US Pharm. 2023;48(10):27-31.
ABSTRACT: Prescription medications, whether prescribed to a child or another household member, can be dangerous for a child if used improperly or overdosed accidentally. Medication design, packaging, and flavor, as well as incorrect medication dosing, storage, and/or disposal of unused medication, can contribute to accidental pediatric medication overdoses. Emergency department visits can be avoided by providing caregivers with the knowledge and tools to safely store and administer medication to children. Pharmacists are well positioned to engage caregivers about safe medication use and advocate for initiatives that aim to improve medication safety in the pediatric population.
Prescription medications, whether prescribed to the child or another household member, can be dangerous when used improperly. Pediatric overdose results in many emergency department visits and hospitalizations, and sometimes death, each year.1 Opioids are a class of prescription medications that require utmost attention for strategies to decrease pediatric overdose.2,3 Pharmacists are well positioned to engage caregivers and advocate for various strategies to improve medication safety in the pediatric population.
Emergency Department Visits
Thousands of children visit the emergency department each year due to medication overdoses.1 About 150,000 children aged younger than 18 years are brought to the emergency department each due to an adverse drug event.4 Children aged younger than 5 years account for an estimated 35,000 emergency department visits annually due to accidental overdose, with over 90% of visits resulting from lack of caregiver oversight.1 Medication errors linked to accidental overdose in children aged younger than 5 years account for around 5% of emergency department visits.1 One of the most common errors caregivers make is incorrectly measuring a child’s medication.1
Areas of Concern
One area of concern for children’s accidental overdose from a prescription or nonprescription medication is due to their curiosity.2 A child may consume a medication for any number of reasons, but a medication’s design has an important role. As an example, a medication may look appealing to a child when it comes in bright colors or looks like candy.2 Certain medication flavors and designs can be beneficial to encourage a child to take a medication; however, to ensure the child’s safety, medication design needs to be considered to aid in the prevention of inadvertent consumption of the medication or taking too much of it.
While a child can overdose on a prescription or a nonprescription medication, opioids and other high-risk medications contribute significantly to fatal overdoses in the pediatric population.3 Concerns with high-risk medications, such as opioids, benzodiazepines, and stimulants, include accidental ingestion as well as intentional misuse or abuse, either of which can contribute to an overdose. Unfortunately, from 2005 to 2018, there was an increase from 24% to 52% in opioid-related deaths in children aged younger than 5 years.3,5,6 Ingestion of more than one prescription medication, whether intentionally or accidentally, is especially dangerous and of concern.6 This article will focus on accidental pediatric medication overdose.
Strategies to Decrease Accidental Overdose Risk
The Prevention of Overdoses and Treatment Errors in Children Taskforce (PROTECT) initiative’s mission is to develop ways to prevent accidental pediatric medication overdoses. The CDC began this initiative in 2008 and continues to lead it today. Its goal is a reduction in emergency department visits due to accidental overdoses, especially in children aged younger than 5 years. To achieve this goal, PROTECT has many partners, including pharmaceutical manufacturers, packaging companies, and government agencies, that implement overdose-prevention strategies.1,7
PROTECT focuses on three areas to prevent pediatric medication overdoses: improving packaging, preventing errors, and educating on proper medication use and storage. The taskforce constantly assesses its progress and determines what must be addressed. PROTECT supports companies’ developing child-resistant packaging for medications and promotes companies’ using the same units, such as milliliters (mL), on dosing directions and measuring devices. PROTECT’s initiatives have influenced multiple changes to improve medication safety in the pediatric population.1,7
The National Council for Prescription Drug Programs (NCPDP) published its recommendations for prescription label standardization, specifically for oral medications. Its first recommendation is to standardize the unit of measure to milliliters. Providers and labels may instruct caregivers to administer a medication with various units of measure, such as teaspoons, which can lead to errors. Milliliters should be the standard unit on labels and measuring devices to promote accurate measurement of a child’s medication dose by caregivers.8
The NCPDP’s second recommendation is to include a leading zero before the decimal point but never a trailing zero after the decimal point. When either part of the recommendation is not followed, significant dosing errors may occur. As an example, anyone may read a dose of .2 mL as 2 mL without a leading zero, or a dose of 2.0 mL as 20 mL with a trailing zero; either could have serious consequences and underscore the importance of this recommendation.8
The NCPDP’s third recommendation is to ensure the availability of proper dosing devices with prescription medications. Dosing devices should be provided with the medication every time it is dispensed. The device needs accurate numeric graduations, milliliter units only, and appropriate volume that correspond to the prescribed amount on the label. The measuring device needs one unit of measure, preferably milliliters, to avoid confusion when measuring the dose. Also, the measuring device’s graduations, volume, and units must correspond with the prescribed dose to prevent caregivers from using household measuring devices, such as teaspoons, which result in dosing errors. Pharmacists must advise caregivers to always use provided dosing devices, especially calibrated oral syringes, for more accurate dosing. Also, a measuring device’s volume should be as close as possible to and hold the entire prescribed dose.8 Pharmacists must provide caregivers with the best possible tools to promote medication safety and try to prevent any serious consequences from a medication administration error.
