Trends in Emergency Department Visits for Unsupervised Pediatric Medication Exposures, 2004-2013

Assessment of acute poisoning in children using poisoning severity scores: A cross-sectional study at Damietta General Hospital Egypt

Acute poisoning is a prevalent health issue, particularly among children, due to their natural curiosity and tendency to explore. This cross-sectional study aimed to evaluate the characteristics, causes, clinical presentation, and outcomes of acute intoxication in children at Damietta General Hospital, Egypt. We included 106 pediatric patients (aged under 18 years) with a clear history or clinical signs of acute poisoning. Data collection encompassed sociodemographic information, type of poison, mode of poisoning, and clinical outcomes. Poison Severity Score (PSS) was employed to assess the severity. The most affected age group was preschool children (3-6 years), accounting for 41.5 % of cases, with males representing 52.8 %. Accidental poisoning constituted 83 % of cases, with household cleaning products (34 %) and petroleum products (18.9 %) being the most common toxic agents. Clinical outcomes revealed that 33 % of patients experienced morbidity, with electrolyte imbalances being the most prevalent complication. The overall cure rate was 94.3 %, while the mortality rate was 5.7 %. This study highlights the significance of parental education and preventive measures, especially in rural areas, to reduce the risk of pediatric poisoning. The PSS proved useful in guiding clinical care, supporting its further use in pediatric toxicology settings.

Misuse, Abuse and Medication Errors' Adverse Events Associated with Opioids-A Systematic Review

Opioids are the strongest analgesics available and are crucial in the treatment of acute and chronic pain. The line between these critical medications and how they are used beyond standard therapeutics in cases such as abuse, misuse, and medication errors needs to be understood, as it affects their safety, efficacy, and manner of use. The aim of this systematic review was to identify what is known about the adverse events resulting from the abuse, misuse, and medication errors associated with opioid use. A systematic search was conducted in the PubMed®, Scopus® and, EBSCO® databases to retrieve studies from the inception to December 2023 reporting abuse, misuse, and medication errors associated with medicinal opioid use. Two authors independently screened titles and abstracts and full text according to eligibility using Covidence® software. Full articles were examined by two independent reviewers, and disagreements were resolved by a third reviewer. The risk of bias was assessed by the JBI's critical appraisal tools. A total of 934 articles were screened by their title and abstract. Then, 151 articles were selected for full text screening. Of these, 34 studies were eligible for inclusion in this review. The included studies varied significantly in their population sizes, ranging from 9 individuals to 298,433 patients, and encompassed a diverse demographic, including all ages and both sexes. The studies consistently reported a range of adverse events associated with opioid use. Fentanyl, morphine, oxycodone, tramadol, and hydrocodone were frequently implicated. The data heterogeneity in this field resulted in challenges in drawing conclusions. The review highlights that some opioids, particularly fentanyl, morphine, and oxycodone, are frequently associated with preventable adverse drug reactions, abuse, and medication errors, underscoring the need for robust preventative measures and ongoing research to mitigate opioid-related harm.

A real-world disproportionality analysis of the FDA adverse event reporting system events for ibuprofen

INTRODUCTION

Ibuprofen is commonly used as an over-the-counter (OTC) antipyretic and analgesic. As the frequency of its use has increased, there has been a corresponding increase in reports of associated adverse events (AEs). However, these events have not been systematically reported in the literature. Meanwhile, the importance of effective pharmacovigilance in evaluating the benefits and risks of drugs is being recognized.

METHODS

The data was obtained indirectly from FAERS using the OpenVigil 2 database, lexically mapped using software such as MySQL, Microsoft Excel, and the R language, and then subjected to four more rigorous algorithms to detect risk signals associated with ibuprofen AEs.

RESULTS

By analyzing data from the past 18 years, 878 ibuprofen-related AEs were identified as primary AEs. Notably, unexpected reproductive system and breast diseases, etc., which were unexpected, were observed as important system organ classes (SOCs) associated with ibuprofen. Among the 651 preferred terms (PTs) that simultaneously satisfy the four arithmetic methods, renal tubular acidosis and lip oedema are proposed as new signals for ibuprofen AEs.

CONCLUSION

This study explores the important and valuable potential AEs and ADRs of ibuprofen at the SOC and PT levels, respectively. To provide a reference on decision-making for ibuprofen to promote rational clinical dosing.

Paediatric hospitalisation related to medications administration errors of non-opioid analgesics, antipyretics and antirheumatics in England and Wales: a longitudinal ecological study

OBJECTIVE

This study aimed to explore paediatric hospitalisation related to medication administration errors (MAEs) of non-opioid analgesics, antipyretics and antirheumatics in England and Wales.

DESIGN

An ecological study.

SETTING

A population-based study on hospitalised patients in England and Wales. Hospital admission data were extracted from the Hospital Episode Statistics database in England and the Patient Episode Database for Wales for the period between April 1999 and April 2020. Admissions cause was confirmed using the diagnostic codes T39.0-T39.9.

PARTICIPANTS

Paediatric patients aged 15 years and below who were hospitalised at all National Health Service (NHS) trusts and any independent sector funded by NHS trusts.

PRIMARY OUTCOME MEASURE

Hospitalisation rates related to MAEs of non-opioid analgesics, antipyretics and antirheumatics.

RESULTS

The yearly number of admissions for MAEs associated with non-opioid analgesics, antipyretics and antirheumatics experienced a notable growth of 21.7% over the span of two decades, rising from 4574 cases in 1999 to 5568 cases in 2020. The observed increase demonstrates a significant upward trend in hospital admissions rate, with a 12.3% growth from 46.16 per 100 000 individuals in 1999 to 51.83 per 100 000 individuals in 2020 (95% CIs 44.83 to 47.50 and 50.47 to53.19, respectively, trend test, p<0.05). The therapeutic categories that exhibited the highest frequency of MAEs were '4-aminophenol derivatives' and 'other non-steroidal anti-inflammatory drugs', accounting for 79.3% and 16.0% of cases, respectively. It is worth noting that there was a significant increase of 28.9% in hospitalisations linked to MAEs specifically associated with '4-aminophenol derivatives.'

CONCLUSION

The research revealed a notable rise in the overall yearly number of hospital admissions associated with MAEs within the paediatric population. This study emphasises the necessity for additional research aimed at mitigating the potential hazards associated with the ingestion of these medications, particularly within susceptible demographics, such as young children.

Trends in Emergency Department Visits for Unsupervised Pediatric Medication Exposures

INTRODUCTION

Emergency department visits and hospitalizations for unsupervised medication exposures among young children increased in the early 2000s. Prevention efforts were initiated in response.

METHODS

Nationally representative data from the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project collected from 2009 to 2020 were analyzed in 2022 to assess overall and medication-specific trends in emergency department visits for unsupervised exposures among children aged ≤5 years.

RESULTS

From 2009 to 2020, there were an estimated 677,968 (95% CI=550,089, 805,846) emergency department visits for unsupervised medication exposures among children aged ≤5 years in the U.S. Most visits involved children aged 1-2 years (2009-2012 [70.3%], 2017-2020 [67.4%]), and nearly one half involved prescription solid medications (2009-2012 [49.4%], 2017-2020 [48.1%]). The largest declines in estimated numbers of annual visits from 2009-2012 to 2017-2020 were for exposures involving prescription solid benzodiazepines (-2,636 visits, -72.0%) and opioids (-2,596 visits, -53.6%) and over-the-counter liquid cough and cold medications (-1,954 visits, -71.6%) and acetaminophen (-1,418 visits, -53.4%). The estimated number of annual visits increased for exposures involving over-the-counter solid herbal/alternative remedies (+1,028 visits, +65.6%), with the largest increase for melatonin exposures (+1,440 visits, +421.1%). Overall, the estimated number of visits for unsupervised medication exposures decreased from 66,416 in 2009 to 36,564 in 2020 (annual percentage change= -6.0%). Emergent hospitalizations for unsupervised exposures also declined (annual percentage change= -4.5%).

CONCLUSIONS

Declines in estimated emergency department visits and hospitalizations for unsupervised medication exposures from 2009 to 2020 coincided with renewed prevention efforts. Targeted approaches may be needed to achieve continued declines in unsupervised medication exposures among young children.

