Trends and Circumstances of Pediatric Fentanyl Deaths in North Carolina: A 10-Year Retrospective Study

This study describes the contextual factors and scientific data associated with fentanyl-related deaths among individuals aged 0-17 years in North Carolina. Using information from the North Carolina Medical Examiner System from 2015 to 2024, 138 pediatric fentanyl deaths were identified. Manually abstracted scene information, toxicology results, and pathological findings allowed for a rarely examined in-depth analysis of circumstances surrounding these deaths. Children less than 2 years (n = 33, 1.38 per 100 000) and adolescents aged 15-17 years (n = 80, 1.96 per 100 000) experienced a fentanyl-related death rate higher than the statewide pediatric fentanyl-related death rate of 0.60 per 100 000 residents. Among children less than 2 years, 78.8% of overdose onset occurred in the decedent's primary residence, and drugs or paraphernalia were present at the scene in 51.5% of cases. Co-sleeping was documented in 60.6% of deaths, with 80.0% occurring in adult beds. Postmortem blood concentrations of fentanyl among children less than two years ranged from less than 0.50 to 280 ng/mL (mean 27.0 ng/mL, median 17 ng/mL). Among adolescents, 62.5% of overdose onset occurred in the decedent's primary residence, followed by a friend's residence (13.8%). History of substance use was documented in 82.5% of cases and drugs or paraphernalia were present in 67.5% of cases. Blood concentrations of fentanyl among adolescents ranged from less than 1.0 to 330 ng/mL (mean 21.7 ng/mL, median 11.0 ng/mL). Scene investigation and documentation allow for the recognition of behavioral trends, which can be targeted for age-specific overdose prevention strategies. Among decedents less than 2 years, notable trends included children co-sleeping in adult beds with access to drugs and drug waste and/or prolonged periods without supervision. Among older adolescents, several cases involved suspected counterfeit pharmaceuticals and/or periods of non-contact with primary caregivers. Improved workflows for pediatric medicolegal death investigation and electronic reporting strategies are already underway.