In a Bangor courtroom last year, Hillary Goding pleaded guilty to manslaughter and was sentenced to 26 years in prison for the fentanyl overdose death of her 3-year-old daughter, Hailey.

In Maine as elsewhere, we would like to believe that fentanyl ingestion in children is rare. Unfortunately, it is not. The first problem is failure to test for fentanyl when a drug test is ordered. The second problem is timely recognition and treatment of opioid ingestion in children.

In a paper on fatal poisoning of children, just published by the journal Pediatrics, the authors acquired data from 40 states participating in the National Fatality Review Case Reporting System from 2005-2018 on death attributed to poisoning among children aged 5 and younger. During this period, 731 poisoning-related fatalities were reported with 42% occurring among infants less than 1 year of age. Opioids were the most common substance contributing to deaths – in 2005, opioids accounted for a quarter of deaths. In 2018, this rose to half of deaths.

In the Mills administration’s January-December 2022 drug overdose report, 10,110 overdoses were reported in Maine, including 716 suspected or confirmed deaths. Nearly 80% of confirmed fatal drug overdoses in 2022 were attributable to non-pharmaceutical fentanyl, either alone or in combination with other illicit drugs, such as cocaine, heroin or methamphetamine.

The 2022 Maine Child Death and Serious Injury Review Panel reported that fentanyl accounted for seven pediatric ingestions during the year. All were because of illicit fentanyl in the child’s home. Despite the increased presence of fentanyl in Maine, the panel said in its report “that not all healthcare facilities or providers of laboratory services employ urine toxicology testing that includes an assay for fentanyl.”

California became the first state to mandate that if a hospital conducts a drug test, it must include fentanyl. The law requires that a general acute care hospital includes drug screening for fentanyl if a person is treated at the hospital and the hospital conducts a urine drug screening to assist in diagnosing the patients. The rule is also known as Tyler’s Law, named after Tyler Shamash, who died of a fentanyl overdose at 19. According to his mother, “The night before he died, he was sent to the hospital with a suspected overdose. When he got there, they did a drug test and it turned out negative. After he died, we found out it did not cover fentanyl.”

According to the January-December 2022 Maine drug overdose report, only in 25% of the suspected and confirmed fatal overdose cases in 2022 was naloxone administered at the scene by emergency medical services, bystanders or law enforcement. This percentage does not tease out if cardiac function was present during resuscitation. Naloxone would be of no benefit if there were no cardiac function. It does suggest, however, that there may be room for improvement in the prehospital use of naloxone, at least until better statistics become available.

The Maine prehospital EMS protocols for altered level of consciousness note that if respirations are less than 12 a minute AND (capitalization taken from the protocol) narcotic overdose is suspected, Narcan should be administered. Unfortunately, in the pediatric patient, a history of narcotic ingestion may not be reported or even known by the care provider.

In the recent Pediatrics paper, the authors emphasize that first responders and clinicians should maintain a high level of suspicion for opioid intoxication among children with altered mental status or respiratory depression. Strikingly, they do not state that treatment with Narcan should be contingent on suspicion but rather only on symptoms of altered mental status or respiratory depression.

One of the first things young doctors are taught is that common things happen commonly. The saying goes that when you hear hoofbeats in the forest, think of horses, not zebras. Nowadays, medical providers at all levels should also think of fentanyl to diagnose and treat children appropriately. Of course, initial treatment should not await test results. On the other hand, you will never find fentanyl if you don’t test for it.