Role of Primary Caregivers Regarding Unintentional Injury Prevention Among Preschool Children: A Cross-Sectional Survey in Low- and Middle-Income Country

Importance

Unintentional childhood injuries significantly strain healthcare resources, and their preventable measures can significantly reduce morbidity and mortality.

Objectives

To investigate the role of primary caregivers in preventing unintentional injuries and to identify the groups that require special health intervention programs to reduce the burden of this public health concern.

Methodology

A cross-sectional survey was conducted at three hospitals in Karachi, Pakistan. Parents of preschool children who visited pediatric clinics were invited to participate in the study by completing a self-administered questionnaire comprising questions about knowledge, attitudes, and practices towards preventing unintentional injuries among children.

Results

With an 80% response rate, the overall mean knowledge, attitude, and practices (KAP) score was 27.40 ± 3.48. Only 14.3% of the participants had a high KAP score, while 83.6% and 2.1% of the respondents had moderate and low KAP scores, respectively. People of lower socioeconomic status, unemployed, less educated, and families with more than one preschool child were less knowledgeable and non-adherent to unintentional preventive injury. It was found that 21% of the children had suffered from an unintentional severe injury in the past, and the internet was the most frequent source of gaining knowledge among parents.

Conclusion

Parental knowledge, attitude, practices, and adherence to child safety measures are sub-optimal in our cohort of studied participants. Raising awareness and providing the counseling are essential in reducing the burden of unintentional injuries.

Trends in opioid and nonsteroidal anti-inflammatory (NSAID) usage in children undergoing common urinary tract reconstruction: A large, single-institutional analysis

INTRODUCTION AND OBJECTIVE

Opioid stewardship is recognized as a critical clinical priority. We previously reported marked reductions in narcotic administration after implementation of an opioid reduction protocol for pediatric ambulatory urologic surgery. We hypothesize that a decrease in post-operative and discharge opioid administration will not increase short-term adverse events.

STUDY DESIGN

All pediatric patients undergoing open or robot-assisted laparoscopic pyeloplasty or ureteral reimplantation between 2015 and 2019 were included. Patients' demographics, opioid and NSAID administration, urology or pain-related emergency department (ED) visits, readmissions, and reoperations within 30 days of surgery, were aggregated.

RESULTS

438 patients, with a median age of 3.5 years (IQR 1.5-8.3) at the time of surgery, met the inclusion criteria. Annual rates of inpatient opioid administration and prescriptions decreased significantly over the study period, while rates of intra-operative, inpatient, and prescribed NSAIDs significantly increased. There was no significant difference in the occurrence of ED visits, readmissions, or reoperations within 30 days of surgery between patients who received an opioid prescription and those who did not. Multivariate regression showed that patients who did not receive an opioid prescription at discharge were found to be at a lower risk for unplanned encounters including ED visits, readmissions, or reoperations (OR:0.5, 95%CI: 0.2-0.9, p = 0.04).

DISCUSSION

The present study shows the decreasing trend in inpatient opioid administration and opioid prescription after discharge, when accompanied by an increase NSAID administration, does not result in a significant change in rates of unplanned encounters and complications, similar to results from previous studies on non-urological and ambulatory urological surgeries.

CONCLUSIONS

Non-opioid pain control after major pediatric urologic reconstruction is safe and effective. We found that a reduction in opioid administration can be associated with a reduced risk of unplanned ED visits, readmissions, or reoperations. Further investigations are required to corroborate this finding.

The Impact of Pediatric Opioid-Related Visits on U.S. Emergency Departments

Background: While there is significant research exploring adults’ use of opioids, there has been minimal focus on the opioid impact within emergency departments for the pediatric population. Methods: We examined data from the Agency for Healthcare Research, the National Emergency Department Sample (NEDS), and death data from the Centers for Disease Control and Prevention. Sociodemographic and financial variables were analyzed for encounters during 2014–2017 for patients under age 18, matching diagnoses codes for opioid-related overdose or opioid use disorder. Results: During this period, 59,658 children presented to an ED for any diagnoses involving opioids. The majority (68.5%) of visits were related to overdoses (poisoning), with a mean age of 11.3 years and a majority female (53%). There was a curvilinear relationship between age and encounters, with teens representing the majority of visits, followed by infants. The highest volume was seen in the Southern U.S., with over 58% more opioid visits than the next highest region (Midwest). Charges exceeded USD 157 million, representing 2% of total ED costs, with Medicaid responsible for 54% of the total. Conclusions: With increases in substance use among children, there is a growing need for pediatric emergency physicians to recognize, refer, and initiate treatments.

Maternal Substance Use Disorders and Accidental Drug Poisonings in Children

INTRODUCTION

Risk factors for accidental drug poisonings in children are poorly understood, including the association with maternal substance use. This study seeks to determine whether maternal substance use disorders before birth are associated with the future risk of accidental drug poisonings in young children.

METHODS

This study was a longitudinal cohort analysis of 1,032,209 children aged <5 years between 2006 and 2020 in Quebec, Canada. The main exposure included maternal substance use disorders before or during pregnancy. The outcome was hospitalization for drug poisonings before age 5 years, including opioids, cannabis, sedatives/hypnotics, stimulants, and other drugs. Adjusted Cox proportional hazards regression was used to compute hazard ratios and 95% CIs for the association of substance use disorders with child drug poisonings during 4,523,003 person-years of follow-up. Analyses were conducted in 2020.

RESULTS

Hospitalization rates for drug poisoning before age 5 years were greater for children of mothers with substance use disorders versus no substance use disorder (84.8 vs 20.7 per 100,000 person-years). Maternal substance use disorders before birth were associated with 2.28 times the risk of future drug poisonings in children (95% CI=1.63, 3.20). The association was stronger for maternal opioid use disorders (hazard ratio=4.16, 95% CI=2.38, 7.27) than other drug use disorders. Associations with child poisonings were stronger between age 1 and 2 years (hazard ratio=3.26, 95% CI=2.09, 5.10) and for poisonings involving opioids, cannabis, and sedative/hypnotic drugs.

CONCLUSIONS

Maternal substance use disorders before childbirth may be markers of future risk of drug poisonings in young children.

Utilization of Monitored Beds for Children Admitted With Unintentional Poisonings

OBJECTIVES

Children with unintentional poisonings (UPs) are frequently admitted to monitored beds (MBs), though most require minimal interventions. We aimed to (1) describe clinical factors and outcomes for children admitted for UPs and (2) identify clinical factors associated with MB placement.

METHODS

In this single-center retrospective cohort study, we studied patients younger than 6 years admitted from the emergency department (ED) for UPs over a 5-year period to a quaternary-care children's hospital. Primary outcome was disposition (MB vs non-MB). Secondary outcomes included length of stay, escalation of inpatient care, 7-day readmission, and death. Covariates included age, certainty of ingestion, altered mental status, and ED provider training level. Subanalysis of drug class effect on disposition was also studied. Associations of clinical factors with MB placement were tested with multivariable logistic regression.

RESULTS

Of 401 patients screened, 345 subjects met inclusion criteria. Most subjects (308 of 345 [89%]) were admitted to MBs. Children with high certainty of ingestion (adjusted odds ratio [aOR], 4.2; 95% confidence interval [CI], 1.52-11.58), altered mental status (aOR, 5.82; 95% CI, 2.45-13.79), and a fellow (vs faculty) ED provider (aOR, 2.34; 95% CI, 1.04-5.24) were more likely to be admitted to MBs. No escalations of care, readmissions, or deaths occurred. Exposures to cardiac drugs had increased MB placement (aOR, 6.74; 95% CI, 1.93-23.59).

CONCLUSIONS

The majority of children admitted for UPs were placed in MBs. Regardless of inpatient placement, no adverse events were observed, suggesting opportunities for optimized resource utilization. Future research may focus on direct costs, inpatient interventions, or prospective outcomes to validate these findings.

