On March 13, 2020, the United States declared the coronavirus disease 2019 outbreak a national emergency.1 Consequently, the abrupt shift in the school and home dynamics, combined with ensuing psychosocial and economic household stressors, placed children at increased risk of harm.2 In particular, early 2020 data indicated an increase in household cleaner and disinfectant exposures.3 However, the impact of the pandemic on overall pediatric ingestions is unclear. Our objective was to compare national trends in pediatric ingestions during the pandemic to a similar prepandemic period.
Methods
All closed cases of ingestions involving children aged ≤19 years reported to US poison control centers from March 13 to December 31, 2020 (pandemic), were compared with an identical period from 2017 to 2019 (prepandemic). A closed case is either one in which the regional poison center determined no further follow-up or recommendations were required or no further information on the case was available.4 All US poison control center operations and reporting were consistent across the study period. Aggregate national data were abstracted from the American Association of Poison Control Centers National Poison Data System.4 Information requests and animal calls were excluded. Abstracted data included age group, sex, substance ingested, reason, exposure and management site, disposition, and medical outcome. Clinically significant outcomes were defined as a moderate or major effect or death.4 Descriptive statistics were used to describe the study cohorts, and categorical variables were compared by using the χ2 test. The significance level was set to α < .05. The study was exempt from review by our institutional review board.
Results
There were 861 626 pediatric ingestions during the pandemic, representing a 6.3% absolute decrease compared with the prepandemic years (Fig 1A). The pandemic period had an increase in proportion of teenagers and children aged ≤5 years compared with the prepandemic years (Table 1). There was a relative increase in intentional ingestions accounting for 10.8% of all ingestions during the pandemic period versus 10.3% during the prepandemic period (0.5% difference, 95% confidence interval: 0.4%–0.6%, P < .001) (Table 1). In addition, there was a relative increase in ingestions occurring at home during the pandemic period when compared with the prepandemic period (1.9% difference, 95% confidence interval: 1.8%–2.0%, P < .0001).
Pediatric ingestion trends 2017–2020. A, Rate of ingestion by age group (≤5 years, 6–12 years, and 13–19 years). Population estimates are based on the US Census Bureau. B, Total yearly ingestions of the most common substances in 2020 (melatonin, ibuprofen, acetaminophen, foreign body, and hand sanitizer) compared with the previous 3 years.
Pediatric ingestion trends 2017–2020. A, Rate of ingestion by age group (≤5 years, 6–12 years, and 13–19 years). Population estimates are based on the US Census Bureau. B, Total yearly ingestions of the most common substances in 2020 (melatonin, ibuprofen, acetaminophen, foreign body, and hand sanitizer) compared with the previous 3 years.
Comparison of Pediatric Ingestions During the Pandemic (2020) Versus Prepandemic Period (2017–2019)
| Year, n (%) | |||
|---|---|---|---|
| Characteristic | 2017–2019; 3-year Average | 2020 | P |
| All Ingestions | n = 2 757 796; n = 919 265 | n = 861 626 | — |
| Age, y | <.001 | ||
| ≤5 | 712 708 (77.5) | 670 352 (77.8) | — |
| 6–12 | 87 006 (9.5) | 76 403 (8.9) | — |
| 13–19 | 119 551 (13.0) | 114 871 (13.3) | — |
| Sex | <.001 | ||
| Male | 470 376 (51.2) | 435 982 (50.6) | — |
| Female | 446 465 (48.6) | 422 762 (49.1) | — |
| Unknown | 2424 (0.3) | 2882 (0.3) | — |
| Reason | <.001 | ||
| Unintentional | 813 237 (88.5) | 758 422 (88.0) | — |
| Intentional | 94 560 (10.3) | 92 918 (10.8) | — |
| Other | 11 468 (1.2) | 10 286 (1.2) | — |
