Medication Safe - Dr. Ben Tsutaoka

Article published in:

MMWR Morbidity and Mortality Weekly Report – published by the Centers for Disease Control and Prevention

2006 Jan 13;55(1):1-5.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5501a1.htm

Centers for Disease Control and Prevention (CDC).

Young children are vulnerable to inadvertent exposure to prescription and over-the-counter (OTC) medications, especially when these items are not stored securely. In 2002, according to death certificate data, 35 children aged <4 years died from unintentional medication poisonings in the United States (CDC, unpublished data, 2005). In 2003, according to reports to U.S. poison control centers, pharmaceuticals accounted for 1,336,209 (55.8%) of unintentional chemical or substance exposures. Of those pharmaceutical exposures, 568,939 (42.6%) involved children aged <6 years. For this report, CDC analyzed 2001-2003 data from hospital emergency department (ED) visits reported by the National Electronic Injury Surveillance System–All Injury Program (NEISS-AIP). The results of this analysis indicated that, during 2001-2003, an estimated 53,517 children aged <4 years were treated annually in U.S. EDs for unintentional medication exposures. An estimated 72% of these exposures were in children aged 1-2 years. Children aged <4 years can reach items on a table, in a purse, or in a drawer, where medications are often stored; young children also tend to put objects they find in their mouths. Parents and others responsible for supervising children should store medications securely at all times, keep them out of the reach of children, and be vigilant in preventing access by children to daily-use containers such as pill boxes.

NEISS-AIP is operated by the Consumer Product Safety Commission and collects data on all types and causes of injuries in patients treated in hospital EDs. Data are collected from a nationally representative subsample of 66 of the 100 NEISS hospitals that were selected as a stratified probability sample of hospitals in the United States and its territories. NEISS-AIP provides data on approximately 500,000 injury-related and consumer-product-related cases each year.

Cases were defined as those involving children aged <4 years treated at a NEISS-AIP hospital ED for nonfatal, unintentional exposures to medications, including all types of prescription and OTC medications. Cases involving only illicit drugs or alcohol were excluded. Cases resulting from the adverse effects of therapeutic use of medications, medical errors (e.g., misprescribed by doctor or pharmacist), or drug exposure of infants from maternal drug use during pregnancy or breastfeeding also were excluded. A brief narrative abstracted from the medical record was used to code, where possible, the route of exposure (e.g., ingestion, inhalation, or external contact), likelihood of exposure (i.e., probable or possible [one case was classified as unclear]), source of medication (e.g., pill box or purse), intended user (e.g., grandparent or parent), and class of medication.

Each case was assigned a sample weight based on the inverse of the probability of selection; these weights were summed to provide national estimates of nonfatal medication exposures. Estimates were based on weighted data for 3,632 patients aged <4 years treated at NEISS-AIP hospital EDs for medication exposures during 2001-2003.

During 2001-2003, an estimated 53,517 (95% CI = 43,166-63,868) children aged <4 years were treated annually in EDs for nonfatal, unintentional medication exposures, an annual rate of 273.5 per 100,000 age-specific population (CI = 220.5-326.4). Children aged 1 year and 2 years had the highest rates (444.4 and 534.6, respectively) and accounted for 72.0% of medication exposure cases. Nearly one in 10 children (9.7%) were hospitalized or transferred for specialized care for their medication exposure. The majority of the cases occurred in the home (75.4%). Among the medication exposures, 85.6% were classified as probable; 98.9% of the exposures resulted from ingestion.

The source of the medication was not specified for 3,100 (85.4%) of the NEISS-AIP cases and the intended user was not specified for 2,982 (82.1%). On the basis of unweighted data, the most common sources of medication exposure were pills left out or pill bottles left open, which was reported in 215 (5.9%) cases. Other incidents involved medications administered in error by a parent or caregiver (3.5%) and children opening pill boxes (2.7%) or purses (3.0%). Among cases with intended users identified, the medications were intended most commonly for use by the child’s grandparent (7.5%) or parent (6.6%). Exposures from OTC medications (42.2%) were slightly more common than from prescription medications (39.2%). Among the approximately 92% of cases for which the class of medication could be identified, the most common medications were central nervous system agents (e.g., acetaminophen or antidepressants) (26.9%), respiratory agents (e.g., cough and cold or anti-asthma agents) (11.6%), and musculoskeletal agents (e.g., nonsteroidal anti-inflammatory agents or muscle relaxants) (8.4%). Other common classes were cardiovascular agents (7.8%), dermatologic agents (e.g., topical antibacterial or analgesic agents) (5.3%), antihistamines (4.9%), and vitamins and therapeutic nutrients (4.5%). Prescription medications accounted for 67% of admissions to hospitals or transfers for specialized care. Among those agents specified, the most common medication classes involved in hospital admissions or transfers were anticonvulsant agents (9.6%), calcium-channel blocking agents (6.8%), antidepressant and mood-stabilizing agents (6.2%), and oral hypoglycemic agents (6.2%).

