NOR/COC ratios to support the interpretation. Nevertheless, NOR/COC ratios did not effectively discriminate between systemic intake and external contamination of hair [72]. Since there was only one case of likely active exposure, it is unclear whether hair concentrations of COC and/or BE alone could prove active exposure as distinct from exposure from their environments. Unfortunately, in none of the passive exposure cases were any details provided of actual or estimated exposures from the smoke of caregivers or other forms of environmental exposure. Hence, it is not possible to simply associate a high concentration in hair with necessarily high, let alone regular exposures. 4.3. Amphetamine-type stimulants MA is the next most common drug of concern given its high addiction potential and ability to cross the placenta [24,41]. This ability to enter the fetal circulation is reflected by the similar median concentrations of MA in hair of neonates (1.6 ng/mg) and the maternal hair (1.8 ng/mg) [41]. Infants are normally exposed to amphetamines from environmental passive exposure from ‘‘meth home labs’’ for MA and MDMA manufacture. Accordingly, infants living in these houses are at potentially high health risks. Three infants from ‘‘meth home labs’’ were positive to hair for MA (0.3–4.5 ng/mg) as well as AMP (0.1 ng/mg) and MDMA (0.1–0.25 ng/mg) [28]. Children from clandestine laboratories also have a high positive rate for amphetamines probably from external contamination such as airborne deposition onto hair, or from handling contaminated surfaces. The positive rate is from 62% to 75% for MA, 55% to 65% for AMP [28,30,63,79] and 12% for MDMA [28]. The concentrations in hair of MA, AMP and MDMA were reported in the range of 0.1– 131 ng/mg, 0.02–4.8 ng/mg and 0.06–2.3 ng/mg [57,63,80]. MDMA was detected in the hair of a 14 month old living in a ‘‘meth lab’’ house at 8.6 ng/mg, with no metabolites detected [80]. However, in this report hair had not been washed, hence the possibility of some significant contamination on the hair cannot be excluded. There were no cases reported of active administration of an amphetamine to a child, hence it is not possible to know what concentrations are achieved in these age groups. In a Korean study, active MA use in adults led to MA and AMP concentrations in hair up to about 50 and 4 ng/mg, with medians of about 2 and 0.75 ng/mg,

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respectively [81]. In a British study, hair concentrations ranged from 0.6 to 32 ng/mg (median 2.6) [82]. 4.4. Heroin Rossi et al. [49] reported coercive heroin administration to a child with the concentrations of 6-AM and morphine ranging from 0.2 to 0.6 ng/mg and from 0.1 to 0.3 ng/mg, respectively. The concentrations of 6-AM and morphine in the hair of children who were passively exposed were in the range of 0.01–11 and 0.01– 1.32 ng/mg, respectively. 4.5. Opiates and opioids Kintz et al. [56] reported 3 children who were allegedly given Feminax tablets which contains paracetamol, codeine, caffeine and scopolamine. The concentrations of codeine in the hair of these 3 children ranged from 0.09 to 0.5 ng/mg, which were similar to the concentrations of codeine (0.01–0.4 ng/mg) in the hair of children who were exposed passively. Methadone is a synthetic opioid largely used for the maintenance treatment of opioid dependence and withdrawal [44–46]. Methadone is metabolized by demethylation to its main metabolite EDDP. Two cases [45,46] were reported involving infants who had died from methadone poisoning. The concentrations of methadone and EDDP in hair of infants were in the range of 0.9– 21 ng/mg and 0.15–5 ng/mg, whereas Tournel et al. [46] reported low levels of methadone (0.9–1.8 ng/mg) in hair. Methadone and EDDP in the hair of toddlers was reported by several authors [20,44,45,47] with the concentrations ranging from 0.13 to 3 ng/mg and <0.01 to 0.8 ng/mg. In these cases, either parents intentionally administrated methadone to children to sedate them or children were exposed accidentally to oral methadone. EDDP in principle can be used as evidence for systemic exposure by methadone, but that this assumption may also be erroneous because of hair contamination by sweat of the mother since patients in methadone maintenance treatment tend to sweat [57]. The concentrations of methadone and EDDP in the hair of children passively exposed to methadone were reported in the range of 0.007–2.2 ng/mg and 0.01–0.07 ng/mg, respectively [18,51,57]. This is in contrast to methadone concentrations in the hair of regular adult users that range up to about 200 ng/mg (median 11). The methadone cases support the notion that hair concentrations of drug, even when actual administration to a child has been confirmed, do not correspond to what is present in the body causing harm. The presence of steadily increasing concentrations in hair segments toward the distal end has been suggested as most likely to be caused by in utero exposure, particularly in children under 1-year old [42]. Tramadol was detected in a child who repeatedly was given the drug with hair concentrations in the range of 1.5–2.3 ng/mg [47]. In another case of active exposure to tramadol, hair concentrations ranged from 0.2 to 2.3 ng/mg in four segments over 6 cm with the highest concentration in the most distal segment. In this case, femoral blood contained detectable amounts of tramadol and the cause of death was given as tramadol toxicity [51]. Tramadol was found throughout several 1-cm segments from 0.06 to 2 ng/mg in a 9-year-old boy who had been kidnapped and imprisoned for about 24 days. Tramadol was possibly given to him on more than one occasion during this period [50]. In the same case, dihydrocodeine (0.01–0.09 ng/mg) was also detected in the hair. 4.6. Cannabis Cannabis (hashish and marijuana) is usually consumed by smoking which often causes an external contamination in hair