Medication Use and Storage, and Their Potential Risks in US Households

Background: Medications stored in US households may pose risks to vulnerable populations and the environment, potentially increasing societal costs. Research regarding these aspects is scant, and interventions like medication reuse may alleviate negative consequences. The purpose of this study was to describe medications stored in US households, gauge their potential risk to minors (under 18 years of age), pets, and the environment, and estimate potential costs of unused medications. Methods: A survey of 220 US Qualtrics panel members was completed regarding medications stored at home. Published literature guided data coding for risks to minors, pets, and the environment and for estimating potential costs of unused medications. Results: Of the 192 households who provided usable and complete data, 154 (80%) reported storing a medication at home. Most medications were taken daily for chronic diseases. The majority of households with residents or guests who are minors and those with pets reported storing medications with a high risk of poisoning in easily accessible areas such as counters. Regarding risk to the aquatic environment, 46% of the medications had published data regarding this risk. For those with published data, 42% presented a level of significant risk to the aquatic environment. Unused medications stored at home had an estimated potential cost of $98 million at a national level. Implications/Conclusions: Medications stored at home may pose risks to vulnerable populations and the environment. More research regarding medications stored in households and their risks is required to develop innovative interventions such as medication reuse to prevent any potential harm.

US Hospital Stays in Children and Adolescents With Acetaminophen Poisoning

OBJECTIVES

Acetaminophen poisoning occurs in all age groups; however, hospital-based outcomes of children with these poisonings were not well characterized. Our objectives were to describe the incidence, characteristics, and outcomes of hospital stays in children with acetaminophen poisoning and evaluate the contribution of intentionality.

METHODS

We used the 2016 Kids' Inpatient Database and validated International Classification of Diseases, 10th Revision diagnostic codes to identify hospitalizations of children aged 0 to 19 years for acetaminophen poisoning. We used standard survey methods to generate weighted population estimates and describe characteristics and outcomes, both overall and stratified by intentionality.

RESULTS

There were 9935 (95% confidence interval [CI], 9252-10 619) discharges from acute care hospitals for acetaminophen poisoning in U.S. children aged 0 to 19 years during 2016, corresponding to a population rate of 12.1 (95% CI, 11.3-12.9) hospitalizations per 100 000 children. Most hospitalizations for both intentional and unintentional acetaminophen poisoning occurred in females, with a strongly age-related sex distribution. Median length of stay was 2 days (interquartile range, 1-4 days); however, nearly half of discharges were subsequently transferred to another type of facility (eg, psychiatric hospital). Median hospital charges for acute care were $14 379 (interquartile range, $9162-$23 114), totaling $204.7 million (95% CI, $187.4-$221.9) in aggregate. Of 31 632 hospital discharges associated with self-harm medication poisoning in children aged 0 to 19 years, acetaminophen was the single most commonly implicated agent.

CONCLUSIONS

Acetaminophen poisoning was the most common cause of U.S. hospital stays associated with medication self-harm poisoning. More effective acetaminophen poisoning prevention strategies are needed, which may reduce the burden of this common adolescent malady.

Pediatric drug overdose mortality: contextual and policy effects for children under 12 years

BACKGROUND

We determine trends in fatal pediatric drug overdose from 1999 to 2018 and describe the influence of contextual factors and policies on such overdoses.

METHODS

Combining restricted CDC mortality files with data from other sources, we conducted between-county multilevel models to examine associations of demographic and socioeconomic characteristics with pediatric overdose mortality and a fixed-effects analysis to identify how changes in contexts and policies over time shaped county-level fatal pediatric overdoses per 100,000 children under 12 years.

RESULTS

Pediatric overdose deaths rose from 0.08/100,000 children in 1999 to a peak of 0.19/100,000 children in 2016, with opioids accounting for an increasing proportion of deaths. Spatial patterns of pediatric overdose deaths are heterogenous. Socioeconomic characteristics are not associated with between-county differences in pediatric overdose mortality. Greater state expenditures on public welfare (B = -0.099; CI: [-0.193, -0.005]) and hospitals (B = -0.222; CI: [-.437, -.007]) were associated with lower pediatric overdose mortality. In years when a Good Samaritan law was in effect, the county-level pediatric overdose rate was lower (B = -0.095; CI: [-0.177, -0.013]).

CONCLUSIONS

Pediatric overdose mortality increased since 1999, peaking in 2016. Good Samaritan laws and investment in hospitals and public welfare may temper pediatric overdoses. Multi-faceted approaches using policy and individual intervention is necessary to reduce pediatric overdose mortality.

IMPACT

Pediatric fatalities from psychoactive substances have risen within the U.S. since 1999. Higher levels of state spending on public welfare and hospitals are significantly associated with lower pediatric overdose mortality rates. The implementation of Good Samaritan laws is significantly associated with lower pediatric overdose mortality rates. We identified no county-level sociodemographic factors associated with pediatric overdose mortality. The findings indicate that a multi-faceted approach to the reduction of pediatric overdose is necessary.

Trends in Childhood Poison Exposures and Fatalities: A Retrospective Secondary Data Analysis of the 2009-2019 U.S. National Poison Data System Annual Reports

Despite significant prevention efforts, childhood poison exposures remain a serious public health challenge in the United States. This study aimed to assess annual trends of pharmaceutical vs. non-pharmaceutical poison exposures in the US among children 0-19 years and compare the odds of death by children's age group. Poison exposure and fatality data were retrospectively extracted from 2009 to 2019 National Poison Data System (NPDS) annual reports for children in all reported age groups. Overall, there was a significant reduction in the annual population-adjusted poison exposures in children (annual percentage change = -2.54%, 95% CI = -3.94% to -1.15%, p < 0.01), but not in poisoning-related fatalities. Children 0-5 had similar odds of dying from exposure to non-pharmaceuticals vs. pharmaceuticals. The odds of children 6-12 dying from non-pharmaceuticals vs. pharmaceuticals was 2.38 (95% CI = 1.58, 3.58), χ² = 18.53, p < 0.001. In contrast, the odds of children 13-19 dying from pharmaceuticals vs. non-pharmaceuticals was 3.04 (95% CI = 2.51, 3.69), χ² = 141.16, p < 0.001. Suicidal intent accounted for 40.63% of pharmaceutical deaths in children 6-12, as well as 48.66% of pharmaceutical and 31.15% of non-pharmaceutical deaths in children 13-19. While a significant decline in overall childhood poison exposures was reported, a decrease in poisoning-related fatalities was not observed. Children in different age groups had contrasting relative odds of death from pharmaceutical and non-pharmaceutical exposures. Among older children, a greater proportion of poisoning-related deaths was due to intentional suicide. These findings provide evidence of age-specific trends in childhood poison exposure risk and directions for future poison prevention efforts and behavioral health partnerships.

Unintentional Opioid Ingestions Presenting to a Pediatric Emergency Department

OBJECTIVES

The purpose of this study was to describe unintentional opioid exposures in young children, including demographics, medical interventions, and clinical outcomes.

METHODS

This was a retrospective, cross-sectional study of children 0 to 6 years of age with possible opioid exposure over a 3-year period (July 2010 to June 2013). Data collected included sex, age, specific drug, whether they were referred to the emergency department (ED) by the Regional Poison Control Center, presence of symptoms, therapeutic interventions, ED disposition, and clinical outcomes for admitted patients.

RESULTS

Median age of patients included in the study was 2 years, and 64% of these children were male. The most common drug of exposure was buprenorphine/naloxone. Of the 429 charts screened, 140 patients were reported to be symptomatic and referred to the ED, of which 113 patients actually presented to the ED. An additional 122 patients presented to the ED without Regional Poison Control Center referral. Of the total 235 patients presenting to ED, 76 (32%) received a therapeutic intervention. Of 231 total opioid exposures, 31 exposures were administered naloxone. Three children underwent endotracheal intubation. Sixty-five patients were hospitalized, with a median length of stay of 1 day. Although there were no fatalities, 1 child suffered severe morbidity (anoxic brain injury).

CONCLUSIONS

While opioid exposures in young children are a common and potentially life-threatening problem, most children remain asymptomatic. The majority of patients are able to be discharged from the ED after observation, and of those who are admitted, most have favorable outcomes and brief hospital stays. A small number of these patients require considerable medical interventions.

Parental perception of medications safe storage in the State of Qatar

PURPOSE

The purpose of this study is to identify parental perception of household medication storage.

