CHOP researchers are sounding the alarm about babies and toddlers being poisoned by fentanyl

The team at the Children’s Hospital of Philadelphia that tracks suspected child abuse is increasingly investigating a devastating ripple effect of the region’s opioid crisis: deaths and poisonings in young children.

Over the last 12 years, four children treated at CHOP for swallowing opioids died, and cases referred to the child protection team have quadrupled since 2019. At least two suffered lasting complications, including brain injury from oxygen deprivation.

The youngest patient was 19 days old.

Most of the children were under the age of two, a CHOP physician found in new research looking at the cases of 69 children, aged 8 and under, who were treated at the hospital for opioid ingestion and referred to its child protection team between 2012 and 2023.

The most common opioid involved was fentanyl, the powerful synthetic opioid now dominant in Philadelphia’s illicit drug markets and driving most of the overdose deaths in the city.

The investigated cases outline, in stark detail, just how dangerous an opioid ingestion can be for children. The most common side effects seen in the cases were an “altered mental status,” abnormal breathing, and seizures.

Eleven children’s hearts stopped. Nearly three-quarters had slowed or stopped breathing. More than half were admitted to an intensive care unit.

The children came from all over the region — 23 area hospitals sent at least 40 children with opioid poisoning to CHOP.

The research was spearheaded by Maria Quidgley-Martin, who treated children exposed to opioids while working as a pediatric emergency medicine fellow at CHOP. She’s presenting early findings from the study, which has not yet been published, at a weekend conference of the American Academy of Pediatrics, a leading medical professional society.

“I felt this was something that wasn’t being talked about,” she said.

And the cases highlighted in her research are only those that were investigated by the hospital’s child protection team. It’s likely the hospital treated other cases of opioid poisoning that didn’t merit an abuse investigation, Quidgley-Martin said.

The increase in opioid poisoning cases at CHOP dovetails with national trends that show how the rise of fentanyl is harming children.

Another new study based on data from poison control centers around the country shows how deaths and life-threatening health complications from an opioid exposure are on the rise, even as children’s exposures to prescription opioids drop.

The vast majority of reported opioid exposures nationwide still involve prescription opioid painkillers, whose widespread prescription in the 1990s and early 2000s fueled the country’s ongoing addiction and overdose crisis.

But a yearslong effort to improve children’s safety around prescription opioids has been hindered by the emergence of illicit fentanyl in America’s drug markets, the authors of the national study wrote.

Up to 50 times stronger than heroin and 100 times more powerful than morphine, fentanyl has legitimate use as an anesthetic and is also used to treat serious pain, like that in cancer patients. But it is also manufactured by drug trafficking organizations and sold on the street in a powdered form.

Reports of children 6 and under being exposed to fentanyl — in both prescription and illicit form — and to other opioids sold on the street increased fivefold between 2016 and 2023. Reports of severe complications tripled.

The CHOP research also highlighted how the spread of fentanyl has put kids at increasing risk of harm.

At CHOP, 65% of the exposure cases investigated by the child protection team between 2012 and 2023 involved fentanyl, with most taking place after 2019. All four of the children who died had ingested fentanyl.

Most of the fentanyl exposure cases investigated at CHOP involved street drugs, Quidgley-Martin said.

Some of the children treated for opioid exposure in recent years also tested positive for xylazine, an animal tranquilizer not approved for human use that’s contaminated most of the city’s illicit fentanyl supply.

Fentanyl poisonings are the scariest opioid exposure cases that Diane Calello sees in the ER at Rutgers Health in Newark. Calello, a pediatric toxicologist, coauthored the recently released national study and serves as the executive medical director of the New Jersey Poison Control Center, which is run out of Rutgers.

This month, Calello also published a study digging into how children in New Jersey ingest opioids. The study, based on data from the poison control center, found that about 86% of the 230 opioid exposures reported in the state between January 2018 and December 2022 involved prescription opioids.

They were swallowed most often at the child’s home. About 40% of children exposed had ingested opioids that belonged to their parents, but 17% had swallowed their grandparents’ medications.

At least five cases involved opioids prescribed to the family pet, mixed with foods like peanut butter to get the pets to swallow them, and then left out.

Among the CHOP cases referred for child abuse investigations, which more often involved illicit fentanyl, 65% of the children exposed had family members with a history of addiction.

In about half the cases, the children’s families had previous contact with a local child protective services agency. And half did not go home after the hospital: They were placed in foster care or sent to live with other family, said Quidgley-Martin, who completed her CHOP training and is now a clinical assistant professor of emergency medicine at the University of Florida.

When treating young patients who have swallowed opioids, Calello often talks about missed opportunities to get them help earlier — like making sure parents who are prescribed opioids know how to store them safely and have naloxone, the opioid-overdose reversing drug, in the house.

“I often wish we could go back in time and have naloxone in the mom’s purse,” Calello said.

Naloxone is safe to use in children, Calello said. And because young children aren’t used to opioids, there’s no risk of them going into withdrawal after a dose of naloxone, like an adult with an opioid tolerance might, she said.

Parents should still call 911 or take a child to the hospital after a suspected ingestion, even if they give them naloxone at home.

Quidgley-Martin also said she was surprised by the number of children who arrived at CHOP, even from other hospitals, without having been treated with naloxone. More doctors should consider the possibility of an opioid exposure if they encounter a child who has difficulty breathing or is confused, she said.

“I have given naloxone to children and seen it reverse an opioid overdose and help them breathe when they were having a hard time,” she said. “I’m recommending that doctors have a very low threshold to try it out if they have a child that doesn’t seem to be breathing right.”

Physicians who prescribe opioids should also talk about overdose risks for everyone in a household, not just their patients.

“People who are writing a prescription for an opioid with an adult patient can say, ‘Hey, this medication may be very familiar to you, but that doesn’t mean it’s not dangerous,’” Calello said. “Even one pill can be enough to kill a child.”