Counseling to Prevent Accidental Pediatric Overdose
Pharmacists should counsel caregivers about proper storage of medications away from children.1,7 PROTECT created the “Up and Away” campaign to educate caregivers on storing medications safely and preventing medication overdoses in children. Medication storage locations must be higher than children can reach and somewhere not visible to them, such as a high kitchen cabinet. Pills outside of their container and liquid medications left out in a child’s sight can look appealing to curious children.9 All patients and especially caregivers should be advised to always keep medications in their original container, properly replace child-resistant caps, and return medications to storage right after use.9,10 Pharmacists should inform caregivers that a child-resistant locking cap must be twisted as much as possible or until a clicking sound is heard. Also, any guests in the home should keep their medicine away from children.9
Caregivers should be counseled on the proper dose of any dispensed medication for a child using a provided measuring device.11 For example, if the dose is written as 1 tablespoon (tbsp) or 3 teaspoons (tsp), the dose should be changed to 15 mL, and the caregiver must be counseled on using the provided measuring device to deliver the correct medication dose. Pharmacists must provide a proper dosing tool, which includes a medicine cup, dosing spoon, dropper, or syringe.12 When dispensing the medication and dosing device, pharmacists can show and clearly mark the dose on the device.12 Pharmacists should educate caregivers about the medication and its administration, storage, and disposal and encourage them to ask questions.11 It is essential for pharmacists to spend time with the caregiver to answer any questions.12 Pharmacists should provide information in the caregiver’s preferred language using the specific pharmacy’s available resources.12 Furthermore, pharmacists need to counsel and provide materials to the caregiver at an appropriate health literacy level.11 Pharmacists have a role in ensuring safe medication administration to children while making the administration process as straightforward as possible for caregivers.
Pharmacists should inform caregivers about prompt and proper medication disposal methods if any leftover medication exists.11 The FDA provides guidance on proper medication disposal, which should be shared with caregivers. Pharmacists can advise caregivers about drug take-back programs. If your pharmacy offers ways to dispose of medications, such as drop-off boxes, inform the caregivers. If programs are unavailable or inconvenient, advise caregivers to dispose of any unused medication promptly and correctly. If the medication is not on the FDA’s flush list, provide caregivers with proper trash disposal instructions:
• Remove medication from its container and mix it with cat litter, used coffee grounds, dirt, or another undesirable substance13
• Place the mixture in a container, such as a resealable zipper storage bag13
• Put the container in the trash13
• Throw the original medication packaging away after removing or scratching out personal information.13
Pharmacists can use the various resources available when educating caregivers and advocating for safe medication use (see TABLE 1). As an example, pharmacists can share the various materials on proper medication storage with caregivers from Up and Away or content provided by the CDC on medication safety for children, including tips on medication storage and safe medication administration, and about prompt and correct medication disposal from the FDA.1,7,9,13-15 The CDC also provides informational images and videos on medication safety targeted to healthcare professionals and caregivers that can be displayed or shared.1,7,13,14 The American Academy of Pediatrics includes helpful resources and tips for caregivers to prevent and treat accidental poisoning on healthychildren.org.12,16-19 Pharmacists can utilize these resources when counseling caregivers and refer them to the websites.
While the intent is to prevent incorrect medication use or overdose, poison control centers provide caregivers with information on what to do if the child is given too much of a medication or exposed to a potential poison. This is a key resource for pharmacists to continuously share with all caregivers. The caregiver can call Poison Help (1-800-222-1222) or use the website to determine how to appropriately handle the situation.17 The Health Resources and Services Administration (HRSA) Poison Help website provides resources on poison prevention and exposure that can be helpful for both pharmacists and caregivers.18,19
Caregivers and pharmacists must also educate children about safe medication use.9 Pediatric patients need to understand their own medications, including the importance of taking them and how to safely use them.20 Millions of children take prescription medications, especially to manage their chronic conditions.20 Pharmacists must counsel both the child and the caregivers to ensure proper medication use.20,21 Children may often be absent from the pharmacy or do not interact with their pharmacist when their medications are dispensed, which may result in pediatric patients having inadequate knowledge about their medications.20,21 Whenever pediatric patients are present, pharmacists should speak to them in age-appropriate language, carefully listen to them, and build a relationship.20,21 Pharmacists could suggest bringing children to these encounters with their caregivers. Having pharmacists introduce themselves to young patients and building trust would allow children to feel more comfortable communicating with their pharmacist and asking important questions.20 Pharmacists can also address correct and safe medication use. Having children be part of the conversation about safe medication use is important and can prevent future harm.
