COVID-19 and Intentional Toxic Pediatric Acetaminophen Ingestions: A Research Brief

A retrospective cohort study of patients admitted to tertiary care pediatric hospitals participating in the Pediatric Health Information System (PHIS; Children’s Hospital Association, Lenexa, KS) was performed. All patients aged 8 to 18 years admitted between January 1, 2016 and December 31, 2022 with an International Classification of Diseases, 10th Revision diagnosis code indicating ingestion or poisoning with acetaminophen were screened for inclusion (T39.1, X40, Y45.5, X60, and Y10). Patients were included if they received antidote therapy with n-acetylcysteine. The Institutional Review Board of the University of Chicago determined this study to be nonhuman subject research. (IRB22-0128).

The study population was divided into 2 cohorts: pre-COVID-19 era (January 2016–February 2020) and the COVID-19 era (March 2020–December 2022), and multiple patient-level metrics were compared. Summer months (June–August) were compared with traditional in-school months (September–May). Descriptive statistics were used to summarize variables of interest, and groups were compared by using χ-square, Fisher’s exact, and Wilcoxon rank tests, as appropriate. All statistical analyses were performed by using SAS Enterprise Guide v.8.3 (Cary, NC).

A total of 12 965 patients with intentional acetaminophen ingestion receiving n-acetylcysteine antidote therapy were included in the analysis (Table 1). The number of patients increased from 1155 in 2016 to 2498 in 2022. The overall mortality rate was 0.2%. Female patients predominated (84%) and the majority of patients were aged between 12 and 15 years (59.5%). Two-thirds of the cohort was diagnosed with depression (61.5%), and one-third was diagnosed with anxiety (37.8%). The distribution of monthly admissions for intentional acetaminophen ingestion during the COVID-19 era was significantly higher than during the pre-COVID-19 era (median 206 [interquartile range 165–246] vs 119 [99–134], P <.001). In addition, during the pre-COVID-19 era, the summer months (June–August) revealed consistently fewer admissions for acetaminophen ingestion compared with in-school months (September–May), with a median monthly volume of 96.5 (interquartile range 84–102) versus 124 (108–141), P <.001. In the COVID-19 era, summer months continued to have fewer acetaminophen ingestions compared with in-school months, 165 (156–187) versus 232 (200–260), P = .006 (Fig 1).

We found that the number of pediatric hospitalizations for intentional acetaminophen ingestion during and after the peak of the COVID-19 pandemic was significantly higher than in the pre-COVID-19 era. In addition, we found an increase in intentional acetaminophen ingestion during the in-school months relative to the summer months in both the pre-COVID-19 and COVID-19 eras. These findings not only reinforce the pre-COVID-19 literature that revealed a higher risk of self-harm behavior during in-school months but also suggest that children are struggling with mental health issues more than they did before the pandemic.^4–6 

Limitations include the use of PHIS, an administrative database devoid of clinical metrics beyond those captured from billing and claims data derived from the International Classification of Diseases, 10th Revision diagnosis and procedure codes. These data represent only a minority of children’s hospitals in the United States; thus, findings may underestimate the actual burden with respect to community hospital admissions. Moreover, the study cohort only included patients with ingestions severe enough to receive n-acetylcysteine, which may underrepresent the number of children with intentional acetaminophen ingestions of lower severity.

In conclusion, these data may inform public health policies and local school governance to ensure adequate mental health resources are available and concentrated on the times that children are in school. Resources should focus on risk reduction, improved mental health referral services, behavioral modification, and stress-coping strategies, as well as anticipatory guidance regarding the potential life-threatening risks associated with acetaminophen ingestion.