The opioid crisis in the United States transcends and affects individuals of all demographics. Historically, opioid overdose has been associated with adults, but trends show an increasing incidence among pediatric patients. ¹ , ² , ³ Opioids are the most common cause of fatal poisonings in young children and represent a significant public health challenge. ⁴ , ⁵ , ⁶ , ⁷ , ⁸ , ⁹ , ¹⁰ , ¹¹

Prompt recognition, resuscitation, and interventions are crucial in managing opioid toxicity in pediatric patients. Emergency clinicians caring for children and adolescents must be prepared to manage opioid toxicity and protect young children from further exposures to decrease future morbidity and mortality. ¹² , ¹³ While there are policies on the opioid crisis in adults, there is a need for guidelines tailored for pediatric patients. ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ This paper discusses the unique opioid overdose characteristics and management in the pediatric population.

The pediatric and adolescent populations are increasingly impacted by the opioid crisis, historically an adult issue. From 2019 to 2021, drug overdose deaths in children aged 10–19 rose by 109%, with opioids being a common factor. ³ , ⁹ , ¹⁸ , ¹⁹ , ²⁰ , ²¹ , ²² , ²³ , ²⁴ , ²⁵ Alarmingly, opioid overdoses in children under 5 years of age, particularly infants and adolescents aged 15–19 years, have surged. ²⁶ In 1‐ to 4‐year‐olds, accidental overdoses are common, with opioids causing over half of these fatalities recently. Fatal overdoses involving opioids jumped from 24.1% in 2005 to 52.2% in 2018; one‐third of these cases were in children under 1 year, many with histories of maltreatment. ⁹ Adolescents aged 15–19 years are also particularly prone to such overdoses due to risky behaviors and substance experimentation.

Echoing adult trends, pediatric opioid overdoses have shifted from non‐synthetic to semi‐synthetic and fully synthetic opioids. ²³ Between 1999 and 2021, fentanyl was involved in 37.5% of pediatric opioid poisoning deaths, predominantly in adolescents aged 15–19 years. ⁸ Pediatric emergency department presentations for opioid overdose or use disorder are rising. The complexity of pediatric overdoses, ranging from prescription to synthetic opioids, underscores the urgency for pediatric‐specific interventions and policies. ²⁷ , ²⁸ Factors such as illicit drug availability, social media influence, and insufficient pediatric‐focused opioid health policies contribute to this rise. ²⁹ , ³⁰ , ³¹ , ³² , ³³ , ³⁴ Children in environments with adult opioid use or socioeconomic disadvantages face increased risks. ²⁴ , ³⁵ , ³⁶ , ³⁷ , ³⁸

Parental opioid use significantly elevates a child's risk of opioid misuse. ³⁹ , ⁴⁰ Children in homes with adults suffering from opioid use disorders experience both immediate and long‐term welfare impacts. ²² In addition, socioeconomic vulnerabilities correlate with higher pediatric opioid misuse rates, disproportionately affecting at‐risk groups. In older children, prescription opioid misuse often leads to illicit opioid use or progression to more potent substances like heroin. ⁴¹

In contrast to adult overdoses, pediatric overdoses often occur when young children accidentally encounter substances at home or during normal exploratory behavior. For instance, opioid analgesic patches, such as those containing fentanyl, pose a unique risk. These patches can be accidentally transferred to children through ingestion, skin contact, or found and inappropriately applied by a child, leading to severe toxicity due to their high potency. ⁴² , ⁴³ , ⁴⁴ In addition, accidental ingestions can result from dosing errors with prescribed medication. ⁴⁵ , ⁴⁶ Notably, secondhand exposure is an emerging concern, where children come into contact with opioids through drug paraphernalia or environmental contamination in households with frequent opioid use. ⁴⁷ , ⁴⁸ , ⁴⁹

Among adolescents, recreational misuse of opioids presents a different profile. Teenagers are more likely to experiment with prescription opioids, and alarmingly, there has been a rise in the use of synthetic opioids like fentanyl, often clandestinely mixed into other recreational drugs. ²⁷ , ⁵⁰ Innovative delivery systems, such as opioid‐laced edibles and vaping products, have also gained popularity in this age group. ⁵¹ , ⁵²