through airborne D9-tetrahydrocannabinol (THC), cannabinol (CBN) and cannabidiol (CBD) which are present in cannabis smoke. The acid metabolite of THC, 11-nor-D9-tetrahydrocannabinol-9-carboxylic acid (THCA) is a market to indicate THC had been absorbed, while the non-psychoactive biogenetic precursor of THC (THCA-A) is a marker for external contamination [64,65]. THCA was successfully used to distinguish active consumption and passive exposure in a contaminated environment in a couple living together [65]. THCA showed a high concentration (>6.6 pg/ mg) in the subject who admitted smoking cannabis and a negative result (
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reason why there is no good evidence that hair concentrations will necessarily be elevated, as seen from the methadone data. The absence of cases involving active administration of amphetamines and only one case for COC means that no conclusions can be drawn from these drugs, although it is likely that if acute exposure cases are eventually reported there may not be clear elevations of drug concentrations in the hair of children. In conclusion, it is clear that hair concentrations alone cannot discriminate from the various exposure routes for drugs of abuse, except in cases where unusually high concentrations have occurred or individual segments show large changes between segments, and the hair has had an appropriate decontamination procedure performed. Other information will be needed before any conclusion over the source or frequency of exposure can be determined. Since hair analysis for children is complicated, there is an obvious need of guidelines to improve the quality and consistency of interpretations

[19]

[20] [21]

[22] [23]

[24]

[25]

[26]

Acknowledgments [27]

