Canada's Shortage of Child-Centric Pharmaceuticals

"As a clinical pharmacologist and someone who is married to a pediatrician, we had a difficult time trying to figure out how to divide adult doses."

"And I figured that if we were having a hard time doing this, and my colleagues with young kids were having a hard time doing this, I can only imagine the impact on the greater Canadian population."

"We may be missing some of the possible harms, because we only know about the cases where people call."

Dr. Jonathan Zipursky, clinical pharmacologist, Sunnybrook Health Sciences Centre, Toronto

"I think it would be very fair to say that if  you talk to the other medical directors of the poison centres in British Columbia, Quebec and Halifax, that they would anecdotally say the same thing -- that they also received a change in calls."

"I think that it really highlights for  us is in some cases how reactive the system is as opposed to how proactive it is."

"Everyone, including health-care professionals and government as well as pharmaceutical companies, we really do need to continue to work together and we need to have even earlier warnings ... so that the right authorities can take action."

Dr. Mark Yarema, medical director, Alberta Health Services' Poison and Drug Information Service

"You can call this the canary in the coal mine. It just speaks to how precarious our supply chain is in Canada. Children are at greater risk in general [particularly young children who require liquid formations they can swallow and who make up a very small market compared to adults and older kids who can take tablets]."

Dr. Stephen Freedman, pediatrician

 

Canada last year saw an alarming and acute unavailability of children's painkillers from pharmacy shelves. A new study verifies what every parent already knew, the shortage of Tylenol and Advil frightened parents and it wasn't unusual for parents under frantic duress to reduce the pain their children were suffering to travel to the U.S. where there was no shortage, to buy up enough painkillers to share with their friends and family members. 

 

Between August and December of 2022 there was a sudden surge of viral illness and that was the time when supplies of children's pain and fever medication dropped precipitously.

Pharmacy shelves bare of these basic over-the-counter necessities to treat children, greeted parents. Which left them with another option that turned out to be fairly troublesome; either to hope they could accurately translate the dose their children usually took by cutting up adult tablets to approximate the formulation and dosage required, or simply to throw up their hands in desperate resignation and decide to forego painkillers completely.

A new study published in the New England Journal of Medicine of which Dr. Zipursky was the lead author, concluded that calls to the Ontario Poison Centre for accidental painkiller overdoses in children more than doubled throughout the shortage. Dr. Zipursky and his co-authors decided they would study Poison Centre data through this period motivated by the reality that they too were parents of children who were affected by the shortage and the potential for well-meaning solutions that sometimes led to overdoses and trips to hospital emergency rooms.

The research team included doctors and scientists from Sinai Health, Sick Children's Hospital in Toronto, Public Health Ontario and others, collected over five years of data from the Ontario Poison Centre servicing 15.6 million people across Ontario, Manitoba and Nunavut, representing over 40 percent of the Canadian population.  Calls to the Poison Centre for acetaminophen and ibuprofen dosing errors in children during the 2022 shortage were compared to the 4.5 years previously and two months immediatly after.

Of the total calls, close to 80 percent involved children aged five or younger. The centre received a median of 44 calls monthly before the shortage of children's painkiller. That number more than doubled during the shortage, to 107 calls monthly; while calls about children in duress for all other reasons remained static. Adjusting for the very high levels of viruses in circulation at the time and the season, the number of calls was significantly higher than what might be expected, it was found.

The researchers assessed severity by analyzing how many children affected by dosing errors were referred to hospital, finding the proportion of calls stayed the same compared to the pre-shortage period. The data did not reflect a large increase in hospitalizations, pointing to the importance of Canada's five poison centres and the role they play through counselling caregivers and health-care providers. Dr. Yarema of Alberta Health Services pointed out that although the study covered mostly Ontario "this truly was a national issue".

While the shortage of children's painkillers was stressful and difficult for children and caregivers alike, pointed out pediatrician Stephen Freedman, it was less concerning than was the shortage of antibiotics immediately following the painkiller shortage. Amoxicillin, a first line of defence for bacterial infections in kids' shortage was particularly disturbing in its unavailability.

"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."

"Canada is, by all accounts a small drug market, but it sources a lot of its medications from abroad. 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."

Dr. Jonathan Zipursky

There are alternatives to provide relief for kids with colds and flus, be it compounded medication from a pharmacist or fractional dosing. (George Rudy/Shutterstock)