Impact of the voluntary withdrawal of over-the-counter cough and cold medications on pediatric ingestions reported to poison centers

Impact of a drug safety communication on the severity of benzonatate exposures reported to poison centers

PURPOSE

Identify if publication of the 2010 drug safety communication (DSC) regarding benzonatate was associated with a decrease in the incidence of severe benzonatate poisonings reported to United States poison centers.

METHODS

This retrospective database study utilized the National Poison Data System to compare the incidence of severe benzonatate poisonings before and after the publication of a drug safety communication. We utilized interrupted time series analysis to compare 2000-2010 (pre-DSC) to 2012-2019 (post-DSC).

RESULTS

There were 18 619 benzonatate exposures reported to US poison centers during the time period covered and 11 554 exposures were included. There was an increase in exposures throughout the time period. There was no difference in the incidence of severe outcomes in the two time periods. In the pre-DSC era, rates of severe outcomes increased by 0.4% per year followed by an immediate non-significant drop of 2.9% in incidence of severe outcomes (P = .15). Finally, the slope of severe outcomes in the post-DSC era showed an increase of 0.3% per year, which was not significantly different from the pre-DSC era (P = .78).

CONCLUSION

Publication of a Drug Safety Communication regarding the risks of benzonatate did not result in a decrease in the proportion of severe benzonatate poisoning reported to US poison centers. Deaths and other severe outcomes continued to occur at a similar rate after the publication.

Mandatory labeling requirements and over-the-counter cough and cold medication use in early childhood

OBJECTIVES

Due to rare but severe adverse events, Health Canada in October 2009 required manufacturers to relabel over-the-counter (OTC) cough and cold medication (CCM) to state that the products should not be used in children <6 years of age. The main objective of this study was to determine whether this labeling standard decreased OTC CCM use among young children with a recent cough, cold or flu.

METHODS

An interrupted time series study was conducted using data from the TARGet Kids! practice-based research network. A total of 3,515 healthy children 1-5 years of age were recruited from 2008-2011; of these, 1,072 had a cough, cold or flu in the previous month. Parents completed a standardized survey instrument. For the primary analysis, use of OTC CCMs prior to and after October 1, 2009 was compared using time series analyses. For the secondary analysis, multivariable logistic regression was used to identify predictors of recent OTC CCM use.

RESULTS

OTC CCM use was reported in 222 of 1,072 (20.7%) children with a cough, cold or flu within the previous month. OTC CCM use declined from 22.2% to 17.8% following the October 2009 Health Canada labeling standard (p = 0.014). Maternal age <35 years (OR 1.49; 95% CI: 1.05-2.13) and having older siblings (OR 1.65; 95% CI: 1.16-2.35) were independently associated with OTC CCM use.

CONCLUSION

Labeling legislation against OTC CCM use for children <6 years resulted in a small decrease in OTC CCM use. Stronger measures may be needed to curtail OTC CCM use, particularly for younger parents and those with multiple children.

The impact of pediatric labeling changes on prescribing patterns of cough and cold medications

OBJECTIVE

To evaluate the impact of initiatives created by the pharmaceutical industry and the Food and Drug Administration to limit the use of over-the-counter (OTC) cough and cold medications (CCMs) in young children in emergency departments (EDs) and ambulatory clinics.

STUDY DESIGN

Analysis of the National Hospital Ambulatory Medical Care Survey and National Ambulatory Medical Care Survey was performed comparing 2005-2006 and 2009-2010 in children aged ≤ 12 years with a reason for visit consistent with cough or cold-related symptoms. Data were stratified by age (<2 years, 2-6 years, and 6-12 years). Descriptive frequencies and survey-weighted χ(2) tests were used to assess OTC and prescription CCM prescription rates in ED and ambulatory clinic settings.

RESULTS

Comparing 2005-2006 and 2009-2010 revealed no changes in ED use of OTC CCMs; however, the use of prescription CCMs decreased, from 6.7% to 2.9% (P = .001). In ambulatory clinics, the overall rate of OTC CCM use increased from 6.3% to 11.1% (P = .001); however, use by children aged <2 years was unchanged. Prescription CCM use in EDs declined in all age groups, but in ambulatory clinics, decreases were significant only in patients aged <2 years.