The authors gratefully acknowledge the assistance by Professors Sys Stybe Johansen and Kristian Linnet to permit one of the authors (WX) to undertake a training placement at the Victorian Institute of Forensic Medicine and the Department of Forensic Medicine at Monash University (February to May, 2015) while enrolled as a post-graduate student at the University of Copenhagen. The support of the China Scholarship Council for providing financial support for WX is gratefully appreciated. References [1] R. Agius, The 18th congress of the Society of Hair Testing (SoHT) in Geneva, Drug Test. Anal. 6 (S1) (2014) 1. [2] N. Fucci, G. Vetrugno, N. De Giovanni, Drugs of abuse in hair: application in pediatric patients, Ther. Drug Monit. 35 (3) (2013) 411–413. [3] S. Vogliardi, M. Tucci, G. Stocchero, S.D. Ferrara, D. Favretto, Sample preparation methods for determination of drugs of abuse in hair samples: a review, Anal. Chim. Acta 857 (2015) 1–27. [4] P. Kintz, Segmental hair analysis can demonstrate external contamination in postmortem cases, Forensic Sci. Int. 215 (1–3) (2012) 73–76. [5] S. Karen, K. Robert, Drug Incorporation into Hair in Analytical and Practical Aspects of Drug Testing in Hair, CRC Press, Boca Raton, 2006, pp. 1–23. [6] T. Baciu, F. Borrull, C. Aguilar, M. Calull, Recent trends in analytical methods and separation techniques for drugs of abuse in hair, Anal. Chim. Acta 856 (0) (2015) 1–26. [7] G.L. Henderson, Mechanisms of drug incorporation into hair, Forensic Sci. Int. 63 (1–3) (1993) 19–29. [8] Y. Gaillard, G. Pepin, Testing hair for pharmaceuticals, J. Chromatogr. B Biomed. Sci. Appl. 733 (1–2) (1999) 231–246. [9] G.-A.O. Lozano, J.O. Vall, R. de la Torre, G. Scaravelli, S. Pichini, Biological matrices for the evaluation of in utero exposure to drugs of abuse, Ther. Drug Monit. 29 (6) (2007) 711–734. [10] X. Joya, B. Friguls, M. Simo, E. Civit, R. de la Torre, A. Palomeque, O. Vall, S. Pichini, O. Garcia-Algar, Acute heroin intoxication in a baby chronically exposed to cocaine and heroin: a case report, J. Med. Case Rep. 5 (2011) 288. [11] R.W. Reid, F.L. O’Connor, A.G. Deakin, D.M. Ivery, J.W. Crayton, Cocaine metabolites in human graying hair: pigmentary relationship, Clin. Toxicol. 34 (6) (1996) 685–690. [12] D.E. Rollins, D.G. Wilkins, G.G. Krueger, M.P. Augsburger, A. Mizuno, C. O’Neal, C.R. Borges, M.H. Slawson, The effect of hair color on the incorporation of codeine into human hair, J. Anal. Toxicol. 27 (8) (2003) 545–551. [13] P. Kintz, The specific problem of children and old people in drug-facilitated crime cases, in: Toxicological Aspects of Drug-Facilitated Crimes, 2014, 255–281. [14] P. Kintz, Interpretation of hair findings in children: about a case involving carbamazepine, Drug Test. Anal. 6 (Suppl. 1) (2014) 2–4. [15] P.-H. Su, Y.-Z. Chang, J.-Y. Chen, Infant with in utero ketamine exposure: quantitative measurement of residual dosage in hair, Pediatr. Neonatol. 51 (5) (2010) 279–284. [16] P. Kintz, P. Mangin, Determination of gestational opiate, nicotine, benzodiazepine, cocaine and amphetamine exposure by hair analysis, J. Forensic Sci. Soc. 33 (3) (1993) 139–142. [17] K. Aleksa, P. Walasek, N. Fulga, B. Kapur, J. Gareri, G. Koren, Simultaneous detection of seventeen drugs of abuse and metabolites in hair using solid phase micro extraction (SPME) with GC/MS, Forensic Sci. Int. 218 (1–3) (2012) 31–36. [18] S. Pichini, O. Garcia-Algar, A. Alvarez, M. Gottardi, E. Marchei, F. Svaizer, M. Pellegrini, M.C. Rotolo, R. Pacifici, Assessment of unsuspected exposure to drugs of

[28]

[29]

[30]

[31]

[32] [33] [34] [35]

[36]

[37] [38]

[39]

[40] [41]

[42] [43]

[44]

[45]

[46]

[47]

[48] [49] [50]

