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Medication shortage in Canada led to increased dosing errors in children, new study shows

A new study has found that dosing errors in children increased during the Canada-wide shortage of pediatric fever and pain medication last year.

The study by Sunnybrook Health Sciences Centre in Toronto looked at the number of monthly calls to the Ontario Poison Centre (OPC) for unintentional acetaminophen and ibuprofen dosing errors among patients 18 years of age or younger between January 1, 2018, and February 28, 2023.

During the medication shortage, between August and December 2022, there was a 40 to 60 per cent increase in calls to the OPC compared to trends over the prior four years.

Margaret Thompson, medical director of the OPC, said the shortage of pediatric analgesia and anti-fever medications led to parents and caregivers using adult preparations for their children’s dosing.

“When (parents) are faced with a situation where they no longer have their usual medication; they might assume that an adult tablet, for example, was the same as a chewable pediatric tablet,” she told in an interview on Tuesday.

“They wanted to give some relief to their kids, understandably.”

During the shortage, a Toronto-based family doctor said some adult painkillers, such as acetaminophen, commonly known as Tylenol, and ibuprofen, known as Advil or Motrin, could be carefully measured for children’s dosage.

However, wrong dosing can occur due to a variety of reasons, from miscalculating the proper translation from milligrams to kilograms to using the wrong syringe size.

“Small changes in the dose may mean the difference between safe and potentially dangerous in terms of health consequences,” Jonathan Zipursky, a clinical pharmacologist and toxicologist at the Sunnybrook Health Sciences Centre and main author of the study told on Tuesday.

Zipursky, a doctor and father of two young children, said there are real consequences to administering the wrong dose to children, so parents have to be extra careful when doing calculations or consult a health-care provider for advice.

During the countrywide shortage of children’s painkillers, the OPC created a dosing guide for parents.


Zipursky said the study published today in the New England Journal of Medicine (NEJM), sheds some light on the importance of drug shortages, especially in vulnerable populations like children, and the importance of forecasting potential supply-demand mismatch.

However, the study only reflects a small portion of the dosing errors during the drug shortage, Thompson told adding she believed the problem was “much bigger.”

“I would expect that it’s maybe one tenth of the issue,” she said.

Thompson said not every dosing error is reported because there is no obligation to disclose them, there is a lack of knowledge about poison centres, and parents might go straight to a pharmacist or hospital rather than call.

The OPC is one of five poison centres in Canada covering 15.6 million people across Ontario, Manitoba and Nunavut. Similar to its regional counterparts, it provides telephone-based front-line service from nurses and pharmacists with specialised training in the effects of poisons seven days a week, 24 hours a day.

If you need to call a poison control centre in your area, you can find a list of locations here or you can call the national line at 1-844-764-7669. Top Stories

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