The initial steps in diagnosing acute opioid intoxication are obtaining a thorough history and performing a complete physical examination while maintaining a high degree of suspicion in situations where the child's mental status is altered or there is evidence of respiratory depression. While the foundational principles of diagnosis and treatment remain consistent across age groups, pediatric patients require a more tailored approach. The medical history should include questions about current medication use, substance use, and possible exposure to adulterated drugs. When taking a medical history, adult patients typically can provide self‐reported information or confirm their substance use. In contrast, pediatric patients, particularly younger children, cannot provide their history, necessitating reliance on information from caregivers. This can lead to incomplete or potentially inaccurate histories, with added complexity in cases of suspected neglect or abuse. It is essential to identify the source of the substances to ascertain the child's safety. It is also crucial to obtain information about the patient's vital signs, respiratory status, level of consciousness, and any other symptoms or signs that may suggest opioid overdose. Children under 2 years of age are more vulnerable to intentional poisonings secondary to their reliance on caregivers and higher susceptibility because of their smaller size. ⁵³ , ⁵⁴

The physical examination for adults and children focuses on mental status, respiratory function, and neurological assessment. However, in pediatrics, there is an increased emphasis on evaluating developmental and age‐appropriate responses, such as varying normal heart rates in children of different ages, especially when assessing conditions like bradycardia. ⁵⁵ , ⁵⁶ Clinical diagnostic signs of opioid toxicity are outlined in Table 1.

Laboratory evaluation is similar to adult patients and should assess electrolytes, blood glucose, and liver and renal function. A standard urine drug screen is not usually necessary to diagnose or treat an acute opioid overdose; however, it may be required to identify poly‐ingestions, determine placement in a treatment program and identify an unknown exposure, especially in younger children or assist with legal proceedings in pediatric cases of child neglect. ⁵⁶ , ⁵⁷ , ⁵⁸ Although physicians often obtain standard urine drug screens in the workup of suspected opioid ingestion, they have a significant false negative rate. A negative urine drug screen does not exclude the possibility of opioid toxicity. ⁵⁹ , ⁶⁰ , ⁶¹ , ⁶² Notably, there are various extended drug screens available that will assess for the presence of a greater number of substances. These tests are generally not rapid and take a few days to result, limiting their usefulness for the acute overdose situation. Even when results are available during the emergency department evaluation, results rarely change management. ⁶³ However, they should be considered in a young child, with physical findings concerning for possible exposure, as this may significantly alter the child's management and disposition.

Pediatric patients are particularly vulnerable to unintentional exposure to adulterated products, especially in environments where adult opioid use is present. ⁶⁴ , ⁶⁵ , ⁶⁶ , ⁶⁷ , ⁶⁸ , ⁶⁹ , ⁷⁰ , ⁷¹ , ⁷² , ⁷³ These products can cause severe respiratory depression and hypotension. Opioids may be combined with other drugs of abuse; therefore, even if a patient denies any opioid use, it may still be on the differential. Clinicians should be aware of the current trends in opioid use in their community, the potential for adulterations, and management changes that may result. Poly‐substance/poly‐pharmacy is another essential consideration in diagnosing acute opioid overdose in pediatric patients. ⁷⁴

The management priority in patients with acute opioid overdose is similar to that in adults and includes airway support, oxygenation, and early administration of an opioid antagonist (naloxone). Table 2 lists the management considerations for acute opioid overdose in children.

Pediatric patients with unwitnessed opioid ingestion may present with an altered level of consciousness; therefore, we considered naloxone administration in the undifferentiated altered mental status patient. ⁷³ , ⁷⁵ , ⁸² , ⁸⁶ Severe opioid toxicity will initially present with respiratory depression leading to respiratory arrest followed by cardiac arrest. ⁷⁶ The focus of treatment should be prompt recognition and activation of the emergency response system and administration of high‐quality cardiopulmonary resuscitation (CPR). It is reasonable to administer naloxone to a child in respiratory arrest with a pulse in addition to standard basic life support/pediatric advanced life support (BLS/PALS) care. ⁷⁶ , ⁷⁷ , ⁷⁸ , ⁷⁹ , ⁸⁰ , ⁸¹ No studies demonstrate improved outcomes for administering naloxone during cardiac arrest and providing high‐quality CPR should be the initial focus of a child found to be in arrest. Naloxone may be administered to a patient in arrest, provided it does not interfere with high‐quality CPR.