471

abuse in children from a Mediterranean city by hair testing, Int. J. Environ. Res. Public Health 11 (2) (2014) 2288–2298. D. Lewis, C. Moore, P. Morrissey, J. Leikin, Determination of drug exposure using hair: application to child protective cases, Forensic Sci. Int. 84 (1–3) (1997) 123– 128. P. Kintz, J. Evans, M. Villain, V. Cirimele, Interpretation of hair findings in children after methadone poisoning, Forensic Sci. Int. 196 (1–3) (2010) 51–54. C. Bartsch, M. Riße, H. Schu¨tz, N. Weigand, G. Weiler, Munchausen syndrome by proxy (MSBP): an extreme form of child abuse with a special forensic challenge, Forensic Sci. Int. 137 (2–3) (2003) 147–151. A. Boroda, W. Gray, Hair analysis for drugs in child abuse, J. R. Soc. Med. 98 (7) (2005) 318–319. E. Vinner, J. Vignau, D. Thibault, X. Codaccioni, C. Brassart, L. Humbert, M. Lhermitte, Neonatal hair analysis contribution to establishing a gestational drug exposure profile and predicting a withdrawal syndrome, Ther. Drug Monit. 25 (4) (2003) 421–432. F. Garcia-Bournissen, B. Rokach, T. Karaskov, J. Gareri, G. Koren, Detection of stimulant drugs of abuse in maternal and neonatal hair, Forensic Sci. Med. Pathol. 3 (2) (2007) 115–118. F. Garcia-Bournissen, B. Rokach, T. Karaskov, G. Koren, Cocaine detection in maternal and neonatal hair: implications to fetal toxicology, Ther. Drug Monit. 29 (1) (2007) 71–76. L.D. Katikaneni, F.R. Salle, T.C. Hulsey, Neonatal hair analysis for benzoylecgonine: a sensitive and semiquantitative biological marker for chronic gestational cocaine exposure, Neonatology 81 (1) (2002) 29–37. F. Garcia-Bournissen, M. Nesterenko, T. Karaskov, G. Koren, Passive environmental exposure to cocaine in Canadian children, Paediatr. Drugs 11 (1) (2009) 30–32. M.S. Castaneto, A.J. Barnes, K.B. Scheidweiler, M. Schaffer, K.K. Rogers, D. Stewart, M.A. Huestis, Identifying methamphetamine exposure in children, Ther. Drug Monit. 35 (6) (2013) 823–830. O. Garcia-Algar, N. Lopez, M. Bonet, M. Pellegrini, E. Marchei, S. Pichini, 3,4methylenedioxymethamphetamine (MDMA) intoxication in an infant chronically exposed to cocaine, Ther. Drug Monit. 27 (4) (2005) 409–411. K. Farst, J.A. Reading Meyer, T. Mac Bird, L. James, J.M. Robbins, Hair drug testing of children suspected of exposure to the manufacture of methamphetamine, J. Forensic Leg. Med. 18 (3) (2011) 110–114. M. Moller, J. Gareri, G. Koren, A review of substance abuse monitoring in a social services context: a primer for child protection workers, J. Popul. Ther. Clin. Pharmacol. 17 (1) (2010) e177–e193. hhttp://www.r-project.org/i, (accessed 20.06.15). hhttp://www.rstudio.com/i, (accessed 20.06.15). F. Ursitti, J. Klein, G. Koren, Clinical utilization of the neonatal hair test for cocaine: a four-year experience in Toronto, Neonatology 72 (6) (1997) 345–351. F.R. Sallee, L.P. Katikaneni, P.D. McArthur, H.M. Ibrahim, L. Nesbitt, G. Sethuraman, Head growth in cocaine-exposed infants: relationship to neonate hair level, J. Dev. Behav. Pediatr. 