Editorial Note:
Data in this report indicate that, during 2001-2003, an estimated 53,517 children aged <4 years were treated in U.S. hospital EDs each year for unintentional exposure to prescription and OTC medications. Consistent with previous studies, most of these exposures occurred in the home among children aged 1-2 years. Certain exposures involved common household medications such as acetaminophen, nonsteroidal anti-inflammatory agents, cold and cough preparations, and vitamin and mineral supplements. Some of these agents can be highly toxic (e.g., acetaminophen or opiod analgesics), and ingestion by young children can lead to death. Children aged <4 years treated in EDs for medication exposures were nearly four times as likely to be hospitalized or transferred for specialized care as children in this age group treated for all unintentional causes of injury (9.7% versus 2.5%).

During the last 3 decades, emphasis on preventing unintended medication exposures has reduced the number of deaths from childhood poisonings. Multiple factors likely have contributed to this decline, including improved packaging, product substitutions and reformulations, education programs, accessibility of poisoning information, and treatment advances. Child-resistant packaging, mandated by the Poison Prevention Packaging Act of 1970, has been credited with reducing prescription medication deaths in children aged <4 years by 45% from 1974 to 1992.

Despite the progress in reducing the number of fatal poisonings, unintentional medication exposures remain a serious threat to the health of young children. Data from this report indicate that, in 2002, approximately 1,500 ED visits and 150 hospital admissions or transfers from EDs occurred for each of the 35 fatalities reported among children aged <4 years. National data on fatal and nonfatal medication exposures should be used to set prevention priorities and develop interventions. Although requirements for child-resistant packaging are mandated by the Poison Prevention Packaging Act, this study determined that at least 12% of ED visits for medication exposures resulted from children gaining access to medications left in the open, in pill boxes, or in purses. Because medication users often transfer medications from their original child-resistant containers to other containers for daily use, manufacturers are encouraged to improve container designs and promote strategies that allow convenient access for the intended user while also protecting children.

The findings in this report are subject to at least three limitations. First, NEISS-AIP provides only national estimates of unintentional medication exposures and not state or local estimates. Second, NEISS-AIP provides data only for patients treated in hospital EDs and does not include children treated in outpatient settings or not treated at all. Finally, narratives abstracted from medical records provided information regarding the source of the medication and the intended user for only 15% and 18% of the cases, respectively; for the remaining cases, the source and intended user of the medication were unknown.

Continued promotion of established prevention measures can help reduce morbidity and mortality from unintentional medication exposures. However, to help develop new prevention strategies and assess their effectiveness in reducing the most common and most severe incidents among young children, additional data on the incident circumstances, specific medications involved, and patient outcomes are needed. More complete incident information will be available through the recently implemented NEISS Cooperative Adverse Drug Event Surveillance project (NEISS-CADES), which collects detailed information (e.g., drug dosage, laboratory testing, and clinical treatment) on all types of adverse drug events, including unintentional drug ingestions by children.

Article published in:

Pediatrics-Official Journal of The American Academy of Pediatrics

2003 Jun;111(6 Pt 1):e683-92.

http://pediatrics.aappublications.org/cgi/content/full/111/6/e683

Agran PF, Anderson C, Winn D, Trent R, Walton-Haynes L, Thayer S.

University of California, Center for Health Policy and Research, Pediatric Injury Prevention Research Group, Irvine, California 92697-5800, USA.

ABSTRACT

OBJECTIVE: Mortality and morbidity data on childhood injury are used to construct developmentally appropriate intervention strategies and to guide pediatric anticipatory counseling on injury prevention topics. Effective anticipatory guidance depends on detailed injury data showing how risks change as children develop. Conventional age groupings may be too broad to show the relationship between children’s development and their risk of various causes of injury. Previous studies revealed differences in overall rates and specific causes of injury by year of age. However, single year of age rates for children younger than 4 years may not reflect the variations in risk as a result of rapid developmental changes. This study was designed to analyze injury rates for children younger than 4 years by quarter-year intervals to determine more specifically the age period of highest risk for injury and for specific causes.

METHODS: We used data from 1996-1998 California hospital discharges and death certificates to identify day of age and external cause of injury (E-code) for children younger than 4 years. The number of California residents for each day of age was estimated from US Census of estimates of California’s population by year of age for the midpoints (1996-1998). Rates were calculated by 3-month intervals. We grouped the E-codes into major categories that would be particularly relevant for developmentally related risks of injury specific to young children. The categorization took into account physical, motor, behavioral, and cognitive developmental milestones of children 0 to 3 years.