METHODS

A prospective cross-sectional study utilizing a questionnaire was carried out at Hamad Medical Corporation, the solely tertiary pediatric hospital in the State of Qatar at the time of the study. Qatar is a young developing country with limited data on the awareness of medication storage among adults with children at home and on the safety practices regarding medication storage.

RESULTS

Three hundred and five questionnaires were completed. The vast majority of parents were married, one-third of them were males, and more than three quarters were college graduates and younger than 40 years of age. Almost 80% of the parents had more than three children but less than seven. In addition, 23% of participants were health-care workers. Almost 90% of the participants stored medications in a place that is easy to reach. However, the same percentage stated that those medications were stored in a locked place and that children did not have access to them. Approximately 10% of caregivers store multiple medications in one bottle, and the same percentage of participants do not check the expiration date on the medication labels. In terms of the most common medications stored at home, antihypertensives were on top of the list. Our study has shown that parental education and being a health-care worker were each associated with the difficulty in reaching medications (P = 0.006 and P = 0.011, respectively). Moreover, the percentage of participants who shared medications was significantly higher among those who were not working in the health-care section compared to those who were (P = 0.004). In addition, being a female parent and a college graduate was associated with the possibility of keeping excess or leftover medications at home (P = 0.025).

CONCLUSION

Parents residing in the State of Qatar have some deficiencies in knowledge about medication storage. Parent's attitudes and perceptions are deemed vital objectives for population's health intervention.

Presence of "One Pill Can Kill" Medications in Medication Organizers: Implications for Child Safety

BACKGROUND

Medication organizers increased compliance, but they do not contain child protective packaging. Medications organizers have been involved in some pediatric exposures; however, previous reports do not describe if "one pill can kill" (1PCK) medications were involved in the exposures. 1PCK medications may cause toxicity even with a single tablet.

OBJECTIVE

The purpose of this study is to describe the type and presence of 1PCK medications dispensed in medication organizers at a single center.

METHODS

Adult patients who received blister packed medications from September 1, 2017 to September 30, 2017 were included in this retrospective review. Medications were excluded if dispensed traditionally during this time. The primary outcome described included 1PCK medications (quantity and type). Secondary outcomes included total number of tablets dispensed, delayed- (DR) and extended-release (ER) formulations, average age of those dispensed 1PCK medications versus those without.

RESULTS

A total of 450 patients received 486 blister packs and 75.5% of which found to include 1PCK medications. Most commonly included 1PCK medications were beta-blockers and calcium channel blockers (42.4 and 49.4%, respectively). Patients receiving 1PCK medications were older (69.1 ± 12.6 vs 62.6 ± 16.7 years old, p < 0.0001) and included more medications (8.5 ± 2.9 vs 5.7 ± 2.9 medications, p < 0.0001). DR and ER formulations were in 150 packs.

CONCLUSION

The majority of dispensed medication organizers included 1PCK medications. Upon dispensing, patients should be questioned for possible proximity exposures. Additionally, they should receive education on medication safety for children that may be in proximity of the medications during home, work, or social activities.

Systematic review and single-centre toxicology study identified analgesics and benzodiazepines as the main causes of paediatric medication poisoning

AIM

This study evaluated medication poisoning in paediatric patients through a systematic review and a retrospective documentary analysis in a Brazilian toxicological centre.

METHODS

The data were systematically collected on PubMed, Scopus and SciELO databases following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. We included epidemiologic and prevalence studies that were published in English or Portuguese from 2013 to 2017 and covered paediatric patients. The retrospective incidence study was carried out in a Brazilian toxicological centre and was a documentary analysis of paediatric medication poisoning cases from 2005 to 2015.

RESULTS

The systematic review comprised 13 papers covering 895 206 poisoning cases from six different countries. The main agents of intoxication were analgesics and antihistamines. The eight papers that explored the reasons for the poisonings showed that 93% of those 762 863 cases were accidental. The Brazilian toxicological centre recorded 443 paediatric patients poisoned by medication such as benzodiazepines, analgesics and antibiotics and found that 63.2% were accidental. However, it agreed with the global findings in many other aspects.

CONCLUSION

The systematic review showed a sustained number of paediatric medication toxicity cases worldwide and the key findings were broadly reflected by the retrospective study carried out in the Brazilian toxicological centre.

Association of Selective Serotonin Reuptake Inhibitors With the Risk of Type 2 Diabetes in Children and Adolescents

IMPORTANCE

Concerns exist that use of selective serotonin reuptake inhibitors (SSRIs) increases the risk of developing type 2 diabetes (T2D) in adults, but evidence in children and adolescents is limited. In the absence of a randomized clinical trial, evidence must be generated using real-world data.

OBJECTIVE

To evaluate the safety of SSRI use in children and adolescents with respect to the associated risk of T2D.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study of patients aged 10 to 19 years with a diagnosis for an SSRI treatment indication was conducted within the nationwide Medicaid Analytic eXtract (MAX; January 1, 2000, to December 31, 2014) and the IBM MarketScan (January 1, 2003, to September 30, 2015) databases. Data were analyzed from November 1, 2018, to December 6, 2019.

EXPOSURES

New users of an SSRI medication and comparator groups with no known metabolic adverse effects (no antidepressant exposure, bupropion hydrochloride exposure, or psychotherapy exposure). Within-class individual SSRI medications were compared with fluoxetine hydrochloride.

MAIN OUTCOMES AND MEASURES

Incident T2D during follow-up. Intention-to-treat effects were estimated using Cox proportional hazards regression models, adjusting for confounding through propensity score stratification. As-treated effects to account for continuous treatment were estimated using inverse probability weighting and marginal structural models.

RESULTS

A total of 1 582 914 patients were included in the analysis (58.3% female; mean [SD] age, 15.1 [2.3] years). The SSRI-treated group included 316 178 patients in the MAX database (publicly insured; mean [SD] age, 14.7 [2.1] years; 62.2% female) and 211 460 in the MarketScan database (privately insured; mean [SD] age, 15.8 [2.3] years; 63.9% female) with at least 2 SSRI prescriptions filled, followed up for a mean (SD) of 2.3 (2.0) and 2.2 (1.9) years, respectively. In publicly insured patients, initiation of SSRI treatment was associated with a 13% increased hazard of T2DM (intention-to-treat adjusted hazard ratio [aHR], 1.13; 95% CI, 1.04-1.22) compared with untreated patients. The association strengthened for continuous SSRI treatment (as-treated aHR, 1.33; 95% CI, 1.21-1.47), corresponding to 6.6 (95% CI, 4.2-10.4) additional cases of T2D per 10 000 patients treated for at least 2 years. Adjusted HRs were lower in privately insured patients (intention-to-treat aHR, 1.01 [95% CI, 0.84-1.23]; as-treated aHR, 1.10 [95% CI, 0.88-1.36]). Findings were similar when comparing SSRI treatment with psychotherapy (publicly insured as-treated aHR, 1.44 [95% CI, 1.25-1.65]; privately insured as-treated aHR, 1.21 [95% CI, 0.93-1.57]), whereas no increased risk was observed compared with bupropion treatment publicly insured as-treated aHR, 1.01 [95% CI, 0.79-1.29]; privately insured as-treated aHR, 0.87 [95% CI, 0.44-1.70]). For the within-class analysis, no medication had an increased hazard of T2D compared with fluoxetine.

CONCLUSIONS AND RELEVANCE

These findings suggest that children and adolescents initiating SSRI treatment may be at a small increased risk of developing T2D, particularly publicly insured patients. The magnitude of association was more modest than previously reported, and the absolute risk was small. The potential small risk should be viewed in relation to the efficacy of SSRIs for its major indications in young patients.

Suspected Nonfatal Drug-Related Overdoses Among Youth in the US: 2016-2019

BACKGROUND AND OBJECTIVES

During the current drug overdose crisis, the United States is experiencing a significant number of overdose deaths, hospitalizations, and emergency department visits. Given the vulnerability of young persons to substance use, it is important to assess how this crisis affects the nation's youth. In this study, we investigate trends in suspected nonfatal drug-related overdoses (all-drugs, opioids, heroin, and stimulants) among youth using syndromic surveillance data from 2016 to 2019.