16 (2) (1995) 77–81. K. Graham, G. Koren, J. Klein, J. Schneiderman, M. Greenwald, Determination of gestational cocaine exposure by hair analysis, J. Am. Med. Assoc. 262 (23) (1989) 3328–3330. J. Klein, T. Karaskov, G. Koren, Clinical applications of hair testing for drugs of abuse—the Canadian experience, Forensic Sci. Int. 107 (1–3) (2000) 281–288. S. Potter, J. Klein, G. Valiante, D.M. Stack, A. Papageorgiou, W. Stott, D. Lewis, G. Koren, P.R. Zelazo, Maternal cocaine use without evidence of fetal exposure, J. Pediatr. 125 (4) (1994) 652–654. E. Vinner, J. Vignau, D. Thibault, X. Codaccioni, C. Brassart, L. Humbert, M. Lhermitte, Hair analysis of opiates in mothers and newborns for evaluating opiate exposure during pregnancy, Forensic Sci. Int. 133 (1–2) (2003) 57–62. P. Kintz, P. Mangin, Evidence of gestational heroin or nicotine exposure by analysis of fetal hair, Forensic Sci. Int. 63 (1–3) (1993) 99–104. F. Garcia-Bournissen, B. Rokach, T. Karaskov, G. Koren, Methamphetamine detection in maternal and neonatal hair: implications for fetal safety, Arch. Dis. Child. Fetal Neonatal Ed. 92 (5) (2007) F351–F355. P. Kintz, Contribution of in utero drug exposure when interpreting hair results in young children, Forensic Sci. Int. 249 (0) (2015) 314–317. N. Taguchi, M. Mian, M. Shouldice, T. Karaskov, J. Gareri, I. Nulman, Z.H. Verjee, G. Koren, Chronic cocaine exposure in a toddler revealed by hair test, Clin. Pediatr. (Phila.) 46 (3) (2007) 272–275. E. Papaseit, E. Corrales, C. Stramesi, O. Vall, A. Palomeque, O. Garcia-Algar, Postnatal methadone withdrawal syndrome: hair analysis for detecting chronic exposure, Acta Pædiatr. 99 (2) (2010) 162–163. P. Kintz, M. Villain, V. Dumestre-Toulet, B. Capolaghi, V. Cirimele, Methadone as a chemical weapon: two fatal cases involving babies, Ther. Drug Monit. 27 (6) (2005) 741–743. G. Tournel, J. Pollard, L. Humbert, J.F. Wiart, V. Hedouin, D. Allorge, Use of hair testing to determine methadone exposure in pediatric deaths, J. Forensic Sci. 59 (5) (2014) 1436–1440. C. Chatterton, K. Turner, N. Klinger, M. Etter, M. Duez, V. Cirimele, Interpretation of pharmaceutical drug concentrations in young children’s head hair, J. Forensic Sci. 59 (1) (2014) 281–286. C. Staub, Hair analysis: its importance for the diagnosis of poisoning associated with opiate addiction, Forensic Sci. Int. 63 (1–3) (1993) 69–75. S. Strano Rossi, C. Offidani, M. Chiarotti, Application of hair analysis to document coercive heroin administration to a child, J. Anal. Toxicol. 22 (1) (1998) 75–77. C. Chatterton, P. Kintz, Hair analysis to demonstrate administration of amitriptyline, temazepam, tramadol and dihydrocodeine to a child in a case of kidnap and false imprisonment, J. Forensic Leg. Med. 23 (2014) 26–31.

