Trends in Fentanyl Poisoning and Management in Children’s Hospitals

Drug poisonings are the third leading cause of pediatric deaths in the United States.1 This is largely due to fentanyl, which contributed to 5% of deaths from opioids in 1999 but 94% in 2021.2 Pediatric hospitalizations from opioid poisoning have similarly increased.3,4 There are limited data describing recent pediatric fentanyl poisoning hospitalizations. Our aim was to further characterize the current trends of pediatric fentanyl poisonings presenting to children's hospitals.We performed a retrospective cross-sectional study of emergency department, observation, and inpatient encounters from 43 children's hospitals participating in the Pediatric Health Information System (PHIS) database. Children aged 0 to 19 years with a fentanyl or fentanyl analog poisoning encounter from October 2020 to September 2023 were included using International Statistical Classification of Diseases, Tenth Revision, (ICD-10) codes established in 2020 (Supplemental Appendix 1). We excluded encounters from hospitals not contributing data into PHIS during the entire study period as well as children with hospice status, HIV, or oncologic diagnoses as these patients might differ from our population of interest (Supplemental Appendix 2). Our primary outcome was the quarterly number of encounters. Secondary outcomes included patient characteristics and outcomes, resource utilization, and regional variability.Categorical data were summarized with frequencies and percentages. Differences in demographic and clinical characteristics were assessed across age strata using χ2 tests. Statistical analyses were performed using SAS v.9.4 (SAS Institute), and P values of less than .05 were considered statistically significant. This study was exempt from institutional review board review.We identified 1250 encounters for fentanyl poisoning of which 73 were excluded. Of these, 96% had a single encounter, 3% had 2 encounters, and the remaining had 3 to 4 encounters.Quarterly volume of fentanyl encounters increased 224% from 45 in quarter 4 2020 to 146 in quarter 3 2023. Visits increased 135% among children aged 0 to 4 years, 167% among children aged 5 to 11 years, and 438% among children aged 15 to 19 years (Figure 1). There was a bimodal age distribution with 49% involving children aged 0 to 4 years and 47% involving children aged 12 to 19 years. Compared with other age groups, adolescents were more frequently male, using nongovernmental insurance, residing in higher-opportunity neighborhoods, and experiencing higher rates of substance use disorders (Table 1).More than 85% of children diagnosed with fentanyl poisoning required hospital admission, and 42.7% required intensive care unit (ICU) care. One-third (33.2%) required respiratory support, and 22.3% of children were intubated. Parenteral naloxone was administered to 34.2%, 2.4% received cardiopulmonary resuscitation, and 2 (0.2%) required extracorporeal membrane oxygenation. There were 17 deaths (1.4%), spanning all age ranges. There was regional variability with most patients from the Midwest and West. The Midwest had a higher proportion of patients aged 0 to 4 years whereas the West had a higher proportion of adolescents (Table 1).Pediatric fentanyl poisoning encounters at children's hospitals increased 3-fold from 2020 to 2023. There was a bimodal age distribution with toddlers and adolescents most affected. The majority of patients required hospital admission with a high rate of ICU care.The increase in pediatric fentanyl poisonings may be influenced by increased screening and knowledge of ICD-10 diagnoses codes but is congruent with published trends.2,3,5 Notably, our data demonstrated a larger proportion of young children, suggesting accidental poisonings play an important and growing role. Younger children had disproportionately lower Child Opportunity Indexes6 (a multidimensional measurement of neighborhood conditions influencing children's health) and higher rates of government insurance, which may indicate these poisonings are affected by socioeconomic factors. Adolescents had high rates of comorbid psychiatric illness, which are known risk factors for opioid overdose.7,8 We observed a 224% increase in fentanyl poisoning encounters over 3 years with nearly half requiring ICU admission (similar to a previous study of opioids).4 This increase in encounters, bimodal age distribution, and regional variability highlight a need for multifaceted public health interventions, including safe medication storage, naloxone education, and treatment for opioid use disorder. Limitations include the use of ICD-10 codes with unknown accuracy and inability to correlate them with confirmatory laboratory results, yet our findings are consistent with contemporary literature.2,3,5 There was notably lower use of intranasal naloxone, which may be due to PHIS data not including interventions given prior to the hospital encounter. Mortality is also likely underestimated as we did not capture deaths outside of the hospital setting. Hospital encounters for fentanyl poisonings in children's hospitals are increasing, primarily affecting toddlers and adolescents, and require a high rate of inpatient care.