There is also the challenge of providing medication education materials that engage children. If the children have the option to learn about their medications through educational videos or games, they may be more engaged.20 Companies and organizations could potentially develop these learning tools. By providing pediatric patients with proper resources that engage and educate them, they are more empowered to manage their own care, especially as they become older.20
Pediatric overdose on prescription medications harms many children every year. Emergency department visits can be avoided by providing caregivers with the knowledge and tools to provide medications safely to children, store medications safely, and promptly and correctly dispose of any unused medication. Pharmacists have a responsibility to properly educate caregivers and pediatric patients about all aspects of safe medication use. As an accessible healthcare professional, pharmacists play a critical role in safe medication use by all. By taking the time to counsel a caregiver and providing resources, pharmacists are empowering caregivers and keeping children safe.
1. CDC. Medication safety program: PROTECT initiative. Updated March 7, 2023. www.cdc.gov/medicationsafety/protect/protect_initiative.html. Accessed March 27, 2023.
2. Gaither JR, Shabanova V, Leventhal JM. US national trends in pediatric deaths from prescription and illicit opioids, 1999-2016. JAMA Netw Open. 2018;1(8):e186558.
3. Gaw CE, Curry AE, Osterhoudt KC, et al. Characteristics of fatal poisonings among infants and young children in the United States. Pediatrics. 2023;151(4):e2022059016.
4. CDC. Adverse drug events in children. Updated February 23, 2023. www.cdc.gov/medicationsafety/parents_childrenadversedrugevents.html. Accessed April 25, 2023.
5. CDC. SUDORS dashboard: fatal overdose data. Updated December 8, 2022. www.cdc.gov/drugoverdose/fatal/dashboard/index.html. Accessed April 26, 2023.
6. Friedrich JM, Sun C, Geng X, et al. Child and adolescent benzodiazepine exposure and overdose in the United States: 16 years of poison center data. Clin Toxicol (Phila). 2020;58(7):725-731.
7. CDC. About PROTECT. Updated April 6, 2023. www.cdc.gov/medicationsafety/protect/about.html. Accessed April 25, 2023.
8. 8. NCPDP recommendations for standardizing dosing in metric units (mL) on prescription container labels of oral liquid medications, version 2.0. Am J Health Syst Pharm. 2021;78(7):578-605.
9. Up and Away. Avoid a trip to the emergency room. 2023. https://upandaway.org/en/. Accessed April 25, 2023.
10. Budnitz DS, Salis S. Preventing medication overdoses in young children: an opportunity for harm elimination. Pediatrics. 2011;127(6):e1597-e1599.
11. Yin HS, Neuspiel DR, Paul IM, et al. Preventing home medication administration errors. Pediatrics. 2021;148(6):e2021054666.
12. Healthychildren.org. How to use liquid medicines for children. Updated October 11, 2021. www.healthychildren.org/English/safety-prevention/at-home/medication-safety/Pages/Using-Liquid-Medicines.aspx. Accessed April 25, 2023.
13. FDA. Where and how to dispose of unused medicines. Updated April 21, 2021. www.fda.gov/consumers/consumer-updates/where-and-how-dispose-unused-medicines. Accessed April 25, 2023.
14. Up and Away. Resources. 2023. https://upandaway.org/en/resources/. Accessed April 25, 2023.
15. CDC. Medication safety program: additional resources. Updated April 6, 2023. https://www.cdc.gov/medicationsafety/library.html. Accessed April 25, 2023.
16. Healthychildren.org. Poison prevention & treatment tips for parents. Updated September 6, 2021. www.healthychildren.org/English/safety-prevention/all-around/Pages/Poison-Prevention.aspx. Accessed April 26, 2023.
17. Poison Help. Get fast, free and confidential poison help. www. poisonhelp.org/. Accessed April 25, 2023.
18. Health Resources and Services Administration. Poison center resources. https://poisonhelp.hrsa.gov/. Accessed April 25, 2023.
19. Health Resources and Services Administration. Poison control center toolkits. https://poisonhelp.hrsa.gov/resources/toolkits. Accessed April 25, 2023.
20. Abraham O, Brothers A, Alexander DS, Carpenter DM. Pediatric medication use experiences and patient counseling in community pharmacies: perspectives of children and parents. J Am Pharm Assoc. 2017;57(1):38-46.e2.
21. Trivedi A. Communicating with parents and involving children in medicines optimisation. Pharmaceutical Journal. 2017;299(7906).
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