February 19, 2023

Drug Overdose Deaths in Children

“What child takes five-hour naps?” I asked myself as I reviewed family statements about the death of a toddler. The autopsy didn’t reveal an obvious cause of death and the child was too old for a SIDS diagnosis. Drug overdose deaths in children this age are unusual, but the toxicology report confirmed my suspicion that drugs were involved. The child’s blood was positive for methadone, a synthetic opioid a caregiver was taking through a methadone clinic. Shocked, I certified the death as a homicide — death at the hands of another. Then I called ChildLine (there were other children in the home), and informed the District Attorney’s office of the findings. (Update February 20, 2023. Criminal charges filed in this case as reported in a Daily Local News article.)

More than 50% of Infant/Toddler Drug Deaths are Homicide or Manner Undetermined

Drug poisoning deaths in the very young are much less likely to be accidental than drug poisoning deaths in adolescents and adults. After all, the very young, especially infants, don’t usually self-administer medications of any kind. A national study found that children aged 1 to 4 years were more than twice as likely to die of opioid poisoning in 2016 as in 1999. Of the 605 infant and toddler deaths during that time, almost 25% were certified as homicides. The coroner certified the manner of death as undetermined in 37.5% and accidental in 38%. Undetermined means the coroner couldn’t decide whether it was an accident or a homicide. So the actual number of homicides was probably higher than 25%. The incidence of homicide was higher (34.5%) when only the 57 infants were considered. Most infants aren’t capable of accidentally ingesting drugs in their environment. That means the manner of death is more likely to be homicide.

Illicit Drugs: Fentanyl Kills Kids Too

Fentanyl, responsible for the majority of accidental drug deaths in adults, causes drug overdose deaths in children too. The DEA issued an alert in 2022 about “brightly-colored” fentanyl pills that would be attractive to children who might think they were candy.

It’s not hard to find media accounts of the tragic consequences. In January 2023, a 23-month-old girl who’d been living in a homeless encampment died of fentanyl toxicity in Nashville, TN. Her parents were addicted to opioids, and investigators found drugs and paraphernalia at the scene. The medical examiner ruled the death as an accident. Fentanyl toxicity caused the deaths of three other children aged 11 months, 18 months, and 4 years, respectively, in 2022. The drug was either readily accessible or purposefully administered to the children. In each of those cases, police arrested the mother (and sometimes a boyfriend). The charges ranged from second degree manslaughter to negligent child abuse resulting in death.

Drug Overdose Deaths in Children due to Medication for Opioid Use Disorder (MOUD)

Prescribed opioids — including medications used to treat opioid use disorder (MOUDs) — are just as dangerous for children as illicit opioids. Methadone and buprenorphine products (e.g. Suboxone, Subutex) have been a boon for addiction treatment. However, after methadone became a treatment for heroin addiction in the late sixties, an article in a pediatric journal warned pediatricians about the risk to their patients. That risk is increasing due to changes in methadone administration since the COVID-19 pandemic.

Early in the pandemic, SAMHSA — the Substance Abuse and Mental Health Services Administration — relaxed federal restrictions on methadone for public health reasons. Now methadone clinics allow patients to take home and self-administer up to 28 days of the liquid opioid. This has been a boon for OUD patients because it decreases stigma and encourages treatment adherence. But we need to know more about how new administration practices affect children. Unfortunately some of that information will come from coroners and medical examiners.

SAMHSA also allowed greater flexibility of buprenorphine prescribing for MOUD when the COVID-19 emergency went into effect in March 2020. A recent study showed no increase in buprenorphine-associated deaths since then. As of January 2023, SAMHSA has announced that any health care provider with a DEA license can prescribe these medications. The drugs, formulated as pills or films, are pleasantly flavored and designed to be absorbed very quickly in the mouth. That means they pose a potential risk to young children. A 2013 research study in the Journal of Pediatrics reported 2380 buprenorphine poisonings from 2009-2012 in children aged 28 days to under 6 years. Four of the overdoses resulted in death. Improper storage of the medications was the most common cause of pediatric poisonings.

Identifying and Preventing Drug Overdose Deaths in Children

It’s up to coroners and medical examiners to investigate sudden unexpected infant and child deaths. As of 12/24/2018, Pennsylvania law (16 P.S. § 1220-B) requires the coroner to “perform or order an autopsy…in the case of the sudden unexplained death of a child who is not more than three years of age.” It’s a shame the legislature didn’t specifically require blood toxicology testing by a certified lab when they passed that law. Retaining a hair sample would be a good idea too. Hair doesn’t decompose and can document chronic administration of a drug as opposed to a one-time “accident.”

There also needs to be more education encouraging use of naloxone in children who may be experiencing an overdose. FDA-approved labeling allows standard nasal spray dosing of 2 – 4 mg dose for all children except those less than 4 weeks of age (neonates). In 2020 FDA recommended prescribing it for households with children at risk of opioid exposure.

• If buprenorphine is less risky than methadone for young children (more research needed) , buprenorphine should be the preferred treatment for patients with children in the household
• Childproof packaging or lockboxes for opioid users (prescribed and illicit) should be used if there are children in the household
• Parents/caregivers on MOUD or who are opioid drug users should have naloxone nasal spray at home in a 2-4 mg dose spray
• Parents, caregivers, and EMS need to know signs of opioid overdose in infants and young children
• Coroners and medical examiners need to do blood toxicology and retain a hair sample on all unexplained or sudden child deaths