RESULTS: There were a total of 23,173 injuries; 636 resulted in death. The overall annual rate for children aged 0 to 3 years was 371/100,000. Beginning at age 3 to 5 months, the overall rate of injury rapidly increased with increased age, peaking at 15 to 17 months. The mean injury rate calculated for each single year of age did not reflect the variation and the highest rate of injury by quarter year of age for children younger than 1 year, 1 year, and 2 years. The leading major causes of injury in descending order were falls, poisoning, transportation, foreign body, and fires/burns. The overall rate of the major category of falls exceeded poisoning, the second leading cause of injury, by a factor of 2. Age-related differences were detected within each major cause of injury. For children 0 to 12 months of age, there was a different leading cause of specific injury for each 3-month period: other falls from height (0-2 months), battering (3-5 months), falls from furniture (6-8 months), and nonairway foreign body (9-11 months). Hot liquid and vapor injuries were the leading specific causes for children 12 to 17 months. Poisoning by medication was the leading specific cause of injury for all age groups from 18 to 35 months and exceeded poisoning by other substances. Pedestrian injury was the leading specific cause of injury for all age groups from 36 to 47 months. Fall from furniture has the highest rates of specific causes of falls from age 3 to 47 months. Fall from stairs peaked at age 6 to 8 months and 9 to 11 months. Fall from buildings was highest at 24 to 26 months. Poisoning by medication peaked at age 21 to 23 months, but poisoning by other substances peaked at 15 to 17 months. The motor vehicle occupant injury rates were fairly stable over the age span of this study. The pedestrian injury rate increased beginning at age 12 to 14 months and by 15 to 17 months was double that of the motor vehicle occupant. Foreign body had a marked peak at age 9 to 11 months. Both battering and neglect rates were highest among infants 0 to 2 and 3 to 5 months. Bathtub submersions had a narrow peak at age 6 to 11 months. Other submersions peaked at 12 to 14 months and remained high until 33 to 35 months.

CONCLUSIONS: We departed from usual groupings of E-codes and devised groupings that would be reflective of age-related developmental characteristics. Differences in rates by narrow age groups for young children can be related to developmental achievements, w can be related to developmental achievements, which place the child at risk for specific causes of injury. We found marked variability in both rates and leading causes of injury by 3-month interval age groupings that were masked by year of age analyses. Children aged 15 to 17 months had the highest overall injury rate before age 15 years. This coincides with developmental achievements such as independent mobility, exploratory behavior, and hand-to-mouth activity. The child is able to access hazards but has not yet developed cognitive hazard awareness and avoidance skills. A remarkable finding was the high rate of battering injury among infants 0 to 5 months, suggesting the need to address potential child maltreatment in the perinatal period. Poisoning was the second major leading cause of injury; more than two thirds were medication. Cultural factors may influence views of medications, storage practices, use of poison control system telephone advice, and risk of toddler poisoning. The pedestrian injury rate doubled between 12 and 14 months and 15 and 17 months and exceeded motor vehicle occupant injury rates for each 3-month interval from 15 to 47 months. Pedestrian injury has not received sufficient attention in general and certainly not in injury prevention counseling for children younger than 4 years. Anticipatory guidance for pedestrian injury should be incorporated before 1 year of age. Effective strategies must be based on the epidemiology of childhood injury. Pediatricians and other pediatric health care providers are in a unique position to render injury prevention services to their patients. Integrating injury prevention messages in the context of developmental assessments of the child is 1 strategy. These data can also be used for complementary childhood injury prevention strategies such as early intervention programs for high-risk families for child abuse and neglect, media and advocacy campaigns, public policies, and environmental and product design.

Article published in:

Pediatrics-Official Journal of The American Academy of Pediatrics

2008 Jan 28 [Epub ahead of print].

http://pediatrics.aappublications.org/cgi/content/abstract/peds.2007-3638v3

Schaefer MK, Shehab N, Cohen AL, Budnitz DS.

A Division of Healthcare Quality Promotion, National Center for Preparedness, Detection, and Control of Infectious Diseases, Coordinating Center for Infectious Diseases.

ABSTRACT

BACKGROUND. Adverse drug events in children from cough and cold medications have been identified as a public health issue with clinical and policy implications. Nationally representative morbidity data could be useful for targeting age-appropriate safety interventions.

OBJECTIVE. To describe emergency department visits for adverse drug events from cough and cold medications in children.

METHODS. Emergency department visits for adverse drug events attributed to cough and cold medications among children aged <12 years were identified from a nationally representative stratified probability sample of 63 US emergency departments from January 1, 2004, through December 31, 2005.

RESULTS. Annually, an estimated 7091 patients aged <12 years were treated in emergency departments for adverse drug events from cough and cold medications, accounting for 5.7% of emergency department visits for all medications in this age group. Most visits were for children aged 2 to 5 years (64%). Unsupervised ingestions accounted for 66% of estimated emergency department visits, which was significantly higher than unsupervised ingestions of other medications (47%), and most of these ingestions involved children aged 2 to 5 years (77%). Most children did not require admission or extended observation (93%).

CONCLUSIONS. Timely national surveillance data can help target education, enforcement, and engineering strategies for reducing adverse events from cough and cold medications among children. Engineering innovations could be particularly helpful in addressing unsupervised ingestions, which is the most frequent cause of adverse events. These innovations could be applicable to other children’s medications.