472

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[51] P. Kintz, Contribution of in utero drug exposure when interpreting hair results in young children, Forensic Sci. Int. 249 (2015) 314–317. [52] P. Kintz, M. Villain, V. Cirimele, Determination of trimeprazine-facilitated sedation in children by hair analysis, J. Anal. Toxicol. 30 (6) (2006) 400–402. [53] Y. Gaillard, R. Breuil, C. Doche, L. Romeuf, C. Lemeur, J.M. Prevosto, L. Fanton, Detection of amitriptyline, nortriptyline and bromazepam in liver CSF and hair in the homicidal poisoning of a one-month-old girl autopsied 8 months after death, Forensic Sci. Int. 207 (1–3) (2011) e16–e18. [54] P. Kintz, M. Villain, M. Cheze, G. Pepin, Identification of alprazolam in hair in two cases of drug-facilitated incidents, Forensic Sci. Int. 153 (2–3) (2005) 222–226. [55] P. Kintz, J. Evans, M. Villain, G. Salquebre, V. Cirimele, Hair analysis for diphenhydramine after surreptitious administration to a child, Forensic Sci. Int. 173 (2– 3) (2007) 171–174. [56] P. Kintz, M. Villain, J. Evans, M.L. Pujol, G. Salquebre, V. Cirimele, A case of abuse in which children were forced to take tablets containing scopolamine: segmental analysis of hair for scopolamine by ultra performance liquid chromatographytandem mass spectrometry, Forensic Toxicol. 25 (1) (2007) 49–52. [57] F. Pragst, S. Broecker, M. Hastedt, S. Herre, H. Andresen-Streichert, H. Sachs, M. Tsokos, Methadone and illegal drugs in hair from children with parents in maintenance treatment or suspected for drug abuse in a German community, Ther. Drug Monit. 35 (6) (2013) 737–752. [58] E. Papaseit, X. Joya, M. Velasco, E. Civit, P. Mota, M. Bertran, O. Vall, O. GarciaAlgar, Hair analysis following chronic smoked-drugs-of-abuse exposure in adults and their toddler: a case report, J. Med. Case Rep. 5 (2011) 570. [59] F. De Giorgio, S.S. Rossi, J. Rainio, M. Chiarotti, Cocaine found in child’s hair due to environmental exposure? Int. J. Leg. Med. 118 (5) (2004) 310–312. [60] F.P. Smith, D.A. Kidwell, Cocaine in hair, saliva, skin swabs, and urine of cocaine users’ children, Forensic Sci. Int. 83 (3) (1996) 179–189. [61] S. Pichini, O. Garcia-Algar, A.T. Alvarez, M. Mercadal, C. Mortali, M. Gottardi, F. Svaizer, R. Pacifici, Pediatric exposure to drugs of abuse by hair testing: monitoring 15 years of evolution in Spain, Int. J. Environ. Res. Public Health 11 (8) (2014) 8267–8275. [62] X. Joya, E. Papaseit, E. Civit, M. Pellegrini, O. Vall, O. Garcia-Algar, G. Scaravelli, S. Pichini, Unsuspected exposure to cocaine in preschool children from a Mediterranean city detected by hair analysis, Ther. Drug Monit. 31 (3) (2009) 391–395. [63] T. Bassindale, Quantitative analysis of methamphetamine in hair of children removed from clandestine laboratories–evidence of passive exposure? Forensic Sci. Int. 219 (1–3) (2012) 179–182. [64] B. Moosmann, N. Roth, M. Hastedt, A. Jacobsen-Bauer, F. Pragst, V. Auwarter, Cannabinoid findings in children hair—what do they really tell us? An assessment in the light of three different analytical methods with focus on interpretation of Delta9-tetrahydrocannabinolic acid A concentrations, Drug Test. Anal. 7 (5) (2014) 349–357. [65] M. Uhl, H. Sachs, Cannabinoids in hair: strategy to prove marijuana/hashish consumption, Forensic Sci. Int. 145 (2–3) (2004) 143–147. [66] F. Pragst, M.A. Balikova, State of the art in hair analysis for detection of drug and alcohol abuse, Clin. Chim. Acta 370 (1–2) (2006) 17–49. [67] J. Gareri, G. Koren, Prenatal hair development: implications for drug exposure determination, Forensic Sci. Int. 196 (1–3) (2010) 27–31. [68] G.A.A. Cooper, R. Kronstrand, P. Kintz, Society of Hair Testing guidelines for drug testing in hair, Forensic Sci. Int. 218 (1–3) (2012) 20–24.