CONCLUSION

Implementation of pharmaceutical industry and Food and Drug Administration initiatives did not decrease the use of OTC CCMs in children aged <2 years in EDs or ambulatory clinics. The use of prescription CCMs was decreased in both settings, however.

Revisiting the safety of over-the-counter cough and cold medications in the pediatric population

Increased reports of serious adverse events in young children have led to numerous investigations of its therapeutic role in the pediatric population. A review of the literature has shown limited support of its use in young children, with the majority of randomized controlled trials showing no difference in endpoints when compared to placebo. Because of the recent recommended changes to pediatric cough and cold medication use, studies have suggested a decline in ingestion misuses, health care referrals, and reports of adverse events. While these patterns of use are reassuring, clinicians should continue to educate and provide caregivers guidance in managing cough and cold symptoms. Although a tremendous improvement in frequency of therapeutic error ingestions in children younger than 2 years was shown in these studies, the same magnitude of improvement was not seen in children 2 to 12 years. Therefore, future research is necessary to investigate its role in children younger than 12 years.

Cough and cold medication adverse events after market withdrawal and labeling revision

BACKGROUND

In October 2007, manufacturers voluntarily withdrew over-the-counter (OTC) infant cough and cold medications (CCMs) from the US market. A year later, manufacturers announced OTC CCM labeling would be revised to warn against OTC CCM use by children aged <4 years. We determined whether emergency department (ED) visits for CCM adverse drug events (ADEs) declined after these interventions.

METHODS

We used National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance data from 2004 to 2011 to estimate the number of ED visits for CCM ADEs before and after each intervention.

RESULTS

Among children aged <2 years, ED visits for CCM ADEs decreased from 4.1% of all ADE ED visits before the market withdrawal to 2.4% of all ADE visits afterward (difference in proportion: -1.7%, 95% confidence interval [CI]: -2.7% to -0.6%). Among children aged 2 to 3 years, ED visits for CCM ADEs decreased from 9.5% of all ADE ED visits before the labeling revision announcement to 6.5% of all ADE visits afterward (difference in proportion: -3.0%, 95% CI: -5.4% to -0.6%). Unsupervised ingestions accounted for 64.3% (95% CI: 51.1% to 77.5%) of CCM ADE ED visits involving children aged <2 years after the withdrawal and 88.8% (95% CI: 83.8% to 93.8%) of visits involving children aged 2 to 3 years after the labeling revision announcement.

CONCLUSIONS

After a voluntary market withdrawal and labeling revision, ED visits for CCM ADEs declined among children aged <2 years and 2 to 3 years relative to ADE ED visits for all drugs. Interventions addressing unsupervised ingestions are needed to reduce CCM ADEs.

New insights into root causes of pediatric accidental unsupervised ingestions of over-the-counter medications

CONTEXT

Changes to regulations, packaging, and labeling and ongoing educational efforts are intended to support appropriate use of medicines. Yet annually poison centers receive > 500 000 reports of accidental or unsupervised exposure to medicines for children under 6 years of age.

OBJECTIVE

To identify root (i.e., fundamental and preventable) causes of accidental unsupervised ingestions (AUIs), we designed a questionnaire and conducted a follow-up survey of caregivers who contacted McNeil Consumer Healthcare (McNeil) following an AUI by a child under 12 years of age.

METHODS

Reports received between 1 October 2008 and 22 January 2009 were screened retrospectively for specific Medical Dictionary of Regulatory Activities (MedDRA) Preferred Terms relating to AUIs. Using the questionnaire, we collected information about the child, caregiver, medicines involved in AUI, management of AUI, and storage location of medicines.

