Tia Dickson, RN, BSN

Primary Children's Hospital

Two pediatric populations, toddlers and teens, seem to mirror one another when it comes to risky behavior. Both groups are developmentally very similar. They are struggling to grow into the next stage of life, but don't have all the right tools yet. From drownings to traumatic injury, risk goes up for toddlers and teens. The same can be said of these children and their risk of overdose. Children younger than six years old account for more than half of all poisonings (most often accidental). Overdose deaths also rise during the teen years. For toddlers, teens, or anyone in-between, our response is the same. Let's take a look at pediatric ingestion.

Toddler Toxicity, Death in A Dose

Jennifer Plumb MD, MPH

Poisoning in children most commonly peaks during the toddler and teen years. The toddler population (ages 1-3 years) is at risk for many reasons. They are attracted to color and appearance of the agent or container. They are more willing to taste dangerous substances as they exhibit hand-mouth behavior nearly 10 times an hour. This is how they explore their environment. Most ingestions of a toxic substance by this age group are in small amounts and result in nontoxic or minimally toxic outcomes. However, there are several substances found in the average home that pose a great risk in small amounts. Ingestion of these substances can lead to death in a single dose.

Ointments

• Camphor: Found in over-the-counter medications such as Vicks® VapoRub™, Tiger Balm, and BENGAY®. As little as 7 grams can be fatal.
  
• Methyl salicylate : Also known as Oil of Wintergreen, it is found in items like BENGAY®, LISTERINE®, various candy and gum, and in essential oils used for burners. A single teaspoon is equivalent to 90 baby aspirin; four times the toxic dose for a 10kg child.
• Podophyllin: This is used to treat genital warts and is in some herbal medicines. Ingested in pure form, 1ml could be a fatal dose.

Pills, Tablets, and Capsules

• Antimalarials : Quinine and chloroquine can cause arrhythmias and cardiac arrest in one dose and within the first hour of ingestion.
• Clonidine: Children can mistake clondine patches for bandaids . It is important to examine the skin when overdose is suspected.
• Tricyclic Antidepressants (TCAs): Can cause status epileticus or cardiotoxicity.
• Calcium channel blockers: Can have immediate effects or toxic symptoms lasting longer than 24 hours since capsules are often sustained released.
• Oral hypoglycemics: Glipizide is commonly found in the homes of diabetic adults. This and other oral hypoglycemic can lower a child’s blood glucose profoundly.
• Narcotics: Opioids are the number one cause of pediatric poisoning fatalities in the United States.

These substances should raise a red flag for the EMS provider. They warrant rapid transportation and treatment. For acute stabilization refer to the Utah Pediatric Off-line Medical Direction Protocol Guidelines.

Teens are exposed to prescription opioids and trends show 25 percent of high school seniors self-report medical or nonmedical use of prescription opioids. In 2016, 3.6 percent of teens aged 12 to 17 reported misusing opioids over the past year. This percentage is twice as high among people ages 18 to 25. Most of this misuse is due to prescription opioids, not heroin.

And research now shows that adult abuse of opioids can be traced to the legitimate use of opioids in teens.

Substance Abuse and Mental Health Services Administration. (2017). https://www.samhsa.gov/data/ ‌

• Out of all 50 US states, Utah had the 7th highest drug overdose rate in the U.S. between 2013 and 2015 and the 5th highest in the nation for prescription overdose deaths.
• Prescription drug deaths in Utah have increased by 400 percent since 2000.

