ORIGINAL PAPER

Adolescent alcohol intoxication in Dutch hospital centers

of pediatrics: characteristics and gender differences
Selma H. Bouthoorn & Joris J. van Hoof &
Nicolaas van der Lely
Received: 20 August 2010 / Accepted: 11 January 2011
# Springer-Verlag 2011
Abstract Gender differences in alcohol intoxication among
adolescents are still largely unknown, whereas these differ-
ences have been studied in adults. To investigate possible
differences, this study analyzed pediatric admissions for
alcohol intoxication to the majority of Dutch hospitals
between 2007 and 2009. Another aim was to explore key
characteristics (e.g. blood alcohol concentration, duration of
reduced consciousness, and age) and trends of alcohol
intoxication among adolescents in the period 20072009.
We analyzed data from the Dutch Pediatric Surveillance
system, which monitors alcohol intoxication among chil-
dren in pediatric departments of Dutch hospitals. Patients
aged 1117 years with reduced consciousness due to
alcohol intoxication were included. The number of adoles-
cents admitted with alcohol intoxication increased sharply
from 2007 to 2009. The average age of the patients treated
for alcohol intoxication increased from 15.3 years in 2007
and 15.4 years in 2008 to 15.7 years in 2009. The duration
of reduced consciousness due to alcohol intoxication also
increased over the 3-year period: from 2.2 to 3.1 h. Gender
differences were observed regarding alcohol intoxication
characteristics. Most strikingly, intoxicated girls were
younger (15.3 vs. 15.7 years), had a lower blood alcohol
concentration (1.79 vs. 1.94 g/l) and were hospitalized for
shorter times than boys. No association was found between
alcohol intoxication and other, possibly illicit drug use. The
drinks most consumed prior to hospital admission were
spirits and beer. Alcohol intoxication among adolescents is
an emerging problem. Differences in intoxication character-
istics between boys and girls were observed. These findings
are important for future prevention and intervention
strategies. In the Netherlands, special policlinics for
children with alcohol intoxication have already been
established.
Keywords Adolescents
.
Alcohol intoxication
.
Gender
differences
.
Characteristics
.
Hospitalization
Introduction
Alcohol use among adolescents is a phenomenon that has
gained increasing attention both in the general media and in
medical scientific literature. In 2007, 56% of Dutch
adolescents aged 12 years, and 93% of children under
16 years old, had consumed alcohol at least once [29].
Regular alcohol use (drinking in the last month) was
reported by 16% of 12-year olds and 78% of 16-year olds
[29]. Over the last few years, there has also been a
significant increase in the number of young people admitted
to hospitals because of alcohol intoxication. This has
occurred not only in the Netherlands but also in other
countries [1, 2, 22, 42, 45]. Compared with other European
countries, the Netherlands, Germany, and Denmark top the
list for binge drinking in adolescents [17]. Binge drinking is
usually defined as drinking 5 units of alcohol for boys and
4 units of alcohol for girls on a single occasion, with the
aim of getting drunk [44].
Alcohol use at a young age is a risk factor for future
alcohol and drug problems [19, 39]. Young people who
S. H. Bouthoorn (*)
:
N. van der Lely
Department of Pediatrics, Reinier de Graaf Hospital,
P.O. Box 5011, 2600 GA, Delft, The Netherlands
e-mail: S.Bouthoorn@rdgg.nl
S. H. Bouthoorn
e-mail: selmabouthoorn@hotmail.com
J. J. van Hoof
Institute for Behavioral Research, University of Twente,
P.O. Box 217, 7500 EA, Enschede, The Netherlands
Eur J Pediatr
DOI 10.1007/s00431-011-1394-9
drink before the age of 15 are four times more likely to
develop alcohol addiction [16, 19]. Adolescent alcohol use
is also associated with traffic accidents, poor school
performance, smoking, other possibly illicit drug use,
criminal behavior, and unsafe or unplanned sexual activity
[6, 28, 32, 35, 36, 41, 48]. Champion et al. [5] observed
that the risk of adolescents girls becoming the victim of
unwanted sexual activity increases about three times if they
binge drink. Reviews of research on neurocognitive effects
of alcohol on adolescents and college students, as well as
animal models of adolescence, have shown that the
adolescent brain is particularly sensitive to the damaging
effects of alcohol [3, 9, 11, 12, 20, 25].
Since 2007, the Netherlands has included alcohol
intoxication among adolescents in a national registration
system for pediatric departments of Dutch hospitals
(NSCK). The aim of this study was to explore character-
istics and trends of alcohol intoxication among adolescents
in the Netherlands in 2007, 2008, and 2009 and to compare
the following key indicators: blood alcohol concentration
(BAC), age, reduced consciousness, and duration of
hospitalization. Another aim of this study was to investigate
differences in alcohol intoxication between boys and girls.
Most previous studies of adolescent alcohol intoxication
characteristics focused mainly on the whole group without
distinguishing between males and females [2, 22, 23, 42,
46]. Differences may be significant for the prevention of
and intervention in this problem. Characteristics of special
interest are age when intoxicated, level of BAC, duration of
coma, length of hospitalization, use of intensive care
facilities, drinking pattern, and illicit drug use.