METHODS

A retrospective analysis of emergency department syndromic surveillance data were used to detect quarterly trends in suspected drug overdoses from April 2016 through September 2019 among youth aged 0 to 10, 11 to 14, and 15 to 24 years. Syndrome definitions were developed using chief complaint free-text and discharge diagnosis codes to identify overdoses involving all-drugs, opioids, heroin, and stimulants. Pearson χ² tests detected quarter-to-quarter changes, and joinpoint regression analysis assessed trends over time.

RESULTS

On average, there was a 2.0% increase for youth aged 0 to 10 years and a 2.3% increase for youth aged 11 to 14 years for suspected all-drug overdoses. Suspected heroin overdoses decreased by an average of 3.3% per quarter for youth aged 15 to 24 years. Among all age groups, suspected stimulant overdoses increased across the study period, 3.3% for 0 to 10-year-olds, 4.0% for 11- to 14-year-olds, and 2.3% for 15- to 24-year-olds.

CONCLUSIONS

Suspected stimulant-involved drug overdoses appear to be rising among youth. These findings could inform targeted interventions, such as stimulant-focused prevention, and comprehensive approaches, including school-based prevention and other strategies to lower morbidity and mortality.

Medication Education Provided to School-Aged Children: A Systematic Scoping Review

OBJECTIVES

To characterize the educational interventions regarding prescription and nonprescription medication use for school-aged children, we systematically reviewed evidence of programs available for this age group.

METHODS

Searches in PubMed, CINAHL, EMBASE, ERIC, and International Pharmaceutical Abstracts were conducted. Search terms focused on: population education, school-age children, and medications. Studies were excluded if they were specific to a particular disease state or class of medication, drugs of misuse and illicit drugs. Data extraction included study design, location, educational intervention and duration, research methods, and main findings.

RESULTS

We found 14 studies representing 8 separate projects. Six projects were identified in the gray literature. Projects ranged from individual sessions to national programs. Quantitative studies showed improvement in knowledge, medication literacy, and confidence. The adoption of medication education strategies was dependent on the educator's comfort level and beliefs regarding medication safety.

CONCLUSIONS

Credible medication education resources are available and have been shown to improve students' knowledge. There remains a need for multifaceted implementation and evaluation strategies. Strategies and resources are available to implement interventions in communities to address medication education in school-age children. Frameworks should be used to facilitate the implementation of effective health promotion strategies around safe-medication use for school-aged children.

Trends in adverse events and related health-care facility utilization from cough and cold medication exposures in children

INTRODUCTION

Initial research following regulatory changes addressing the pediatric safety of cough and cold medications (CCMs) demonstrated decreases in adverse events (AEs). Using a national multi-source surveillance system, we studied subsequent CCM-related AE case rate trends and associated health-care facility (HCF) evaluation in children.

METHODS

Data were collected from 2009 to 2016. Case eligibility included: age <12 years; exposure to an over-the-counter product containing ≥1 CCM pharmaceutical ingredient; ≥1 significant AE that occurred in the United States.

RESULTS

About 4756 (72.6%) cases were determined at least potentially related to an index ingredient. Accidental unsupervised ingestions (AUIs; 3134; 65.9%) were the most common case type. Nearly half of AE cases involved children 2 to <4 years old (2,159; 45.4%). The AE case rate did not change significantly over time (p = 0.22). The proportion of AE cases resulting in HCF admission increased from 32.4% (207) in 2009 to 43.4% (238) in 2016 (p < 0.01). Exposures to diphenhydramine (1,305; 67.3%) and/or dextromethorphan (591; 30.5%) were involved in the majority of HCF admissions.

CONCLUSIONS

The proportion of AE cases resulting in HCF admission increased from 2009 to 2016. Efforts to prevent AUIs such as packaging innovation and engineering controls, particularly for diphenhydramine and dextromethorphan-containing products, should be pursued.

Exploratory Ingestions of Novel Anticoagulants and Antiplatelets: What Is the Risk?

BACKGROUND

Historically, anticoagulants and antiplatelet agents included warfarin and aspirin, respectively. In recent years, numerous novel anticoagulants (eg, direct thrombin inhibitors and factor Xa inhibitors) as well as the adenosine diphosphate receptor antagonists have increased significantly. Little information on the bleeding risk after exploratory ingestion of these agents is available. The primary purpose of this study is to evaluate the bleeding risk of these agents after an exploratory ingestion in children 6 years or younger.

METHODS

This retrospective multicenter poison control center study was conducted on calls between 2005 and 2014. The following agents were included: apixaban, clopidogrel, dabigatran, edoxaban, prasugrel, rivaroxaban, or ticagrelor. Bleeding characteristics and treatment rendered were recorded.

RESULTS

A total of 638 cases were identified. Most cases involved antiplatelet agents. No patient developed any bleeding complication. The administration of charcoal was independent of the amount of drug ingested.

CONCLUSION

Accidental, exploratory ingestions of these agents seem well tolerated, with no patient developing bleeding complications.

No pain is gain: A prospective evaluation of strict non-opioid pain control after pediatric appendectomy

INTRODUCTION

Opiates are often prescribed after pediatric operations despite safety concerns and lack of evidence confirming superiority compared to other pain control modalities. In this study, we use daily parental surveys to prospectively evaluate a strict non-opioid pain control strategy after laparoscopic appendectomy.

METHODS

After IRB approval, children who underwent laparoscopic appendectomy for nonperforated acute appendicitis were recruited to the study. For these patients, our standard practice is to provide instructions to administer alternating acetaminophen and ibuprofen over-the-counter (OTC) postoperatively, and no opiate prescriptions are written. Parents of enrolled children received a daily RedCap survey via text message or e-mail on postoperative days (POD) 1 through 5 to prospectively assess pain control and medication usage. Trends were compared across postoperative days.

RESULTS

One hundred twenty patients were enrolled in the study, and none received opiate prescriptions. Postoperative pain survey response rates were 54% on POD1, 47% on POD2, 35% on POD3, 34% on POD4, and 29% on POD5. Pain level was 4.7 ± 2.3 (out of 10) on POD1, and down-trended significantly each postoperative day to reach 0.7 ± 1.2 by POD5. On POD1, 85% of parents administered OTC medications, which reduced significantly to 14% by POD5. Parent-reported success rates to manage pain by OTC regimen were 85% on POD1, 94% on POD2, 91% on POD3, and 100% on POD4 and POD5.

CONCLUSION

Strict non-opioid pain control after appendectomy exhibits high performance based upon prospective parental surveys. This strategy should be implemented as standard of care and tested for application to other surgical conditions.

LEVEL OF EVIDENCE

Level II.

Circumstances Involved in Unsupervised Solid Dose Medication Exposures among Young Children

OBJECTIVE

To identify types of containers from which young children accessed solid dose medications (SDMs) during unsupervised medication exposures and the intended recipients of the medications to advance prevention.

STUDY DESIGN

From February to September 2017, 5 US poison centers enrolled individuals calling about unsupervised solid dose medication exposures by children ≤5 years. Study participants answered contextually directed questions about exposure circumstances.

RESULTS

Sixty-two percent of eligible callers participated. Among 4496 participants, 71.6% of SDM exposures involved children aged ≤2 years; 33.8% involved only prescription medications, 32.8% involved only over-the-counter (OTC) products that require child-resistant packaging, and 29.9% involved ≥1 OTC product that does not require child-resistant packaging. More than one-half of exposures (51.5%) involving prescription medications involved children accessing medications that had previously been removed from original packaging, compared with 20.8% of exposures involving OTC products (aOR, 3.39; 95% CI, 2.87-4.00). Attention deficit hyperactivity disorder medications (49.3%) and opioids (42.6%) were often not in any container when accessed; anticonvulsants (41.1%), hypoglycemic agents (33.8%), and cardiovascular/antithrombotic agents (30.8%) were often transferred to alternate containers. Grandparents' medications were involved in 30.7% of prescription medication exposures, but only 7.8% of OTC product exposures (aOR, 3.99; 95% CI, 3.26-4.87).

