Tiny amounts of fentanyl can cause 'alarming and incredibly sad' overdose deaths of young children

It wouldn't take much fentanyl to cause a child to overdose — the amount a toddler would get in hospital for extreme pain probably weighs less than a grain of table salt.

"A child isn't someone who is tolerant to opioids. They've never had fentanyl," said Dr. Margaret Thompson, the medical director of the Manitoba Poison Centre and an emergency room physician.

The overdose deaths of three young children who were in the care of their parents in Winnipeg have left hard-to-answer questions about how such heartbreaking losses can be prevented.

Layla Mattern Muise, who was three months old, and one-year-olds Romeo Stewart and Hanna Boulette all died of fentanyl-related overdoses in Winnipeg in 2022 and 2023. In all three cases, one or both parents have recently been charged in their deaths.

In a fourth case, a two-year-old child was taken to hospital in critical condition due to an overdose on Dec. 30. A visitor to the child's Winnipeg home has been charged in that incident.

"We don't want to talk about child deaths, for sure," said Thompson, who is also a medical toxicologist. "There isn't a lot of evidence … how to prevent these sorts of things."

The Manitoba Chief Medical Examiner's Office said in an email that the medical examiner has certified one overdose death of a child age two or younger in 2023, one in 2022, two in 2021, one in 2019 and then none for several years until as far back as 2010, when there was one.

A prescription medication was implicated in one death, while the remainder involved opioids, the email said.

Sherry Gott, the Manitoba advocate for children and youth, was not available for an interview on Tuesday or Wednesday, but sent an email statement that called child drug poisonings "alarming and incredibly sad."

A comprehensive mental health and addictions strategy is critical to preventing such deaths in future, said Gott.

That includes examining the root causes and socioeconomic factors that contribute to addiction, "and then investing resources and providing supports to help those who are struggling," Gott said in the statement.

"Without a mental health and addictions strategy, I fear we will continue to see child deaths of this nature."

Prevention strategies

As an emergency physician, Thompson uses fentanyl to treat patients in extreme pain —  but "very small quantities can be enough to give pain relief" in those cases, she said.

A standard dose would be one microgram of fentanyl per kilogram of weight, and a child of one or two might weigh about 10 kilograms (just over 20 pounds), Thompson said.

A microgram is one millionth of a gram, so a medical dose for a toddler would be about 10 millionths of a gram — less than the weight of the average grain of table salt.

Fentanyl is an opioid, and people build up a tolerance to opioids over time — even those using prescription opioids — but children have zero tolerance, Thompson said.

When fentanyl is purchased on the street, it may have other substances in it as well.

"Some of them are even more potent than fentanyl, so even smaller amounts would be required," she said.

But just touching fentanyl won't poison a child. While fentanyl patches are used for pain control, they are specially formulated to be absorbed over a long time through skin; the type of powder that is more commonly obtained through illegal sales doesn't work that way.

It's more likely that children could get it on their fingers and then put their fingers in their mouths, Thompson said.

The simple answer is that drugs — whether prescription, recreational (including cannabis or alcohol) or illicit — should always be locked up and out of sight of children, Thompson said.

However, she knows that a person impaired by drug use might not even be alert enough to do that.

"Having a safe caregiver if you are using is maybe another prevention strategy," she said, or leaving the home to use drugs away from children.

If partners are both addicted to drugs, they could mitigate risks for their children by taking turns using, Thompson said.

"If both people are dependent, they get a chance to use the drug," she said. "'Use with a buddy' is also an important message for helping prevent yourself from having a fatal outcome."

Users should also have access to naloxone, the antidote to fentanyl, which also works for children, she said.

If there is any suspicion a child may have ingested a drug, caregivers should immediately call 911.

Health-care providers are worried about treating the child, not the stigma associated with drug use, Thompson said.

"We want to help everyone have a better life and we want to prevent an exposure to somebody who isn't using."