RESULTS

Two hundred twenty reports met inclusion criteria and attempts to contact these caregivers were made throughout a 2-week period in March 2009; caregivers completed the questionnaire for 45 reports. All AUIs occurred in children under 7 years and 56% were boys. In 56% of AUI cases, the child involved was the intended recipient of the medicine; in 71%, a pediatric medicine was involved. Most AUIs occurred in the child's home; most caregivers reported not observing the AUI. Sixty percent of caregivers reported that the medicine involved in AUI was not in the normal storage location when AUI occurred. Among children involved in AUIs, 84% did not experience any symptoms. Seven children experienced mild, self-limiting symptoms which resolved. AUIs often occurred < 24 h after last therapeutic use when the medicine was removed from its normal storage location.

CONCLUSIONS

These new insights may help guide-targeted interventions and educational efforts to focus caregivers' attention to reengaging childproofing mechanisms and returning medicines to a secure location, high and out of sight, immediately after use.

Effect of cough and cold medication restriction and label changes on pediatric ingestions reported to United States poison centers

OBJECTIVE

To determine the impact of industry and Food and Drug Administration initiatives implemented to limit the use of over-the-counter (OTC) cough and cold medications in children younger than 6 years of age.

STUDY DESIGN

This is a retrospective database study of OTC cough and cold medication ingestions reported to US poison centers between 2000 and 2010. Data analyzed from the National Poison Data System included the month and year of ingestion, reason for ingestion, health care utilization, and medical outcome. Ingestion frequencies were stratified by age and reason. Data were divided into pre- and postintervention periods for comparative analysis.

RESULTS

Unintentional ingestions of OTC cough and cold medications decreased 33.4% and therapeutic errors by 46.0%. Health care facility referral declined for unintentional ingestions (28.9% <2 years of age, 19.9% 2-5 years of age, P < .0001) and therapeutic errors in children younger than 2 years of age (59.2%, P < .0001). Moderate and severe adverse outcomes decreased for unintentional ingestions in children younger than 2 years of age by 32.4% and by 21.3% in 2- to 5-year olds, P < .0001.

CONCLUSIONS

The restriction of OTC cough and cold medications has led to a decline in unintentional ingestions, therapeutic errors, health care facility referral, and serious medical outcomes in children younger than 2 years of age. There has also been a decline in ingestions in 2- to 5-year-old children.

Evaluation of changes in poisoning in young children: 2000 to 2010

OBJECTIVE

The nature of pediatric poisonings is dynamic, with changes occurring over time. We evaluated poisoning in children younger than 6 years for trends during an 11-year period regarding the substances involved in the poisoning, medical outcomes, and health care use.

METHODS

This was retrospective study of poisoning in children younger than 6 years reported to 12 poison centers in 5 U.S. states for the years 2000 through 2010. Data abstracted included substance category involved in the exposure, age of patient, year of occurrence, location of patient management, and medical outcome.

RESULTS

There were 2,577,036 poison exposures in children younger than 6 years, with a 12.4% increase from 210,270 poison exposures in 2000 to 236,425 poison exposures in 2010. There was a 33% increase (P < 0.05) in pharmaceutical related exposures in children younger than 6 years and a 2.8% decline in the number of nonpharmaceutical related exposures. Among those substance categories representing more than 1% of exposures, the only pharmaceutical showing decline was cough/cold preparations. There was a 53% increase in serious medical outcomes, including 119 deaths and a significant increase in health care facility use, primarily owing to pharmaceutical exposures.

CONCLUSIONS

Poisoning in young children increasingly involves pharmaceuticals and is associated with an increased number of serious outcomes and children treated in a health care facility. We believe that these changes are related to increased availability of medications in the home and poison prevention education efforts should include a focus on the availability of these products to small children.

Treating cough and cold: Guidance for caregivers of children and youth

Despite the widespread use of over-the-counter (OTC) cough and cold medications (CCMs), the effectiveness of most CCMs has not been proven in children. A meta-analysis summarizing trials using OTC CCMs for viral-induced cough found no evidence for or against the use of OTC medicines in both paediatric and adult populations when cough frequency and severity, as well as physician assessments, were compared. Furthermore, North American data suggest that OTC CCMs may be associated with medication errors and adverse events, resulting in visits to emergency departments and even leading to death. The present article provides information on current evidence for cough and cold therapies, including fluid intake, humidified air, antihistamines, echinacea, zinc, honey and vitamin C, for caregivers of children and youth.

