The rate of intentional medication overdose in children in the United States has been increasing.1,2  The coronavirus disease 2019 (COVID-19) pandemic resulted in a marked increase in pediatric intentional medication overdose. In 2021, the rate of suicide attempts by intentional medication overdose increased by 30% compared to 2019. Moreover, data from the National Poison Data System revealed that calls for suspected suicide with acetaminophen increased by 71% in 2021 and 58% in 2022 when compared to 2019.3  However, the consequences of the COVID-19 pandemic with respect to pediatric hospitalizations for intentional acetaminophen ingestion requiring antidote therapy in children’s hospitals have not yet been described. In addition, with the return to a pre-pandemic academic calendar, the association between in-school months and summer months with regard to acetaminophen ingestion hospitalizations is not well established. This study sought to describe the impact of COVID-19 on children’s hospital admissions for pediatric intentional acetaminophen ingestion requiring antidote therapy, particularly with respect to traditional in-school versus summer months.

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).

TABLE 1

Characteristics and Outcomes Of PHIS Encounters With Intentional Acetaminophen Ingestion, With Comparison Between Pre-COVID-19 and COVID-19 Eras

CharacteristicAll, n = 12 965Pre-COVID-19 Era
(Jan 2016–Feb 2020), n = 5577
COVID-19 Era
(Mar 2020–Dec 2022), n = 7388
P
Age category, y, n (%)    <.001 
 8–11 719 (5.5) 357 (6.1) 362 (5.1)  
 12–15 7718 (59.5) 3256 (55.4) 4462 (63)  
 16–18 4528 (34.9) 2264 (38.5) 2264 (31.9)  
Female sex, n (%) 10 888 (84) 4847 (82.5) 6041 (85.2) <.001 
Race/ethnicity, n (%)     
 Non-Hispanic white 6746 (52) 3145 (53.5) 3601 (50.8) <.001 
 Non-Hispanic Black 1916 (14.8) 834 (14.2) 1082 (15.3)  
 Hispanic 2505 (19.3) 1036 (17.6) 1469 (20.7)  
 Asian 455 (3.5) 183 (3.1) 272 (3.8)  
 Other 1343 (10.4) 679 (11.6) 664 (9.4)  
Primary payer, n (%)    .362 
 Government 6194 (47.8) 2798 (47.6) 3396 (47.9)  
 Private 6304 (48.6) 2881 (49) 3423 (48.3)  
 Other 467 (3.6) 198 (3.4) 269 (3.8)  
COI Category, n (%)    .117 
 Very low 2222 (17.1) 1036 (17.6) 1186 (16.7)  
 Low 2509 (19.4) 1118 (19) 1391 (19.6)  
 Moderate 2716 (20.9) 1221 (20.8) 1495 (21.1)  
 High 2542 (19.6) 1134 (19.3) 1408 (19.9)  
 Very high 2955 (22.8) 1353 (23) 1602 (22.6)  
 Missing 21 (0.2) 15 (0.3) 6 (0.1)  
Mental health diagnosis, n (%)     
 Depressive disorders 7975 (61.5) 3937 (67) 4038 (57) <.001 
 Suicide or self-injury 11 517 (88.8) 5164 (87.9) 6353 (89.6) .002 
 Anxiety disorders 4906 (37.8) 1969 (33.5) 2937 (41.4) <.001 
 Substance-related and addictive disorders 1566 (12.1) 797 (13.6) 769 (10.8) <.001 
 Trauma and stressor-related disorders 1750 (13.5) 726 (12.4) 1024 (14.4) .001 
 Other mental health diagnosis 233 (1.8) 116 (2) 117 (1.7) .168 
Discharge disposition, n (%)    <.001 
 Died 29 (0.2) 16 (0.3) 13 (0.2)  
 Home 4662 (36) 2183 (37.1) 2479 (35)  
 Psychiatric hospital 6500 (50.1) 2789 (47.5) 3711 (52.4)  
 Hospice 47 (0.4) 22 (0.4) 25 (0.4)  
 Other 390 (3) 252 (4.3) 138 (1.9)  
 Other hospitals 724 (5.6) 388 (6.6) 336 (4.7)  
Antidote therapy, n (%)    <.001 
 Enteral n-acetylcysteine 202 (1.6) 168 (2.9) 34 (0.5)  
 Parenteral n-acetylcysteine 12 638 (97.5) 5613 (95.5) 7025 (99.1)  
 Both enteral and parenteral 125 (1) 96 (1.6) 29 (0.4)  
Hospital interventions/procedures, n (%)     
 Liver transplant 16 (0.1) 5 (0.1) 11 (0.2) .258 
 Vasoactive infusions 160 (7) 75 (6.7) 85 (7.4) .514 
 Hemodialysis 61 (2.7) 21 (1.9) 40 (3.5) .018 
 Arterial catheter 23 (1) 7 (0.6) 16 (1.4) .068 
 Noninvasive ventilation 18 (0.8) 7 (0.6) 11 (1) .372 
 Central venous catheter 50 (2.2) 18 (1.6) 32 (2.8) .056 
 Continuous veno–venous hemofiltration 17 (0.7) 5 (0.4) 12 (1) .099 
 ECMO 9 (0.4) 6 (0.5) 3 (0.3) .298 
