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Journal Article


Budnitz DS, Lovegrove MC, Geller RJ. J. Am. Med. Assoc. JAMA 2020; ePub(ePub): ePub.


(Copyright © 2020, American Medical Association)






As the US struggled to address the rapid increase in prescription drug overdoses among adults in the 2000s, the number of medication overdoses among young children also increased from an estimated 57 000 emergency department (ED) visits among children younger than 6 years in 2004 to an estimated 81 000 in 2010. In contrast to adult overdoses, however, medication overdoses among young children have significantly declined since 2010, to an estimated 46 000 ED visits in 2018 (CDC unpublished data, February 2020). The vast majority of these overdoses (95%) involved unintentional exposures by children, and 5% involved errors from adults administering medications to children. While prescription status and owner of the medication were not always specified, the estimated proportions of these overdoses specifically related to prescription medications and over-the-counter (OTC) medications were 41% and 28%, respectively, for medications intended for use by adults and 6% and 11%, respectively, for medications intended for use by children (CDC unpublished data, February 2020).

How was the increasing trend in the 2000s reversed over the subsequent decade since 2010? Attributing national trends to specific interventions is difficult; however, efforts to improve safety packaging for medications, standardize dosing instructions, and educate adults on safe medication use and storage likely contributed.

First, changes in the packaging of liquid medications began in the 2010s. Since the Poison Prevention Packaging Act of 1970 (PPPA), nearly all prescription and OTC medications have been sold in bottles with child-resistant closures. If always used correctly, safety closures are effective in slowing children's access to bottle contents; however, bottles are easily opened by young children when caps are not immediately and fully secured. Beginning in 2011, OTC medication manufacturers and several pharmacy retailers voluntarily began adding "flow restrictors" to bottles of infants' acetaminophen (paracetamol) and prescription liquids. Flow restrictors narrow or fully occlude the opening of the bottle and limit the release of medication until the bottle is squeezed or the opening is penetrated with an oral syringe, thereby providing passive poisoning protection even if a child-resistant closure is removed (eFigure 1 in the Supplement). From 2012 to 2015, both the number of calls to poison centers for unintentional pediatric acetaminophen exposures and the amount of acetaminophen ingested have declined, and, in 2015, the US Food and Drug Administration (FDA) recommended flow restrictors for all pediatric OTC liquids containing acetaminophen. Further reductions in exposures would be expected if flow restrictor use was expanded to additional OTC medications with high rates of pediatric ingestions (eg, diphenhydramine) and to prescription medications by additional pharmacy retailers.

Second, changes in dosing pediatric liquid medications have been underway to reduce errors leading to overdoses. Throughout the 20th century, teaspoonfuls and tablespoonfuls were the most commonly used dosing units, and kitchen spoons were the dosing instruments of choice. However, kitchen spoons are not calibrated to dose medications, and many prescribed doses can only be measured accurately using milliliters (mL), leading to a confusing mix of dosing units for caregivers to navigate. Therefore, in the 2010s, medication manufacturers, federal health agencies, standards organizations, and health care professionals collaborated to promote universal use of metric units for oral pediatric liquids...

Language: en


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