Child Welfare Involvement and Health Outcomes in Infants With Prenatal Substance Exposure

Importance The child welfare system (CWS) is often contacted when a child is born with prenatal substance exposure, but there is limited evidence on the beneficial and iatrogenic effects of CWS involvement. Objective To examine whether involvement with the CWS at birth is associated with injuries and moderate- to high-complexity emergency department (ED) use in the first year of life among infants identified with prenatal substance exposure. Design, Setting, and Participants Retrospective cohort study using probabilistically linked administrative data of Pennsylvania statewide child welfare administrative records linked to Medicaid claims. Births from January 1, 2015, to December 31, 2018, were followed up for 12 months. Data were analyzed from October 9, 2025, to March 21, 2026. A sibling fixed-effects design compared infants born to the same mother who differed in their CWS involvement status. The cohort included Medicaid-covered infants identified with prenatal substance exposure who were named in confirmed child welfare cases at birth involving alleged maltreatment or a sibling and met continuous Medicaid enrollment and successful linkage criteria. The discordant sibling sample included infants born to mothers with at least 2 infants who differed in involvement status. Exposure Involvement with the CWS in the birth month. Main Outcomes and Measures Primary outcomes included any injury, serious injury (Abbreviated Injury Scale score ≥3 or CWS-documented fatalities/near fatalities), and moderate- to high-complexity ED visits (Current Procedural Terminology evaluation and management codes 99283-99285; critical care codes 99291-99292), including repeat visits. Secondary outcomes included well-child visits, low-resource-intensity ED visits, and maternal postpartum care. Results In this study in 5858 of infants (3001 male and 2839 female) identified with prenatal substance exposure, by age 1 year, 14.5% had an injury-related claim, 33.8% had a moderate- to high-complexity ED visit, and 14.3% had a repeat ED visit. In sibling fixed-effects models, involvement with the CWS at birth was associated with a 20% relative reduction in moderate- to high-complexity ED visits (−7.3 percentage points [pp]; 95% CI, −10.8 to −3.9 pp) and a 24% relative reduction in repeat ED visits (−3.7 pp; 95% CI, −6.3 to −1.2 pp). Conversely, on-time well-child visits were 15% lower (−7.8 pp; 95% CI, −11.7 to −4.0 pp) for CWS-involved siblings. Conclusions and Relevance Results of this study suggest that child welfare involvement is associated with reduced health care use among infants with prenatal substance exposure, especially moderate- to high-complexity ED use.