CONCLUSIONS

Efforts to reduce pediatric SDM exposures should also address exposures in which adults, rather than children, remove medications from child-resistant packaging. Packaging/storage innovations designed to encourage adults to keep products within child-resistant packaging and specific educational messages could be targeted based on common exposure circumstances, medication classes, and medication intended recipients.

Medication Errors From Over-the-Counter Cough and Cold Medications in Children

OBJECTIVE

Out of hospital medication-related adverse events (AEs) from cough and cold medications (CCMs) can have significant public health impact. The objective of this study was to characterize pediatric medication error AEs involving over-the-counter (OTC) CCMs to identify preventable factors.

METHODS

Multisource national data surveillance system study using an expert panel evaluating CCM AEs related to medication errors.

INCLUSION CRITERIA

age <12 years, and at least 1 significant AE from at least 1 index ingredient from a CCM OTC product.

RESULTS

From 2009 through 2016, 4756 cases were determined to have a significant AE related to an OTC CCM ingredient and 513 (10.8%) cases were due to a medication error. Nearly half of medication errors involved children 2 to <6 years old (n = 235; 45.8%). Many involved administration by a parent (n = 231; 45.0%) or alternative caregiver (n = 148; 28.8%). In nearly all cases (93.2%), the medication error involved the wrong dose of the medication. Health care facility evaluation occurred in 381 (74.3%) cases. Diphenhydramine and dextromethorphan were responsible for most medication errors and medication errors involving health care facility evaluation. There were no deaths from medication errors.

CONCLUSION

In this multiyear surveillance study, medication errors most commonly occurred in children <6 years old who received the wrong volume of a liquid product. Diphenhydramine and dextromethorphan dosing errors were the most common cause of medication errors resulting from CCM use. Continued standardization of measuring devices, concentrations, and units of measure along with consumer education are needed to further decrease medication errors from CCMs.

Parents' attitudes toward post-operative narcotic use in pediatric patients

OBJECTIVE

To understand parent perceptions of post-operative narcotic use in the pediatric otolaryngology patient population.

METHODS

This was a descriptive survey of caregivers on children being seen in a university pediatric otolaryngology clinic. Caregiver role, age of child, previous exposure to analgesics, choice of analgesics, comfort and concern with narcotic use in this child, knowledge of narcotic side effects, and knowledge about narcotic disposal were included. Comfort and concern questions were scored on a 10-point VAS where the higher numbers indicated more concern/discomfort.

RESULTS

301 caregivers participated, 84.5% were mothers, 11% were fathers and the rest were custodial grandparents. 45.2% knew someone addicted to narcotics. Respondents were uncomfortable with their child experiencing pain in a hypothetical postoperative situation, with 63.9% having at least some discomfort with it. First choice of medication to treat hypothetical post-tonsillectomy pain was ibuprofen (47.5%) followed by acetaminophen (38.9%). 29.9% were concerned about addiction, and 26.6% were concerned about drowsiness as a sequela of narcotic use. There were significant differences between respondents who knew a person addicted to narcotics and those who did not for comfort using narcotics in their child (VAS median 6.0 versus 5.0, p = 0.025), concern that their child would become addicted to narcotics (VAS median 5.0 versus 2.0, p = 0.001), concern about side effects (VAS median 7.0 versus 6.0, p = 0.007) and concern about having narcotics in the home (VAS median 3.0 versus 0.0, p < 0.001).

CONCLUSIONS

The national opioid epidemic exposes more parents to narcotic addiction in the community, which affects their perceptions of pediatric post-operative narcotic use. These experiences may need to be considered when planning postoperative pain management strategies in children.

Unsafe storage of household medicines: results from a cross-sectional study of four-year-olds from the 2004 Pelotas birth cohort (Brazil)

BACKGROUND

Unintentional child poisoning represents a significant public health problem across the globe, placing a substantial burden on health services emergency departments. Around the world, every year, thousands of children die as a result of physical injuries, most of which involve children under 5 years old. Medicines are the main products involved in poisoning, and children under 5 years old are the most vulnerable age group. The objective of this study was to measure the prevalence of unsafe storage of medicines in households with a 4-year-old child.

METHODS

We used data from the follow-up of 4-year-old in the 2004 Pelotas Birth Cohort Study in Brazil (N = 3799). "Unsafe storage" was considered present when medicines were stored unlocked and within reach of children (at a height below the eye level of the average adult). Independent variables included maternal and family socioeconomic and demographic characteristics and the child's health care. All information was collected during household interviews with the mothers using a standardized questionnaire. The overall prevalence rate with a 95% confidence interval (95% CI) and the prevalence associated with various independent variables were determined.

RESULTS

The storage of medicines in unlocked areas was reported by 80.9% of the mothers, and, within reach of children for 26.5%. The overall prevalence rate of unsafe storage of medicines was 21.4% (20.1-22.7%). The main storage locations used were the kitchen (57.0%) and bedroom (53.3%).

CONCLUSIONS

The results indicate that medicines were unsafely stored in a 21.4% number of homes, which can contribute to the vulnerability of children to poisoning from medicines. To minimize this risk, education about the safe storage of medicines should be reinforced by health professionals.

Flow Restrictors and Reduction of Accidental Ingestions of Over-the-Counter Medications

INTRODUCTION

Flow restrictors are child-resistant packaging innovations designed to limit the amount of liquid dispensed from a medication bottle. In 2011, flow restrictors were added to pediatric liquid single-ingredient acetaminophen formulations. The hypothesis of this study is that implementation would be associated with reduced volume and severity of pediatric acetaminophen exposures reported to the U.S. National Poison Data System.

METHODS

This study describes accidental unsupervised ingestions of acetaminophen in children aged <6 years. Exposures were grouped into pre-implementation (pre-period; January 4, 2010-July 17, 2011); transition (July 18, 2011-July 15, 2012); and post-implementation (post-period; July 16, 2012-December 25, 2016) periods. Cumulative and annual rates of change per million units (i.e., bottles) sold were calculated for the pre- and post-periods for acetaminophen and pediatric liquid ibuprofen (comparator without flow restrictors). Pre- to post-period rate ratios were used to compare products and to estimate the potential effect on other over-the-counter medications. Analysis was conducted in 2017 and 2018.

RESULTS

The pre- and post-period cumulative acetaminophen exposure rate was 507.2 (95% CI=481.1, 534.6) and 325.6 (95% CI=305.8, 346.7) per 1 million units sold, respectively. Declines in the pre- versus post-period rate ratios were seen for exposures with any effect (0.642, 95% CI=0.591, 0.696) and with clinically significant outcomes (0.728, 95% CI=0.581, 0.913). In the post-period, acetaminophen exposures decreased faster than ibuprofen with a rate of change ratio of 0.936 (95% CI=0.912, 0.960) for all exposures and 0.939 (95% CI=0.909, 0.970) for exposures with any effect.

CONCLUSIONS

The addition of flow restrictors to pediatric liquid acetaminophen was associated with a reduction in the number and severity of exposures. Application of flow restrictors to other liquid medications should be considered.

Adverse events associated with diphenhydramine in children, 2008-2015

Introduction: Diphenhydramine (DPH) exposures in children may be the result of accidental unsupervised ingestions, caregiver error, and intentional misuse of DPH-containing cough and cold medications (CCM). We sought to understand the nature of pediatric ingestions of DPH, particularly the toxicity and outcome of a single product, single ingredient DPH (DPH-only) exposures, in order to derive ingredient-specific information about the clinical effects and course of such cases.Methods: As part of a U.S. multi-year safety surveillance program to assess the safety of over-the-counter (OTC) medications used in cough and cold preparations in children <12 years of age, an expert panel reviewed cases involving symptomatic adverse events potentially related to oral exposures to these medications. After individual review, the cases were categorized by causal relationship of the reported ingredients to the adverse event, exposure intent (therapeutic, non-therapeutic, unknown intent), and dose (therapeutic, supratherapeutic, or unknown). Following panel review, any disagreement on classification was discussed until a consensus was reached. The data were then analyzed with respect to descriptive findings.Results: The panel reviewed 6618 eligible cases and determined 2802 were at least potentially related to oral exposure to DPH. Of these, 2028 were DPH-only cases (39.1% of all cases judged at least potentially related to a cough and cold medication). The majority (79.5%) of DPH-only cases occurred in children 2 to <4 years of age and involved accidental unsupervised ingestions (74.7%). Liquid pediatric formulations were the most common (51.7%) products reported followed by solid pediatric formulations (24.0%). The most common adverse events were tachycardia (53.4%), hallucinations (46.5%), somnolence (34.7%), agitation (33.9%), and mydriasis (26.3%). Seizures occurred in only 5.5% of cases. Five (0.2%) deaths were reported; in the death cases, the DPH dose was judged supratherapeutic in one and unknown in the other four. Child abuse was reported in four of the five death cases and three of the five deaths were homicides.Conclusions: Exposures to DPH-only products were the most common type of exposure detected in our study of adverse events associated with CCM in children. The majority of the DPH-only cases were the result of accidental unsupervised ingestions. Most adverse events were relatively mild self-limited anticholinergic effects and few deaths occurred. Deaths involving DPH were often associated with child abuse or homicide. Interventions targeting the prevention of accidental unsupervised are likely to be impactful in preventing morbidity associated with DPH-only exposure.

