Child Protection Referrals for Ingestions Associated With Ingestion Type but Not Patient Demographics

Lack of guidelines for Child Protective Services (CPS) referrals for neglect in unintentional ingestions or chemical exposures (IOCE) may lead to variations and inequities in care. We aimed to assess if patient demographics or characteristics of unintentional IOCE were associated with CPS referrals in a pediatric emergency department (PED).

Retrospective study of electronic health records of patients < 12 years old presenting to a PED with IOCE from 01/01/2020 - 12/31/2024. Unintentional IOCE was determined by ICD 10 and verified by independent manual chart review by 2 trained reviewers. We excluded intentional IOCE, visits with CPS referral prior to PED presentation or for unrelated reasons, and repeat visits. Predictors included demographics (age, race, ethnicity, insurance type, area deprivation index (ADI) score), IOCE type grouped by risk level (household products, over-the-counter drugs/non-controlled prescription drugs, alcohol/cannabinoids/nicotine, controlled prescription drugs/illegal drugs, unknown) and PED disposition (as proxy for clinical severity). Primary outcome was CPS referral. Bivariate and multivariate analyses were used to determine odds of CPS referral by demographics, IOCE type and clinical severity.

635 records met inclusion criteria, 132 were excluded, leaving 503 unique patient visits. Of these, 109 (22%) had CPS referrals. In multivariable regression, female gender (OR 2.04; 95% CI 1.08-4.00), alcohol/cannabinoid/nicotine ingestion (OR 185.2; 95% CI 52.04-930.47), controlled/illegal drug ingestion (OR 17.67; 95% CI 4.63-90.46), unknown ingestion (OR 7.65; 95% CI 1.43-47.24), and hospital admission (OR 8.65; 95% CI 3.89-19.69) were associated with greater odds of CPS referral. Age, race, ethnicity and ADI were not associated with CPS referral.

CPS referrals were associated with IOCE type and clinical severity, but not with demographics except female gender. Higher likelihood of CPS referral for ingestions of legal recreational drugs than for controlled and illegal drugs may reflect bias and should be explored further. Because ingestion type and severity of an isolated episode may not reflect risk of ongoing harm, a key component of supervisory neglect, guidelines detailing thresholds for CPS referral in cases of drug ingestion/chemical exposure may reduce variability and promote equitable care.