| Exposure site | <.001 | ||
| Residence | 882 457 (96.0) | 843 935 (97.9) | — |
| School | 17 554 (1.9) | 3475 (0.4) | — |
| Other | 19 255 (2.1) | 14 216 (1.6) | — |
| Management site | <.001 | ||
| Managed on-site (non-HCF) | 713 205 (77.6) | 687 181 (79.8) | — |
| Patient already in or en route to HCF when PCC called | 146 284 (15.9) | 125 478 (14.6) | — |
| Patient was referred by PCC to HCF | 44 432 (4.8) | 43 642 (5.1) | — |
| Other | 15 344 (1.7) | 5 325 (0.6) | — |
| Outcomea | <.001 | ||
| No effect | 208 499 (22.7) | 186 261 (21.6) | — |
| Minor effect | 86 566 (9.4) | 84 283 (9.8) | — |
| Clinically significant | 33 187 (3.6) | 35 906 (4.2) | — |
| Death | 69 (0.0) | 81 (0.23) | — |
| Other | 591 013 (64.3) | 555 218 (64.4) | — |
| Ingestion managed at a HCF | n = 438 853; n = 146 284 | n = 125 478 | — |
| Age, y | <.001 | ||
| ≤5 | 62 619 (42.8) | 45 728 (36.4) | — |
| 6–12 | 11 151 (7.6) | 9980 (8.0) | — |
| 13–19 | 72 515 (49.6) | 69 770 (55.6) | — |
| Sex | <.001 | ||
| Male | 59 676 (40.8) | 47 192 (37.6) | — |
| Female | 86 399 (59.1) | 78 106 (62.2) | — |
| Unknown | 210 (0.1) | 180 (0.1) | — |
| Reason | <.001 | ||
| Unintentional | 72 067 (49.3) | 52 714 (42.0) | — |
| Intentional | 70 910 (48.5) | 69 838 (55.7) | — |
| Other | 3307 (2.3) | 2926 (2.3) | — |
| Outcomea | <.001 | ||
| No effect | 50 487 (34.5) | 38 966 (31.1) | — |
| Minor effect | 41 986 (28.7) | 38 382 (30.6) | — |
| Clinically significant | 28 679 (19.6) | 30 365 (24.2) | — |
| Death | 61 (0.0) | 71 (0.23) | — |
| Other | 25 132 (17.2) | 17 765 (14.2) | — |
| Disposition | <.001 | ||
| Hospitalized | 54 983 (37.6) | 54 674 (43.6) | — |
| ICU | 15 842 (10.8) | 14 591 (26.7) | — |
| Treated and released | 85 921 (58.7) | 66 200 (52.8) | — |
| Other | 5380 (3.7) | 4604 (3.7) | — |
| Year, n (%) | |||
|---|---|---|---|
| Characteristic | 2017–2019; 3-year Average | 2020 | P |
| All Ingestions | n = 2 757 796; n = 919 265 | n = 861 626 | — |
| Age, y | <.001 | ||
| ≤5 | 712 708 (77.5) | 670 352 (77.8) | — |
| 6–12 | 87 006 (9.5) | 76 403 (8.9) | — |
| 13–19 | 119 551 (13.0) | 114 871 (13.3) | — |
| Sex | <.001 | ||
| Male | 470 376 (51.2) | 435 982 (50.6) | — |
| Female | 446 465 (48.6) | 422 762 (49.1) | — |
| Unknown | 2424 (0.3) | 2882 (0.3) | — |
| Reason | <.001 | ||
| Unintentional | 813 237 (88.5) | 758 422 (88.0) | — |
| Intentional | 94 560 (10.3) | 92 918 (10.8) | — |
| Other | 11 468 (1.2) | 10 286 (1.2) | — |
| Exposure site | <.001 | ||
| Residence | 882 457 (96.0) | 843 935 (97.9) | — |
| School | 17 554 (1.9) | 3475 (0.4) | — |
| Other | 19 255 (2.1) | 14 216 (1.6) | — |
| Management site | <.001 | ||
| Managed on-site (non-HCF) | 713 205 (77.6) | 687 181 (79.8) | — |
| Patient already in or en route to HCF when PCC called | 146 284 (15.9) | 125 478 (14.6) | — |
| Patient was referred by PCC to HCF | 44 432 (4.8) | 43 642 (5.1) | — |
| Other | 15 344 (1.7) | 5 325 (0.6) | — |
| Outcomea | <.001 | ||
| No effect | 208 499 (22.7) | 186 261 (21.6) | — |
| Minor effect | 86 566 (9.4) | 84 283 (9.8) | — |
| Clinically significant | 33 187 (3.6) | 35 906 (4.2) | — |
| Death | 69 (0.0) | 81 (0.23) | — |
| Other | 591 013 (64.3) | 555 218 (64.4) | — |
| Ingestion managed at a HCF | n = 438 853; n = 146 284 | n = 125 478 | — |
| Age, y | <.001 | ||
| ≤5 | 62 619 (42.8) | 45 728 (36.4) | — |
| 6–12 | 11 151 (7.6) | 9980 (8.0) | — |
| 13–19 | 72 515 (49.6) | 69 770 (55.6) | — |
| Sex | <.001 | ||
| Male | 59 676 (40.8) | 47 192 (37.6) | — |
| Female | 86 399 (59.1) | 78 106 (62.2) | — |
| Unknown | 210 (0.1) | 180 (0.1) | — |
| Reason | <.001 | ||
| Unintentional | 72 067 (49.3) | 52 714 (42.0) | — |
| Intentional | 70 910 (48.5) | 69 838 (55.7) | — |
| Other | 3307 (2.3) | 2926 (2.3) | — |
| Outcomea | <.001 | ||
| No effect | 50 487 (34.5) | 38 966 (31.1) | — |
| Minor effect | 41 986 (28.7) | 38 382 (30.6) | — |
| Clinically significant | 28 679 (19.6) | 30 365 (24.2) | — |
