Q&A: What pediatricians need to know about xylazine

Key takeaways:

• Xylazine-laced opioids are a “true national health crisis.”
• Exposed children are at high risk of death if medical intervention is not sought.

The Biden administration has declared xylazine-laced fentanyl an “emerging threat” to the United States — the first time an administration has made such a declaration.

Xylazine is a non-opioid animal tranquilizer that is not approved for human use. Combined with heroin or fentanyl, it is known as “tranq dope” and has been associated with a large increase in overdose deaths in the U.S.

In December, Stephanie A. Deutsch, MD, MS, FAAP, and Allan R. De Jong, MD, FAAP, physicians at Nemours Children’s Health in Wilmington, Delaware, published a case report in Pediatrics about three children exposed to opioids laced with xylazine, including two who experienced cardiac arrest.

We spoke with Deutsch about the White House’s designation, the threat xylazine poses to children, and what pediatricians need to know about the drug.

Healio: What did you think of the White House designation?

Deutsch: The White House designation of xylazine as an emerging public health threat is certainly unprecedented but absolutely warranted, given the rampant deadly effects of this drug among adults and its negative health impact on children.

There is growing concern that illicit opioids distributed across the nation are adulterated with xylazine, posing a true national health crisis. Although prioritizing xylazine detection, treatment among exposed users and enhanced tracking of data/drug trends will all be critical to combating this crisis, White House experts may have additional action steps planned, and we await further information from (White House drug czar) Rahul Gupta, MD, MPH, FACP, and others.

Healio: How do children who have ingested synthetic opioids containing xylazine present, and how are they treated? What is their outlook?

Deutsch: Exposed children have presented as critically ill. Xylazine has proven near fatal in multiple pediatric cases we have treated. Exposed children frequently have experienced protracted symptoms, meaning [that] the intoxication effects, lowering heart rate and respiratory rate and depressing mental status last longer than with a typical opioid ingestion.

We have seen children experience cardiorespiratory arrest requiring CPR before arriving at the hospital and/or requiring mechanical ventilation (intubation) to support oxygenation. Exposed children also historically have received multiple doses of naloxone with limited clinical effect, and frequently are admitted to our pediatric ICU for close monitoring and naloxone infusion.

Naloxone has little effect to reverse symptoms of xylazine exposure. Exposed children are at high risk of death if medical intervention is not sought.

Healio: Why did you think it was important for pediatricians to know about the cases you treated?

Deutsch: It is important for pediatricians to be aware of novel drug trends among adults because these trends directly impact risk to children. Substances used recreationally by adults may be present in the home environment of the child, resulting in inadvertent exposure.

Pediatricians should recognize that infants and children presenting with profound clinical symptoms that look like opioid intoxication but are not responsive to naloxone may represent scenarios where xylazine is an adulterant. Pediatricians should consider prescribing naloxone to families impacted by xylazine, opioids or other substance use as a preventive measure.

Healio: How would you recommend parents discuss this with their children?

Deutsch: Families impacted by substance use should be expeditiously linked to substance use disorder treatment. Parents who may have substances in their home should take precautions to prevent inadvertent exposures to children, such as use of lock boxes and keeping substances up high and out of reach of children.

All health care professionals should consider naloxone prescriptions for their adult and pediatric patients and should educate household members on how to administer naloxone to a symptomatic adult or child. Caregivers of older children and adolescents should counsel their children on the dangers of substance use, particularly that substances are frequently adulterated with unknown or other dangerous substances, like xylazine, that can be lethal.

Healio: Besides treatment, what else do children who have been exposed to these substances need?

Deutsch: Families impacted by substance use benefit from linkage to substance use disorder treatment, and all families should take precautions to keep substances up high and out of reach of children. Children exposed to dangerous substances may have other identified safety concerns or experience other psychosocial adversities. Health care professionals partnering with social work and other multidisciplinary colleagues can best address the multiple needs families may face related to substance use, mental health issues or other safety concerns.

Although xylazine has frequently been detected as an adulterant, it is possible next year another substance will be introduced into the drug supply and pose a public health risk to adults and children. Research and funding are needed to ensure novel drug trends and substance use patterns are recognized across the nation to keep both adults and children safe.

References:

Deutsch SA, De Jong AR. Pediatrics. 2022;doi:10.1542/peds.2022-058684.

The White House. Biden-Harris administration designates fentanyl; combined with xylazine as an emerging threat to the United States. https://www.whitehouse.gov/ondcp/briefing-room/2023/04/12/biden-harris-administration-designates-fentanyl-combined-with-xylazine-as-an-emerging-threat-to-the-united-states/. Published April 12, 2023. Accessed April 21, 2023.