Effect of cough and cold medication withdrawal and warning on ingestions by young children reported to Texas poison centers

OBJECTIVE

This study examined whether the withdrawal of over-the-counter cough and cold medication labeled for use in children younger than 2 years in October 2007 and the warning against use of the products in children younger than 4 years in October 2008 affected cough and cold medication ingestions by young children reported to a statewide poison system.

METHODS

Cases were all cough and cold medication ingestions by children aged 0 to 5 years reported to the Texas Poison Center Network during October 1998 to September 2009. The annual number of ingestions was determined, and the percent change from the previous year calculated.

RESULTS

During October 1998 to September 2007, the number of ingestions exhibited a mean annual increase of 2.5%. The number of ingestions declined by 16.0% during October 2007 to September 2008 and 9.3% during October 2008 to September 2009. During October 2007 to September 2008, the number decreased by 26.5% in children aged 0 to 1 years, 13.5% in those aged 2 to 3 years, 5.4% in those aged 4 to 5 years, 23.4% therapeutic errors or adverse drug reactions, and 11.5% in all other circumstances.

CONCLUSIONS

The voluntary withdrawal and subsequent voluntary warning of over-the-counter cough and cold medications appear to have resulted in a decline in ingestions reported to Texas poison centers not only among children aged 0 to 1 and 2 to 3 years but also among children aged 4 to 5 years, although the degree of decline was greatest for the youngest age groups. The decrease was observed not only among therapeutic errors and adverse drug reactions, but also in other circumstances of ingestion, although the decrease was greater for the former circumstances.

Decrease in therapeutic errors involving prescription cough and cold medications in young children

OBJECTIVES

This study sought to determine whether an increase in therapeutic errors involving prescription cough and cold medications (CCM) reported to poison centers was observed following the October 2007 voluntary withdrawal of over-the-counter CCM.

METHODS

Analysis of therapeutic errors involving prescription CCM in children under 2 years of age for the 33 months before and the 27 months after the October 2007 withdrawal.

RESULTS

Total counts of therapeutic errors involving prescription CCM in children under 2 years of age decreased from 452 to 337 per year. Rates of therapeutic errors decreased from 0.43 cases/100,000 person-month prewithdrawal to 0.32 postwithdrawal, a 25.6% decrease (p<0.0001).

CONCLUSIONS

An increase in harm as measured by the number of poison center calls for therapeutic errors involving prescription CCM was not observed in the 27-month time period after the withdrawal. A significant decrease in therapeutic errors involving these products is reported.

Adverse events from cough and cold medications after a market withdrawal of products labeled for infants

OBJECTIVE

A voluntary market withdrawal of orally administered, over-the-counter, infant cough and cold medications (CCMs) was announced in October 2007. The goal of this study was to assess CCM-related adverse events (AEs) among children after the withdrawal.

METHODS

Emergency department (ED) visits for CCM-related AEs among children <12 years of age were identified from a nationally representative, stratified, probability sample of 63 US EDs, for the 14 months before and after announcement of withdrawal.

RESULTS

After withdrawal, the number and proportion of estimated ED visits for CCM-related AEs involving children <2 years of age were less than one-half of those in the prewithdrawal period (1248 visits [13.3%] vs 2790 visits [28.7%]; difference: -15.4% [95% confidence interval [CI]: -25.9% to -5.0%]), whereas the overall number of estimated ED visits for CCM-related AEs for children <12 years of age remained unchanged (9408 visits [95% CI: 6874-11 941 visits] vs 9727 visits [95% CI: 6649-12 805 visits]). During both periods, two-thirds of estimated ED visits involved unsupervised ingestions (ie, children finding and ingesting medications).

CONCLUSIONS

ED visits for CCM-related AEs among children <2 years of age were substantially reduced after withdrawal of over-the-counter infant CCMs. Further reductions likely will require packaging improvements to reduce harm from unsupervised ingestions and continued education about avoiding CCM use for young children. Monitoring of CCM-related harm should continue because recommendations were updated in October 2008 to avoid the use of CCMs for children <4 years of age.