| Death | 61 (0.0) | 71 (0.23) | — |
| Other | 25 132 (17.2) | 17 765 (14.2) | — |
| Disposition | <.001 | ||
| Hospitalized | 54 983 (37.6) | 54 674 (43.6) | — |
| ICU | 15 842 (10.8) | 14 591 (26.7) | — |
| Treated and released | 85 921 (58.7) | 66 200 (52.8) | — |
| Other | 5380 (3.7) | 4604 (3.7) | — |
HCF, health care facility; PCC, poison control center; —, not applicable.
No effect: no signs or symptoms.4 Minor effect: minimally bothersome symptoms; self-limited; resolved without intervention (eg, self-limited gastrointestinal symptoms).4 Clinically significant outcomes include moderate effect or major effect or death. Moderate effect: systemic symptoms requiring intervention; not life-threatening (eg, brief seizure readily resolved with treatment; high fever).4 Major effect: life-threating symptoms (eg, status epilepticus, respiratory failure requiring intubation).4 Other: cases that were not followed or unable to be followed to a known outcome but judged as likely nontoxic exposures, exposures with minimal clinical effects, or exposure deemed not responsible to the effect.4
Ingestions of hand sanitizers increased by 43% (18 099 vs 12 653, P < .0001) and melatonin by 70% (44 957 vs 26 431, P < .0001) during the pandemic period. Additionally, melatonin ingestions supplanted analgesics as the most frequently ingested substance during the pandemic period (Fig 1B). Clinically significant outcomes associated with ingestions increased during the pandemic period (4.2% vs 3.6%, P < .001). Whereas overall ingestions managed at a health care facility decreased by 14.2% during the pandemic, there was an increase in the proportion of adolescents (P < .001), intentional ingestions (P < .001) and hospitalizations (P < .001) (Table 1).
Discussion
Ingestion-related calls to poison control centers and those subsequently managed at health care facilities decreased during the pandemic. The latter is consistent with a report of an overall decrease in pediatric emergency department visits.5 This decline may be secondary to a combination of social restrictions, apprehensions in seeking care at a medical center, and increased parental supervision due to work-from-home advisories.5,6 The majority of ingestions occurred at the home, aligning with school and child care closures during the pandemic.
The increase in clinically significant ingestions observed in our study could be a consequence of misperceptions of health care facility safety during the pandemic. This may have subsequently contributed to delays in presentations and potentially worse outcomes.6
The increase in the proportions of adolescent and intentional ingestions may reflect heightened social, emotional, and psychological stressors on this age group. Initiatives focusing on implementing support systems for this vulnerable population are warranted. The heightened hand sanitizer and melatonin ingestions parallel the ubiquitous rise in the sale and use of such products during the pandemic and ease of accessibility among children.3,7 This demands continued attention, given reports of methanol-contaminated hand sanitizer ingestions with severe adverse outcomes.8
Limitations include voluntary reporting to poison control centers and reliance on secondhand narratives, which may include partially incomplete information. Additionally, drug concentrations are rarely obtained to confirm ingestions. Finally, incomplete coding of the poison control center data may have also skewed ingestion frequencies.
Conclusions
Pediatric ingestion calls to poison control centers decreased during the pandemic. However, there were significant increases in intentional hand sanitizer and melatonin ingestions and those with clinically significant outcomes. Further studies are required to determine the long-term impact of the pandemic on pediatric ingestions to institute appropriate preventive measures and resource allocation.