 Mechanical ventilation 328 (14.4) 167 (14.9) 161 (14) .544 
 Transfusion 47 (2.1) 20 (1.8) 27 (2.3) .345 
CharacteristicAll, n = 12 965Pre-COVID-19 Era
(Jan 2016–Feb 2020), n = 5577
COVID-19 Era
(Mar 2020–Dec 2022), n = 7388
P
Age category, y, n (%)    <.001 
 8–11 719 (5.5) 357 (6.1) 362 (5.1)  
 12–15 7718 (59.5) 3256 (55.4) 4462 (63)  
 16–18 4528 (34.9) 2264 (38.5) 2264 (31.9)  
Female sex, n (%) 10 888 (84) 4847 (82.5) 6041 (85.2) <.001 
Race/ethnicity, n (%)     
 Non-Hispanic white 6746 (52) 3145 (53.5) 3601 (50.8) <.001 
 Non-Hispanic Black 1916 (14.8) 834 (14.2) 1082 (15.3)  
 Hispanic 2505 (19.3) 1036 (17.6) 1469 (20.7)  
 Asian 455 (3.5) 183 (3.1) 272 (3.8)  
 Other 1343 (10.4) 679 (11.6) 664 (9.4)  
Primary payer, n (%)    .362 
 Government 6194 (47.8) 2798 (47.6) 3396 (47.9)  
 Private 6304 (48.6) 2881 (49) 3423 (48.3)  
 Other 467 (3.6) 198 (3.4) 269 (3.8)  
COI Category, n (%)    .117 
 Very low 2222 (17.1) 1036 (17.6) 1186 (16.7)  
 Low 2509 (19.4) 1118 (19) 1391 (19.6)  
 Moderate 2716 (20.9) 1221 (20.8) 1495 (21.1)  
 High 2542 (19.6) 1134 (19.3) 1408 (19.9)  
 Very high 2955 (22.8) 1353 (23) 1602 (22.6)  
 Missing 21 (0.2) 15 (0.3) 6 (0.1)  
Mental health diagnosis, n (%)     
 Depressive disorders 7975 (61.5) 3937 (67) 4038 (57) <.001 
 Suicide or self-injury 11 517 (88.8) 5164 (87.9) 6353 (89.6) .002 
 Anxiety disorders 4906 (37.8) 1969 (33.5) 2937 (41.4) <.001 
 Substance-related and addictive disorders 1566 (12.1) 797 (13.6) 769 (10.8) <.001 
 Trauma and stressor-related disorders 1750 (13.5) 726 (12.4) 1024 (14.4) .001 
 Other mental health diagnosis 233 (1.8) 116 (2) 117 (1.7) .168 
Discharge disposition, n (%)    <.001 
 Died 29 (0.2) 16 (0.3) 13 (0.2)  
 Home 4662 (36) 2183 (37.1) 2479 (35)  
 Psychiatric hospital 6500 (50.1) 2789 (47.5) 3711 (52.4)  
 Hospice 47 (0.4) 22 (0.4) 25 (0.4)  
 Other 390 (3) 252 (4.3) 138 (1.9)  
 Other hospitals 724 (5.6) 388 (6.6) 336 (4.7)  
Antidote therapy, n (%)    <.001 
 Enteral n-acetylcysteine 202 (1.6) 168 (2.9) 34 (0.5)  
 Parenteral n-acetylcysteine 12 638 (97.5) 5613 (95.5) 7025 (99.1)  
 Both enteral and parenteral 125 (1) 96 (1.6) 29 (0.4)  
Hospital interventions/procedures, n (%)     
 Liver transplant 16 (0.1) 5 (0.1) 11 (0.2) .258 
 Vasoactive infusions 160 (7) 75 (6.7) 85 (7.4) .514 
 Hemodialysis 61 (2.7) 21 (1.9) 40 (3.5) .018 
 Arterial catheter 23 (1) 7 (0.6) 16 (1.4) .068 
 Noninvasive ventilation 18 (0.8) 7 (0.6) 11 (1) .372 
 Central venous catheter 50 (2.2) 18 (1.6) 32 (2.8) .056 
 Continuous veno–venous hemofiltration 17 (0.7) 5 (0.4) 12 (1) .099 
 ECMO 9 (0.4) 6 (0.5) 3 (0.3) .298 
 Mechanical ventilation 328 (14.4) 167 (14.9) 161 (14) .544 
 Transfusion 47 (2.1) 20 (1.8) 27 (2.3) .345 

COI, Child Opportunity Index; ECMO, extracorporeal membrane oxygenation.

FIGURE 1

Distribution of monthly admissions for acetaminophen ingestion by era comparing in-school months to summer months.

FIGURE 1

Distribution of monthly admissions for acetaminophen ingestion by era comparing in-school months to summer months.

Close modal

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.46 

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.

Dr Kane conceptualized and designed the study, drafted the initial manuscript, and contributed to the initial analysis; Ms Luo assisted with the design of the study, assisted with database creation, and drafted the initial manuscript; Dr Said provided content expertise; Dr Zaniletti conducted the main analyses; and all authors critically reviewed and revised the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.

FUNDING: Ms Luo was supported by the Summer Research Program of the Scholarship and Discovery Curriculum at the University of Chicago Pritzker School of Medicine.

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest relevant to this article to disclose.

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