[69] T. Gray, M. Huestis, Bioanalytical procedures for monitoring in utero drug exposure, Anal. Bioanal. Chem. 388 (7) (2007) 1455–1465. [70] N. Taguchi, M. Mian, M. Shouldice, T. Karaskov, J. Gareri, I. Nulman, Z.H. Verjee, G. Koren, Chronic cocaine exposure in a toddler revealed by hair test, Clin. Pediatr. 46 (3) (2007) 272–275. [71] C. Vignali, C. Stramesi, M. Vecchio, A. Groppi, Hair testing and self-report of cocaine use, Forensic Sci. Int. 215 (1–3) (2012) 77–80. [72] J.D. Ropero-Miller, M.A. Huestis, P.R. Stout, Cocaine analytes in human hair: evaluation of concentration ratios in different cocaine sources, drug-user populations and surface-contaminated specimens, J. Anal. Toxicol. 36 (6) (2012) 390– 398. [73] L. Tsanaclis, J.F.C. Wicks, Differentiation between drug use and environmental contamination when testing for drugs in hair, Forensic Sci. Int. 176 (1) (2008) 19–22. [74] P.R. Stout, J.D. Ropero-Miller, M.R. Baylor, J.M. Mitchell, External contamination of hair with cocaine: evaluation of external cocaine contamination and development of performance-testing materials, J. Anal. Toxicol. 30 (8) (2006) 490–500. [75] G. Romano, N. Barbera, I. Lombardo, Hair testing for drugs of abuse: evaluation of external cocaine contamination and risk of false positives, Forensic Sci. Int. 123 (2–3) (2001) 119–129. [76] Ropero-Miller, J.D., Stout, P.R., International, R., and U.S.o. America, Analysis of cocaine analytes in human hair: evaluation of concentration ratios in different hair types, cocaine sources, drug-user populations, and surface-contaminated specimens, NIJ Final Report. Document, (22553), (2009). [77] J.F. Casale, J.M. Moore, An in-depth analysis of pharmaceutical cocaine: cocaethylene and other impurities, J. Pharm. Sci. 83 (8) (1994) 1186. [78] J.F. Casale, Cocaethylene as a component in illicit cocaine, J. Anal. Toxicol. 31 (3) (2007) 170–171. [79] M.J.N. Mecham, Unintentional victims: development of a protocol for the care of children exposed to chemicals at methamphetamine laboratories, Pediatr. Emerg. Care 18 (4) (2002) 327–332. [80] F. Garcia-Bournissen, F. Asrar, Z. Verjee, T. Karaskov, G. Koren, Contamination of hair with 3 4-methylene dioxymethamphetamine (ecstasy) in 2 young girls from a meth lab, Clin. Pediatr. (Phila.) 47 (2) (2008) 186–188. [81] E. Han, M.P. Paulus, M. Wittmann, H. Chung, J.M. Song, Hair analysis and selfreport of methamphetamine use by methamphetamine dependent individuals, J. Chromatogr. B Anal. Technol. Biomed. Life Sci. 879 (7–8) (2011) 541–547. [82] G.A. Cooper, D.L. Allen, K.S. Scott, J.S. Oliver, J. Ditton, I.D. Smith, Hair analysis: selfreported use of speed and ecstasy compared with laboratory findings, J. Forensic Sci. 45 (2) (2000) 400–406. [83] N. Roth, B. Moosmann, V. Auwa¨rter, Development and validation of an LC-MS/MS method for quantification of (9-tetrahydrocannabinolic acid A (THCA-A), THC, CBN and CBD in hair, J. Mass Spectrom. 48 (2) (2013) 227–233. [84] Y. Gaillard, G. Pepin, Screening and identification of drugs in human hair by highperformance liquid chromatography-photodiode-array UV detection and gas chromatography-mass spectrometry after solid-phase extraction. A powerful tool in forensic medicine, J. Chromatogr. A 762 (1–2) (1997) 251–267. [85] N. Allibe, H. Eysseric-Guerin, P. Kintz, M. Bartoli, C. Bost-Bru, F. Grenier, V. Scolan, F. Stanke-Labesque, Amitriptyline poisoning of a baby: how informative can hair analysis be? Forensic Sci. Int. 249 (0) (2015) 53–58.