Drs Lelak and Sethuraman conceptualized and designed the study, analyzed and interpreted the data, and drafted and revised the manuscript and tables for important intellectual content; Dr Vohra conceptualized and designed the study, coordinated and supervised data collection, analyzed and interpreted the data, and critically reviewed the manuscript for important intellectual content; Drs Neuman and Toce designed the study, analyzed and interpreted the data, and revised the manuscript critically for important intellectual content; Dr Farooqi conducted data analyses and critically reviewed the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
Comments
RE: re: COVID-19 and Pediatric Ingestions
RE: COVID-19 and Pediatric Ingestions
Other Contributors:
Jocelyn Y. Cheng, Clinical Neurophysiology, Epilepsy and Sleep Medicine Physician, Eisai Inc.
Shannon S. Sullivan, Clinical Professor of Sleep Medicine, Stanford University School of Medicine
23 August 2021
We read the recent article by Lelak and colleagues with interest.1 We applaud the authors for studying the impact of the COVID-19 pandemic on pediatric ingestions.
The authors report an overall decrease in ingestion-related calls to poison control centers. However, they note a concurrent increase in clinically significant ingestions. Additionally, an increase in intentional ingestions among teens, as well as a parallel increase in ingestion of melatonin and hand sanitizer, are also noted.
Before the pandemic, robust evidence showed that most teens in the United States tended to be sleep-deprived, with widespread negative effects on physical, social, and emotional health, and safety.2 Studies in the pandemic suggest an increase in sleep duration among teens and younger children, later bedtime, and improved social jet lag during the pandemic.3 Unfortunately, the pandemic also led to reductions in physical activity, sunlight exposure, and social opportunity, as well as an increase in overall stress and anxiety levels. The American Academy of Sleep Medicine recently issued a health advisory emphasizing the importance of adequate sleep during the pandemic.
Insomnia among young people has also increased.4 We agree with the authors that an increase in intentional ingestion rates may be related to heightened social, emotional, and psychological stressors. Use of melatonin may be a surrogate marker of undiagnosed and untreated sleep disorders, such as insomnia, and we encourage further investigation. Data regarding intentional versus unintentional melatonin ingestion will also be of interest.
It should be noted that melatonin ingestions have been on a three-year upward trend, with the upswing starting prior to the pandemic. As such, comparing ingestions over 2019 to the same period in 2020 may be a more revealing comparison.
Melatonin is often described in lay publications as a safe, natural sleep aid. Since it is available without a prescription, it is more easily accessible. Concerningly, there is a widespread misconception that over-the-counter substances require no prescription because they are safe. Furthermore, melatonin containers often lack child-safety packaging, increasing the risk of unintentional ingestion by younger children. With the increased prevalence of insomnia during the pandemic, it is also plausible that melatonin may have a presence in more homes than in previous years.
While beyond the scope of this study, there exists an important public safety concern related to the quality and safety of supplements that warrants consideration. Melatonin is sold as a supplement (i.e., not subject to pharmaceutical regulation). There is literature indicating that various melatonin supplements may often contain quantities of the active ingredient differing from the amount disclosed on the label and may be additionally contaminated with other active ingredients that are not disclosed on the label, such as serotonin.5
Despite inherent limitations of this type of analysis, the current study provides important information regarding ingestions among children during the pandemic. On behalf of the Public Safety Committee of the American Academy of Sleep Medicine, we agree with the authors that further investigation is warranted to determine the long-term impact of the pandemic on pediatric ingestions.
REFERENCES
1. Lelak KA, Vohra V, Neuman MI, Farooqi A, Toce MS, Sethuraman U. COVID-19 and pediatric ingestions. Pediatrics. 2021;148(1)e2021051001.
2. Shochat T, Cohen-Zion M, Tzischinsky O. Functional consequences of inadequate sleep in adolescents: a systematic review. Sleep Med Rev. 2014 Feb;18(1):75-87.
3. Lim MTC, Ramamurthy MB, Aishworiya R, Rajgor DD, Tran AP, Hiriyur P, Kunaseelan S, Jabri M, Goh DYT. School closure during the coronavirus disease 2019 (COVID-19) pandemic - Impact on children's sleep. Sleep Med. 2021 Feb;78:108-114.
4. Bacaro V, Chiabudini M, Buonanno C, De Bartolo P, Riemann D, Mancini F, Baglioni C. Sleep characteristics in Italian children during home confinement due to covid-19 outbreak. Clin Neuropsych. 2021 Feb 1;18(1).
5. Erland LA, Saxena PK. Melatonin natural health products and supplements: presence of serotonin and significant variability of melatonin content. J Clin Sleep Med. 2017;13(2):275-281.
Competing Interests: None declared.