Rarely, a patient with respiratory failure may have decreased tidal volumes with deceptively normal respiratory rates. ⁸² , ⁸³ End‐tidal CO₂ monitoring may be helpful in these situations. Airway protection may be necessary for central nervous system depression or vomiting. Naloxone is not beneficial if a patient has been intubated and is mechanically ventilated, as it may cause increased agitation and necessitate increased sedation. In patients who present with recent ingestion (in the last hour) and are alert with a reassuring mental status, gastrointestinal decontamination with activated charcoal may be considered, with a dose of 1 g/kg administered orally. ⁸⁴ Activated charcoal administration should be avoided in patients with an altered mental status, as it may be aspirated if the patient vomits. Activated charcoal or whole bowel irrigation with airway protection in place may be required if there has been significant ingestion or, in the case of body packers or stuffers. ⁸⁵ , ⁸⁶ Large‐volume packaging or stuffing may require surgical decontamination. ⁸⁷ , ⁸⁸ , ⁸⁹ Intravenous or inhaled opioid overdoses do not warrant the use of gastric decontamination.

Naloxone has a rapid onset of action and typically works within 1 min if given intravenously. ⁹⁰ , ⁹¹ , ⁹² One dose of naloxone typically lasts 45–70 min. The recommended dosing of naloxone is 0.1 mg/kg IV with an initial maximum of 2 mg per dose. A lower dose may be used to avoid precipitated opioid withdrawal in older children or adolescents who may not be opiate naive. They should receive an initial dose of 0.04 mg IV, which can be titrated up to effect. ⁹³ , ⁹⁴

Larger doses of naloxone may be required to reverse drugs with high receptor affinity (e.g., fentanyl and fentanyl analogs, buprenorphine, codeine, and diphenoxylate‐atropine). ⁹⁵ , ⁹⁶ Escalating naloxone doses may be given, although >10 mg within 30 min may have diminishing returns. ⁹⁷ If multiple doses of naloxone are required, a continuous infusion may be necessary. ⁹⁸ Infusion rates are titrated to maintain respiratory effort while avoiding withdrawal symptoms.

Naloxone is most rapidly absorbed if administered intravenously but may be given in many alternative routes if IV access has not been obtained. Intranasal, intraosseous, intramuscular, subcutaneous, endotracheal, and even intralingual administration (with injection into the sublingual vein) may be used. ⁹⁶ Intranasal naloxone is equally efficacious as intravenous or intramuscular and has been integrated into many prehospital protocols. ⁹⁹ , ¹⁰⁰ , ¹⁰¹ , ¹⁰² , ¹⁰³ , ¹⁰⁴ , ¹⁰⁵ , ¹⁰⁶ While most of the data on prehospital naloxone administration are focused on adults, some data on children show that intranasal naloxone administration is as efficacious as intravenous administration. ¹⁰⁷ , ¹⁰⁸ Naloxone is safe. However, there have been rare adverse events in adults, including pulmonary edema, at an incidence of 0.2%−3.6%. It has been infrequently reported in adolescents, and a single case report in a 3‐year‐old is in the literature. ¹⁰⁹

Patients who respond to naloxone may develop recurrent central nervous system or respiratory depression as the effects of the naloxone wear off before the opioids they are treating. ⁷⁸ , ¹¹⁰ , ¹¹¹ , ¹¹² , ¹¹³ The time a patient requires monitoring depends on the medication, route, time of ingestion, and required intervention. The onset of action of intravenous opioid use is immediate; subcutaneous takes effect within 15 min, nasal within 30 min, and oral ingestions may take 4–6 h for peak effects. ¹¹⁴ , ¹¹⁵ Most opioid effects last a total of 3–6 h. Fentanyl is the shortest acting with about 1 h of activity, and methadone is the longest acting opioid, lasting 24–48 h. Naloxone is shorter acting than most opioids, with a duration of action of 30–70 min.

