The Canadian report, published Wednesday in the New England Journal of Medicine, found the shortage of children’s pain medication contributed to a “large increase in calls” to a poison control centre related to both acetaminophen and ibuprofen dosing errors.
“We found that there was an over doubling of the number of calls that were made to the Ontario Poison Centre related to dosing errors, related to the administration of medications for fever and pain for children, specifically, acetaminophen or Tylenol; and ibuprofen, commonly known as Advil or Motrin,” said Dr. Eyal Cohen, co-author of the report and a physician in pediatric medicine at SickKids in Toronto.
“It was surprising that we saw a real risk of harm to children related to the shortages that occurred during that period of time,” he added.
Between August and December 2022, Canada had a scarcity of pediatric acetaminophen and ibuprofen due to the resurgence of respiratory illnesses, as the pandemic eased and kids started going back to school. In response, hospitals and medical professionals issued alternative guidance, including giving adult pain medication based on children’s weight and age.
“There was guidance issued about how to divide adult doses, and we figured that if it was challenging for us to figure out what kind of drugs we should be giving to our kids and how to divide those doses, that must be a much larger problem for the general population,” Dr. Jonathan Zipursky, a co-author on the study and a clinical pharmacologist and toxicologist at Sunnybrook Health Sciences Centre.
The report, called ‘Pediatric Dosing Errors during a National Shortage of Fever and Pain Medications’ looked at the monthly number of phone calls from parents and hospitals to the Ontario Poison Centre (OPC) for unintentional acetaminophen and ibuprofen dosing errors between Jan. 1, 2018, and Feb. 28, 2023, among children aged 18 and younger.
The OPC covers the province of Manitoba and the territory of Nunavut as well.
“During the post-shortage period, calls to the OPC related to this age group decreased to expected levels for acetaminophen and ibuprofen,” the authors stated in the report.
The report suggests possible reasons for the spike in calls for dosing errors included parents and caregivers improperly dividing pills intended for adults, sourcing drugs from other countries with unfamiliar dosing instructions, or having low health literacy or limited English proficiency.
Starting in the summer of 2022, infant and children’s acetaminophen and ibuprofen products were flying off the shelves at retail outlets, pharmacies and hospitals across Canada.
At the time, Health Canada said the shortage was due to unprecedented demand, as pediatricians noted an unusually early rise in viral illnesses over the spring and summer months in 2022.
“During the fall and winter of this year, we experienced a significant drug shortage of Tylenol and Advil. And as a parent, it was stressful trying to find drugs for my own six-year-old and three-year-old,” Zipursky said.
As children’s pain medication disappeared from shelves, many parents had to divide up adult Tylenol or Advil in order to relieve their kids’ pain or fever.
Barry Power, a pharmacist and editor-in-chief of the Canadian Pharmacists Association, previously told Global News in November 2022, that although parents can give children adult Advil and Tylenol, it’s important to ensure the proper dose is administered.
He stressed it is “easy to give the wrong amount,” and was concerned about accidental overdoses of children.
'Desperate times call for desperate measures'
On Aug. 15, 2022, SickKids in Toronto sent out a letter to parents addressing the pain medicine shortage. In it, the hospital said: “You can consider using other forms of acetaminophen or ibuprofen, but speak to your pharmacist or health-care provider first to ensure you give your child the right dose.”
Other medical professionals gave the same advice.
Caring for Kids, a site developed by the Canadian Paediatric Society (CPS) stated on its website: “Tablet and capsules (and other solid dosage forms) that are used for adults can be used for children depending on your child’s age, size, and ability to swallow solid medications. In some cases, tablets can be split.”
In an email to Global News, a spokesperson from CPS said, “We advised caregivers to, ‘always speak with a pharmacist about available options that are appropriate and safe for your child.’”
The guidance from SickKids and other organizations was “certainly well-intentioned,” Zipursky said.
“Desperate times call for desperate measures,” he said.
“We were in a situation that we hoped never to be in … kids needed to be treated for fevers and pain, and we parents were scouring shelves for drugs, so we needed to give them something in the absence of having appropriate medications.”
Cohen believes, if anything, the recommendations reduced the risk of overdosing, as it “provided safe guidance on how to do it.”
“Parents were using adult medications anyways to treat their children’s pain and fever. I do think it was the right call. Unfortunately, the issue with the guidance is imperfect because some parents and families don’t understand English or French. Some parents and families may still make mistakes with the cutting up of the medications,” he said.
Although overdosing on pain medication can lead to severe side effects, the OPC did not encounter a significant number of cases where it was necessary to advise parents to take their children to the hospital, said Dr. Margaret Thompson, the medical director of the Ontario, Manitoba and Nunavut Poisons Centre.
“In most cases, the suggestion was that ‘you could stay home and monitor your child for the following symptoms and if they develop any of these symptoms, you should call us back or you should take your child to a hospital,” she said.
Symptoms of overdosing in children from these medications may be gastrointestinal symptoms first, she said.
“Patients might be nauseated. They might vomit because of both of those medications. It’s hard for a little one to express that they’re nauseated, but the parent might find that they’re refusing to eat, for example,” she added.
Not a permanent solution
Although it was the best many medical professionals could do at the time, Zipursky and Cohen stressed it is still not a fix for the future.
Both doctors hope that Canadians never find themselves in a situation where they have to divide adult medications for children, suggesting that the key to preventing such circumstances is by predicting the supply and demand of drugs.
“Canada is, by all accounts a small drug market, but it sources a lot of its medications from abroad,” Zipursky said. “Perhaps this sheds light on the importance of producing some medications here and not only producing medications at home but also building in systems where we can increase production during times of need.”
Global News reached out to Health Canada asking what the government is doing to help prevent possible shortages in the future but did not hear back at the time of publication.
If parents do find themselves in a situation where they can’t access pain medication for their kids, Zipursky strongly urges them to consult with a doctor or pharmacist as their first course of action.