The Prevalence of Modifiable Parental Behaviors Associated with Inadvertent Pediatric Medication Ingestions

Introduction

Our aim was to examine potential risk factors and modifiable behaviors that could lead to pediatric poisonings. Our secondary objectives were to explore socioeconomic factors associated with caregiver (parent/guardian) safe medication storage and knowledge of poison control contact information.

Methods

We conducted a prospective, cross-sectional survey of caregivers of patients 2–10 years old presenting to an inner city pediatric emergency department. Caregiver and patient demographic data, prescription and nonprescription medication type, storage and when and where taken, were recorded. We used multivariable regression to explore factors associated with secure prescription medication storage and knowledge of poison control center contact information.

Results

Of 1457 caregivers, 29% took daily prescription and 17% took daily non-prescription medications. Only 25% of caregivers stored their prescription medications in a secure place, and <3% stored medications in a locked drawer or safe. Of demographic and socioeconomic factors, only income ≥$80,000 was associated with storage of prescription medication in a secure place (odds ratio [OR], 2.47; 95% confidence interval [CI], 1.27–4.81). When asked how they would access poison control in case of an ingestion, the majority, 86%, had an appropriate plan. In multivariable regression, the only factor associated with knowledge of poison control center contact information was college education in the caregiver (OR 1.6; 95% CI, 1.10–2.32).

Conclusion

A minority of caregivers store medications in a safe place and even fewer keep prescription medications under lock and key. The majority, however, were aware of how to contact a poison control center in case of ingestion.

Ingestion of Over-the-Counter Liquid Medications: Emergency Department Visits by Children Aged Less Than 6 Years, 2012-2015

INTRODUCTION

Unintentional medication ingestions by young children lead to nearly 60,000 emergency department visits annually; 15% involve oral liquid medications. Safety packaging improvements have been shown to limit liquid medication ingestions. Estimated rates of emergency department visits for pediatric ingestions by product were calculated to help target interventions.

METHODS

Frequencies and rates of emergency department visits for unintentional pediatric ingestions were estimated using adverse event data from the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project and retail sales/pharmacy dispensing data from Information Resources, Inc. and QuintilesIMS (collected 2012-2015; analyzed 2017). Rates of emergency department visits for ingestions of over-the-counter liquid medications were compared with those for prescription solid medications.

RESULTS

From the results of 568 cases, an estimated 6,427 emergency department visits (95% CI=4,907, 7,948) were made annually after a child aged <6 years accessed one of the four most commonly implicated over-the-counter liquid medications without caregiver oversight. Nearly two thirds (63.8%) of these visits were made by children aged ≤2 years and 9.0% resulted in hospitalization. Acetaminophen was the most commonly implicated over-the-counter liquid medication (2,515 estimated emergency department visits annually). Rates of emergency department visits for liquid diphenhydramine and acetaminophen ingestions (8.1 and 7.4 emergency department visits per 100,000 bottles sold) were higher than rates for other common over-the-counter liquids and comparable to high-rate prescription solid medications (clonidine and buprenorphine/naloxone: 11.1 and 10.5 emergency department visits per 100,000 dispensed prescriptions, respectively).

CONCLUSIONS

Product-specific rates of emergency department visits for unintentional ingestions can help prioritize preventive interventions, such as enhancing safety packaging with flow restrictors.

Pediatric Behavioral Health-Related EMS Encounters: A Statewide Analysis

Objectives: Pediatric behavioral health disorders and related emergency department visits are increasing, but effects on emergency medical services (EMS) are unknown. This study's objective was to describe the statewide epidemiology of pediatric behavioral health-related EMS encounters in Florida, including mental health and substance use. Methods: This analysis is a retrospective study of pediatric behavioral health-related EMS encounters from Florida's statewide EMS Tracking and Reporting Systems Database from 2011 to 2016. Demographic, clinical, EMS, and geographic characteristics are described. We also compared characteristics between patients who did and did not receive an acute EMS behavioral/psychiatric intervention. Results: There were 22,254 pediatric behavioral health-related EMS encounters during the study period, one-quarter of which were noted to have suspected or confirmed ingestion/substance use. The median age was 16 and the majority of patients were female and white. A total of 946 patients (4%) had an acute EMS behavioral/psychiatric intervention. EMS scene, ED turnaround, and total EMS time were significantly longer for intervention patients. Of the 14 counties in the top quartile of percentages of intervention patients, 7 were rural, 10 did not have any hospitals with child/adolescent psychiatric services, and 7 did not have any child psychiatrists. Conclusions: Pediatric behavioral-health related EMS encounters had a significant proportion of suspected ingestions/substance use, and we found disproportionate effects on rural agencies. Increases in EMS resource utilization (including longer EMS times) occurred in certain settings with limited behavioral health infrastructure. Those findings suggest an opportunity for community paramedicine to alleviate EMS utilization and decrease the frequency of pediatric behavioral health emergencies.

US National Trends in Pediatric Deaths From Prescription and Illicit Opioids, 1999-2016

IMPORTANCE

It is not yet known how many children and adolescents die each year from opioid poisonings and how mortality rates have changed over time.

OBJECTIVE

To examine national trends in pediatric deaths from prescription and illicit opioids.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional in which serial mortality data from the Centers for Disease Control and Prevention were analyzed. The population included 8986 children and adolescents (age, <20 years) who died in all US settings from opioid poisonings between 1999 and 2016. Data were collected and analyzed between June 1 and October 31, 2018.

EXPOSURES

All opioids.

MAIN OUTCOMES AND MEASURES

Age-specific mortality rates per 100 000 were estimated with smoothing spline Poisson regression.

RESULTS

Of the 8986 children and adolescents who died between 1999 and 2016 from prescription and illicit opioid poisonings, 6567 (73.1%) were male, 7921 (88.1%) were among adolescents aged 15 to 19 years, and 605 (6.7%) were among children aged 0 to 4 years. The overall pediatric mortality rate increased from 0.22 (95% CI, 0.19-0.25) to 0.81 (95% CI, 0.76-0.88) per 100 000, an increase of 268.2% (P for time effect <.001). The highest annual rates were among adolescents aged 15 to 19 years, but time trends revealed a steady linear increase among children aged 0 to 4 years and those aged 5 to 9 years as well as a steady linear increase until 2008 among the cohorts aged 10 to 14 years and 15 to 19 years, when rates briefly declined before rising again. Among adolescents aged 15 to 19 years, heroin was implicated in 1872 deaths: rates increased from 0.21 (95% CI, 0.17-0.25) to 1.06 (95% CI, 0.97-1.17), an increase of 404.8%, whereas rates for prescription opioids increased by 94.7% from 0.57 (95% CI, 0.49-0.66) to 1.11 (95% CI, 0.99-1.25) (all P for time effect <.001). Between 2014 and 2016, there were 1508 opioid deaths among adolescents aged 15 to 19 years; of these, 468 (31.0%) were attributed to synthetic opioids. Across time, 7263 (80.8%) of all pediatric deaths were unintentional, 5537 (61.6%) occurred outside of a medical facility, and 3419 (38.0%) children died at home or another residential setting. Among children younger than 5 years, 148 (24.5%) deaths were attributed to homicide.