Some patient populations may require admission to the hospital. These include infants and young children, suspected abuse, unsafe social situations, ingestion of long‐acting agents, any concerns of suicidality or self‐harm, and patients with signs of recurrence of respiratory depression or noncardiogenic pulmonary edema. Adolescent patients who are monitored for a time based on the type of ingestion after administration of naloxone can be safely discharged to home if clinically improved. ¹¹⁶ , ¹¹⁷ , ¹¹⁸ Discharge criteria can be seen in Table 3.

When young children present following an acute opioid overdose, providers should consider the safety of the home environment. Since most ingestions in young children are exploratory or accidental, determining how the child accessed opioids is vital. While many adults may have legitimately prescribed medications, caregivers are responsible for ensuring these medications are properly stored. ¹¹⁹ Lack of appropriate supervision is a form of child neglect reportable to child protective services; however, the American Academy of Pediatrics notes that even careful caregivers can have a brief supervision lapse and recommends assessing the child's overall ongoing risk in the home. ¹²⁰ Furthermore, identifying parents and caregivers who suffer from an untreated opioid use disorder is crucial as they place children under their care at risk, and intervention to protect these children is critical. ¹²¹ Physicians are mandated reporters of child abuse and neglect and have a duty to report a reasonable suspicion of neglect, so it is essential to involve social work colleagues when available in determining the overall safety of the home environment and whether reporting to child protective services is warranted. ¹²² Given the mortality associated with opioid overdose, most opioid ingestions in children should be reported to child protective services. ¹²⁰ , ¹²¹ Given the risk of bias based on race or other socioeconomic factors for mandated reporting, many institutions have instituted protocols to report all pediatric ingestions to child protective services to avoid selective reporting.

One of the most efficacious forms of harm reduction is the distribution of intranasal naloxone. Increased access to naloxone decreases the risk of fatal opioid overdoses. All patients or families with members at high risk for an overdose should be prescribed or provided with take‐home naloxone. ¹²³ The lay public can be trained to administer naloxone successfully, ¹²⁴ , ¹²⁵ and there has been a case study of a pediatric patient who received a home naloxone nasal spray with improved symptoms. ¹²⁶ A study focusing on pediatric opioid fatal overdoses also recommends disseminating naloxone to households where individuals are in recovery or have a history of substance misuse. ⁴⁹ Families should be counseled that minors can purchase naloxone in most states. While many states have standing orders that allow the purchase of naloxone without a prescription, the U.S. Food and Drug Administration also approved naloxone for over‐the‐counter sale in March 2023. ¹²⁷

Families should be educated on the safe administration, storage, and disposal of pain medications. Physicians should communicate the importance of adequately disposing of unused and expired medicines in the home to reduce the risk of children and adolescents having access to prescription drugs, including opioids. ¹²⁸ In pediatric patients with accidental exploratory ingestions at home, ensuring a safe home environment with adequate disposition planning is imperative. This may require consultation with hospital social workers, when available, and local child protective services to ensure safety.

Patients who desire substance use treatment should be provided with referrals to inpatient or outpatient facilities that can assist in initiating medication‐assisted treatment for opiate use disorder. ¹²⁹

The issue of acute opioid overdose in pediatric patients demands that all emergency physicians have an acute awareness and consider the unique features of an opioid overdose in a child. In addition to recognition of subtle presentations, early treatment may reverse the devastating consequences of an opioid overdose, and timely involvement of social work may help protect the at‐risk child. The devastating consequences of opioid overdose on children's lives necessitate immediate action to prevent, identify, and address this problem (Table 4).

The authors declare no conflict of interest.

The authors gratefully acknowledge the American College of Emergency Physicians Pediatric Emergency Medicine Committee and the Pain Management and Addiction Medicine Section.

Sandelich S, Hooley G, Hsu G, et al. Acute opioid overdose in pediatric patients. JACEP Open. 2024;5:e13134. 10.1002/emp2.13134