From Utah Naloxone

There are different types of opiates/opioids that people use, and that children are exposed to in their homes. All of these are capable of leading to overdose and death. They include:

• Oxycodone (Oxycontin®, Percodan®, Percocet®, Tylox®)
• Hyodrocodone (Lortab®, Vicodin®, Hycodan®, Lorcet®, Vicoprofen®, Hycet®, Norco® )
• Methadone®
• Morphine
• Meperidine (Demerol®)
• Codeine (Fioricet®, Tylenol #3™)
• Oxymorphone (Opana®)
• Fentanyl (Duragesic®)
• Hydromorphone (Dilaudid®)
• Buprenorphine (SUBOXONE®, Subutex®, Butrans®)
• Counterfeit opioids (u-47700, pink)
• Heroin

Opioid overdose kills because it causes respiratory depression. This leads to:

• Slow or no breathing—Cyanosis from very slow breathing which progresses to apnea when the breathing stops
• Cardiac arrest as the heart stops because it’s not getting oxygen
• Circulatory collapse as circulation of blood to the brain stops

An opioid overdose is recognizable by the following signs and symptoms:

• Somnolence—Can’t arouse them, they don’t respond to painful stimuli
• Respiratory depression—Very slow or gurgling respirations and, ultimately, no breathing (apnea)
• Cyanosis—Turning blue, noticed first around lips and fingers
• Pinpoint pupils (miosis)
• Cold or clammy skin
• Bradycardia—Slow heartbeat (<50)

Fortunately, opiate overdose is reversible through timely administration of the drug naloxone (Narcan®) and the provision of emergency care. This is a very safe antidote and has been used in ambulances and hospitals for decades. It is also stronger than the opioids it counters, so it will reverse the respiratory depression and stop the overdose very effectively if administered in time. It is only effective against opioid overdoses and not against overdoses of other substances such as alcohol, cocaine, methamphetamine, or benzodiazepines. In some cases, more than one dose of naloxone is needed to reverse the effects of an opioid overdose. Unfortunately, its reversal effects last only 30-90 minutes. This requires that patients be observed after receiving naloxone because they are at risk of overdosing again from the potentially longer-acting substances still in their bodies when the naloxone wears off.

First responders play a very important role in administering naloxone to those who are experiencing an opioid overdose. It is an antidote that acts only on the opiate receptors in the brain and is very safe. The main side effect of administration is possible agitation and aggression since the patient may be sent immediately into opioid withdrawal. Vomiting is also reported about 10-15% of the time it is administered.

Death by opioid overdose is a tragedy that can be simply and safely reversed by administration of naloxone. These deaths are occurring at alarming rates in our state. Administration of naloxone by medical providers and laypersons can save lives. And the lives saved are those of our neighbors, our family members, our friends, and each of them is loved by others. These lives matter.

Overdose Deaths Surged in Pandemic, As More Drugs Were Laced With Fentanyl. https://www.delawarepublic.org/post/overdose-deaths-surged-pandemic-more-drugs-werelaced-fentanyl April 22, 2021

The Health 202: Overdose deaths may have topped 90,000 in 2020. https://www.washingtonpost.com/politics/2021/04/07/health-202-overdose-deaths-may-havetopped-90000-2020/ April 7, 2021

The Spike in Drug Overdose Deaths During the COVID-19 Pandemic and Policy Options to Move Forward. https://www.commonwealthfund.org/blog/2021/spike-drugoverdose-deaths-during-covid-19-pandemic-and-policy-options-move-forward March 25, 2021.

COVID-19 complications likely increasing the severity of Utah’s opioid crisis. https://www.ksl.com/article/50049960/covid-19-complications-likely-increasing-the-severityof-utahs-opioid-crisis November 19, 2020

Recruiting Participants for Pediatric Emergency Care Champions (PECC) Development Collaborative

Pediatric emergency care coordinators, also known as PECCs, are vital to improving care for children in emergency settings. Led by the EMSC Innovation and Improvement Center (EIIC), the PECC Workforce Development Collaborative is a free program that begins in September and is designed to help prehospital and hospital emergency providers, along with EMSC State Partnership program managers, become effective pediatric champions. Pediatric experience is not required to join.

Does your agency have a PECC? Are they registered for our 1st PECC conference?

If you're a pediatric advocate within your agency, we need you. Please contact our program manager, Mark Herrera (markherrera@utah.gov), to find out how you can help. Join BEFORE our first Annual PECC Conference on September 30th (see below). We have designated PECCs from 47 agencies already registered.