CONCLUSIONS AND RELEVANCE

Over 18 years, nearly 9000 children and adolescents died from opioid poisonings, and the mortality rate increased nearly 3-fold. These findings suggest that the opioid epidemic is likely to remain a growing public health problem in the young unless legislators, public health officials, clinicians, and parents take a wider view of the opioid crisis and implement protective measures that are pediatric specific and family centered.

What do Australian & New Zealand caregivers know about children's ibuprofen? The results of an online survey?

Background

Children’s formulations containing ibuprofen are frequently used to treat pain and fever. These medications, available over-the-counter, have the potential to cause adverse events if usage/safety information is not adhered to. This study aimed to investigate caregivers’ knowledge about the safe use of a commonly purchased children’s formulation containing ibuprofen.

Methods

A convenience sample of caregivers in Australia and New Zealand, who had purchased Nurofen® for Children, completed an online survey assessing their knowledge of product information and dosage instructions available on/in the product packaging.

Results

In total, 219 caregivers (mainly female 95%, mean age ± SD; 35 ± 6.82 years) completed the online survey. Responses suggest limitations in their knowledge about the active ingredients, contraindications and side effect profile associated with the product. Most respondents had a good understanding about the correct dosage to give children based on their weight and/or age, but many lacked a good understanding about the correct interval between doses and the maximum number of daily doses.

Conclusions

These findings suggest that caregivers administering ibuprofen to children have gaps in their product knowledge. Strategies to help improve caregivers’ knowledge about the safe administration of these products should be prioritised in an attempt to reduce the likelihood of children experiencing ibuprofen related adverse events. Improving caregiver knowledge to address these gaps is an important issue for all health care providers.

Electronic supplementary material

The online version of this article (10.1186/s12887-018-1297-2) contains supplementary material, which is available to authorized users.

Frequency of Poison Center Exposures for Pediatric Accidental Unsupervised Ingestions of Acetaminophen after the Introduction of Flow Restrictors

OBJECTIVE

To assess the temporal association of flow restrictor introduction and the rate of accidental unsupervised ingestions (AUIs) of liquid acetaminophen products.

STUDY DESIGN

The National Poison Data System was used to identify AUIs of single ingredient acetaminophen in patients aged <12 years reported between 2007 and 2015. Six regional poison centers obtained additional information using a structured telephone survey.

RESULTS

Pediatric AUIs involving acetaminophen averaged 30 000 exposures per year between 2007 and 2012. From 2012 to 2015, after flow restrictor introduction, exposures steadily decreased at a rate of 2400 fewer exposures annually, reaching 21 877 exposures in 2015. Normalized to sales volume, exposures involving liquid acetaminophen products decreased by 40% from 2010 to 2015. Exposures involving products with flow restrictors tended to have a lower estimated ingestion per exposure, fewer exposures exceeding a 150 mg/kg acetaminophen threshold, and were associated with lower rates of hospital admissions when compared with products without restrictors. Caregivers reported improper storage and child confusion of the medicine with treats as common contributing factors to exposures.

CONCLUSIONS

The introduction of flow restrictors was associated with a decrease in pediatric AUIs of liquid acetaminophen products. Decreases in the dose ingested and risk of hospital admission per exposure may also have resulted. Efforts to optimize flow restrictors and increase their use with medicines associated with high pediatric overdose risk should be encouraged.

Antipyretic Medication Exposures Among Young Children Reported to US Poison Centers, 2000-2015

This study used the National Poison Data System database to retrospectively analyze the characteristics and medical outcomes of exposures to antipyretic medications involving children younger than 6 years in the United States. From 2000 through 2015, United States Poison Control Centers recorded an average of 74 387 antipyretic exposures annually among children younger than 6 years. Most exposures involved ibuprofen (55.1%) or acetaminophen (40.1%). From 2000 to 2009, the number of exposures increased by 73.0%, followed by a 25.2% decrease from 2009 to 2015. Children exposed to acetaminophen had 1.98 times higher odds of a serious medical outcome compared with those exposed to ibuprofen. Although generally safe at the correct dosage, antipyretic exposures continue to cause pediatric morbidity and, in rare cases, death. Prevention efforts should focus on reducing child access; educating caregivers about the potential dangers of antipyretics; and discouraging their use, except when needed to improve a child's comfort.

Opioid drug poisonings in Ohio adolescents and young adults, 2002-2014

CONTEXT

Opioids represent a drug class that adolescents and young adults intentionally misuse and abuse. When taken on their own or with other substances in this manner, opioids pose an increased risk of overdose and potential death.

OBJECTIVE

To determine trends of opioid drug poisonings among adolescents and young adults in Ohio from 2002 to 2014 using Poison Control Center (PCC) data.

METHODS

Data were obtained from Ohio PCCs from 2002 to 2014 for opioid drug poisonings amongst 10-29 year olds. Trends were evaluated with Poisson regression. Ohio counties with higher opioid drug poisoning rates were identified using age-adjusted resident population estimates. Chi-square tests were conducted to compare these county rates to the Ohio rate.

RESULTS

Both unintentional and intentional Ohio PCC opioid drug poisonings peaked in 2009, and there were significant declines through 2014. Almost 40% of intentional opioid drug poisonings were for young adults aged 18-24 years. Suspected suicide poisonings were 64.9% female, misuse poisonings were 54.5% male, and abuse poisonings were 60.1% male. Commonly reported substances included tramadol, heroin, and acetaminophen combinations with hydrocodone or oxycodone. Benzodiazepines and ethanol were the most common substances reported in conjunction with opioids. The top four Ohio counties with significantly higher opioid drug poisoning rates than the state average in 2014 were Hamilton, Mahoning, Butler, and Fairfield.

CONCLUSION

This study enhances the understanding of Ohio's opioid epidemic so that future prevention efforts and legislation can better target needed resources. Both males and females would benefit from opioid education early in their lives.

Pediatric Poisonings: The Risk of Over-the-Counter Pharmaceuticals

Every week in the United States, 56% of children younger than age 18 years and 82% of adults take at least one medication. Nonprescription medications, including acetaminophen and ibuprofen, are among the most commonly used pharmaceuticals across all age groups. Use of nonprescription medications, traditionally available over-the-counter, has become ubiquitous. Unfortunately, with such abundant use there is an associated risk for therapeutic misuse, intentional misuse, and even abuse. [Pediatr Ann. 2017;46(12):e454-e458.].

Adolescents from upper middle class communities: Substance misuse and addiction across early adulthood

In this prospective study of upper middle class youth, we document frequency of alcohol and drug use, as well as diagnoses of abuse and dependence, during early adulthood. Two cohorts were assessed as high school seniors and then annually across 4 college years (New England Study of Suburban Youth younger cohort [NESSY-Y]), and across ages 23-27 (NESSY older cohort [NESSY-O]; ns = 152 and 183 at final assessments, respectively). Across gender and annual assessments, results showed substantial elevations, relative to norms, for frequency of drunkenness and using marijuana, stimulants, and cocaine. Of more concern were psychiatric diagnoses of alcohol/drug dependence: among women and men, respectively, lifetime rates ranged between 19%-24% and 23%-40% among NESSY-Os at age 26; and 11%-16% and 19%-27% among NESSY-Ys at 22. Relative to norms, these rates among NESSY-O women and men were three and two times as high, respectively, and among NESSY-Y, close to one among women but twice as high among men. Findings also showed the protective power of parents' containment (anticipated stringency of repercussions for substance use) at age 18; this was inversely associated with frequency of drunkenness and marijuana and stimulant use in adulthood. Results emphasize the need to take seriously the elevated rates of substance documented among adolescents in affluent American school communities.

A clinical and safety review of paracetamol and ibuprofen in children

The antipyretic analgesics, paracetamol, and non-steroidal anti-inflammatory agents NSAIDs are one of the most widely used classes of medications in children. The aim of this review is to determine if there are any clinically relevant differences in safety between ibuprofen and paracetamol that may recommend one agent over the other in the management of fever and discomfort in children older than 3 months of age.