Ethanol in a child’s autopsy specimen could reflect ingestion or microbial production. In a seven-child diphenhydramine series, three ethanol-positive cases had different supporting evidence: one was interpreted as likely ingestion and two as likely microbial activity. The measured concentration alone did not decide the origin.
The cases came from a selected drug-positive series
Wallage and Elliot described seven Ontario deaths in children aged four months to eight years. The source cases were selected for diphenhydramine detection, principally through a 2016–2022 search of deaths under five, with selected older children added.
This design did not estimate the frequency of ethanol ingestion or postmortem formation among all pediatric deaths. The three ethanol findings were case examples within a selected series, not a representative three-person ethanol experiment.
The analytical result identified ethanol, not its source
Specimens were collected at autopsy, with blood and urine placed in tubes containing sodium fluoride and sodium citrate. Targeted headspace GC-FID testing addressed ethanol and other volatile substances. Screening and drug-identification procedures varied across the years represented.
A result from that method established ethanol in the tested sample. It did not distinguish a swallowed ethanol molecule from one produced by microorganisms. The report did not provide serial ethanol measurements from these children to demonstrate the direction or magnitude of change over time.
Case 2: scene evidence supported ingestion
A six-year-old child had ethanol at 18 mg/dL in femoral blood and diphenhydramine at 1.2 mg/L. Scene information described alcohol and adult sleeping medication. No decomposition was observed at autopsy.
The authors considered ingestion the likely ethanol origin, and the certified cause included combined diphenhydramine and ethanol toxicity. That was an integrated case interpretation using scene, pathology and toxicology. It was not a rule that any pediatric ethanol concentration of 18 mg/dL proves ingestion or fatal synergy.
Case 4: decomposition and another volatile supported production
A three-year-old child had ethanol at 49 mg/dL in heart blood. Widespread decomposition was noted, and n-propanol was detected during headspace analysis. Diphenhydramine was 0.17 mg/L and was considered incidental to death from complications of a viral infection.
The authors interpreted the ethanol as likely microbial production. They did not derive a numerical production correction from the n-propanol result. Its presence supported that interpretation in context, rather than measuring how much ethanol had formed.
Case 6: infection complicated the origin question
A two-year-old child had ethanol at 11 mg/dL in heart blood and 13 mg/dL in urine. Cultures showed heavy growth of Klebsiella pneumoniae, and the cause of death was septicemia complicating acute gastroenteritis. Diphenhydramine was 0.051 mg/L and considered incidental.
The authors again favored microbial activity as the ethanol explanation. A documented organism capable of contributing to fermentation made that interpretation plausible; it did not establish the precise time or amount of ethanol production in this child. The paired urine result was not converted to an earlier blood alcohol concentration.
Interpretation requires preserving uncertainty
These cases support examining specimen site, decomposition, microbiology, accompanying volatiles and scene information together. They do not establish a pediatric ethanol cutoff separating ingestion from production, and they do not show that every infection produces ethanol.
For related limits, see why absent 1-propanol cannot exclude microbial ethanol and why assay uncertainty does not quantify postmortem formation.
Primary source
Wallage HR, Elliot M. Postmortem diphenhydramine blood concentrations in children. Journal of Analytical Toxicology. 2025;49:129–133. doi:10.1093/jat/bkae084.
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