WE HAVE A 95.9% RESPONSE RATE; ONLY 2 MORE HOSPITALS!

The survey closes August 31.

SHOUT OUT to Jordan Valley West and Kane County Hospital YOU NEED YOU!

If you have contact with the Emergency Department Managers of either of these hospitals please let them know we are awaiting their assessment.

They can find the survey link here . . .

https://emscimprovement.center/domains/pediatric-readiness-project/

How dangerous is the Delta variant for children?

An internal CDC document obtained by The Washington Post July 29 said it is “likely” the Delta variant causes more severe illness than previous variants. That has not been conclusively established, however, and some infectious disease experts say they do not see persuasive evidence of a difference.

One thing is clear: “It is certainly more transmissible,” said Sean O’Leary, vice chair of the Committee on Infectious Diseases for the American Academy of Pediatrics. For comparison, the Alpha variant, which was the most predominant in the United States before this one, was estimated to be 50 percent more transmissible than the original coronavirus.

The Delta variant is 50 to 60 percent more transmissible than the Alpha variant. “We’re in this situation where things are opening up while this is more predominant,” O’Leary said. “There are a lot of reasons for concern for all of us in general. Cases have jumped for kids specifically.”

The virus’s ability to spread quickly is especially worrisome because only 30 percent of the children who are eligible are vaccinated, according to the CDC. “That’s pitiful,” said Jennifer Lighter, pediatric infectious-disease specialist at New York University Langone Health. Covid-19 and the flu in children have “the same kind of morbidity,” she said, but added, “If it’s preventable, I don’t want any child getting it.”

https://www.washingtonpost.com/lifestyle/2021/07/22/covid-delta-variant-children/

How can I protect my unvaccinated child?

These are the best ways to protect your child, or a child you care for, who cannot get vaccinated yet:

• Get vaccinated yourself. COVID-19 vaccines reduce the risk of people getting and spreading COVID-19.

• If your child is two years and older, make sure your child wears a mask in public settings and takes other actions to protect themselves.
  • To set an example, you also might choose to wear a mask.
• If your child is younger than two years or cannot wear a mask, limit visits with people who are not vaccinated or whose vaccination status is unknown and keep distance between your child and other people in public.

Utah health department 'strongly' recommends indoor masking for K-12 students
https://www.ksl.com/article/50216644/utah-health-department-strongly-recommends-indoor-masking-for-k-12-students

CDC Checklist: Planning for In-Person Classes https://www.cdc.gov/coronavirus/2019-ncov/community/pdf/Back-to-School-Planning-for-In-Person-Classes.pdf

Covid-19 Trackers

Johns Hopkins Global tracker (desktop)

Johns Hopkins Global tracker (mobile)

Utah Department of Health

Do you have a question for our EMSC Medical Director, Hilary Hewes, MD, PCH, ER Attending Physician about this newsletter topic or anything related to pediatrics? Shoot an email to the following address tdickson@utah.gov.

You have the right to close the loop on care you provided. For follow up on patients brought to Primary Children's Hospital, contact the PCH EMS Liaison, Lynsey Cooper at Lynsey.Cooper@imail.org.

Pediatric Education for the Prehospital Provider

Register online at www.peppsite.com. Look up classes in Utah and find the one that works for you. Once you find the class, go to jblearning.com, and look up pepp als in the search tool. Purchase the number ($18.95). Return to peppsite.org to register for the class and follow the prompts.

If you have any questions, please email Erik Andersen at erikandersen@utah.gov or text/call 435-597-7098. Continue to watch the website for additional classes.

The Emergency Medical Services for Children (EMSC) Program aims to ensure that emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure that the system is backed by optimal resources and that the entire spectrum of emergency services (prevention, acute care, and rehabilitation) is provided to children and adolescents, no matter where they live, attend school, or travel.

Email: tdickson@utah.gov
Website: https://bemsp.utah.gov/
Phone: 801-707-3763
Facebook: facebook.com/Chirp-UtahDepartmentofHealth