Materials and methods
Data collection
Data were collected by the NSCK. The NSCK monitors the
prevalence of ten to twelve predetermined diseases,
disorders, or syndromes, by sending short monthly ques-
tionnaires to participating Dutch pediatricians in general
hospitals and in academic hospitals, requesting them to
report on these diseases. Questionnaires were sent to 92%
of the general Departments of Pediatrics and 83% of the
pediatricians in academic hospitals. Upon notification of a
case, an elaborate questionnaire is sent to the responding
pediatrician, who will fill it in and return it to the research
group. Since 2007, admission for alcohol intoxication
(BAC>0 g of alcohol/l of blood) among children of 0
18 years has been one of the topics in the system.
The elaborate questionnaire concerning alcohol intoxi-
cation consisted of four parts: (1) general and demographic
information about the adolescent (gender, age, family
structure, patient code, and date of birth), (2) alcohol use
in previous months (average number of glasses per
week day (MondayThursday) and average number of
glasses per weekend day (FridaySunday]) and the use of
other, possibly illicit substances before alcohol intoxication
(none, cannabis, cocaine, gamma hydroxyl butyric acid
(GHB), ecstasy, amphetamine/speed, magic mushroom,
other), (3) intoxication and hospital treatment character-
istics (time of hospital admission, BAC, duration of
impaired consciousness, duration of hospitalization, and
use of intensive care facilities) and (4) hospital information
(e.g. pediatrician and hospital code).
The first two parts were answered directly after treatment
by the intoxicated adolescent (self-reporting). The last two
parts were answered by the pediatrician.
Response
In 2007, the NSCK monitored 297 cases of alcohol
intoxication from 56 different departments of pediatrics
(out of 98 Dutch hospitals). After notification in the NSCK
system, an elaborate questionnaire was send to the
pediatrician concerned, and 238 questionnaires were
returned (a response rate of 80%). In 2008, 337 cases were
monitored, with a response rate of 89% (299 returned
questionnaires). These adolescents were admitted to 66
Departments of Pediatrics. In 2009, there were 500 reported
cases of alcohol intoxication from 75 different hospitals.
The number of returned questionnaires was 438 (a response
rate of 88%). Not all elaborate questionnaires were filled in
completely, which is probably due to the heavy workload of
pediatricians. In this article, the number of cases (n) will be
supplied when relevant.
Patient sample
This study included all cases of adolescents treated with an
alcohol intoxication collected within the NSCK system if
the following criteria were confirmed:
a. Patients were admitted to a department of pediatrics in
2007, 2008, or 2009;
b. Patients were aged 11 to 17 years;
c. Patients had a BAC>0 g/l; and
d. Patients were admitted because of impaired consciousness.
These criteria resulted in a sample of 813 adolescents
(203 patients treated in 2007, 245 in 2008, and 365 in
2009).
Statistical analyses
Data were analyzed using SPSS Statistics 18. For the
comparison of continuous variables, the two-sample t test
Eur J Pediatr
and one-way ANOVA were used. The Kolmogorov
Smirnov test was used to test normality. The Chi-square
test was used to show wether there was a significant
association between two nominal variables. Linear regres-
sion was used to examine the relationship between one
dependent variable and one or more independent variables.
Pearsons correlation coefficient was used. Confidence
intervals (95% CIs) were calculated using SPSS. Percent
or mean with 95% CI was reported. We considered P values
less than 0.05 as statistically significant.
Results
Trends from 2007 to 2009
Considering the number of hospital admissions due to
alcohol intoxication monitored by the NSCK, there was
an increase of hospitalization of adolescents with reduced
consciousness due to alcohol intoxication of 21% in
2008 (245 cases) compared with 2007 (203 cases). In
2009, there was an increase of 80% (365 adolescents)
compared with 2007, and an increase of 49% compared
with 2008. A different age distribution of the admitted
adolescents in 2007 to 2009 was observed. The average
age increased from 15.3 years in 2007 to 15.4 years in
2008 and to 15.7 years in 2009 (P=0.001). This is
especially due to the fact that the prevalence among 17-
year olds increased significantly in 2009 compared with
2007 (Table 1). In 2008, the youngest child who was
hospitalized due to alcohol intoxication was 11 years old
at time of admission. In 2007 and 2009, the youngest
adolescent admitted was 12 years old. An equal number of
boys and girls were hospitalized in all three years
(Table 1). Duration of hospitalization decreased in 2009
compared with 2007 (P=0.029). BAC remained the same
over the years, while duration of coma increased (P=
0.046) due to an increase in 2009 compared with 2007
(Table 1).
Gender differences
To focus on gender differences, we analyzed all 813 cases
regarding prevalence rates per age. Most striking is the fact
that girls of 13 and 14 years ended up in hospital more
often than their male counterparts. At the age of 15,
hospital admission rates were similar. For adolescents of 16
and 17 years the trend was reversed: more boys than girls
were hospitalized. Alcohol intoxication prevalence was
highest among 16-year old boys (32.5%) and 15-year old
girls (29.2%). The average age of hospitalization due to
alcohol intoxication for boys was 15.7 years old, and for
girls the average age was 15.3 (P<0.001) (Table 2).
A significant difference was observed between the average
BAC among boys and girls (1.94 vs. 1.79 g/l; P=0.001). The
correlation between age and BAC appeared to be weak
(Pearsons r=0.17; P<0.001), even when considered sepa-
rately for boys and girls (Pearsons r=0.16; P<0.001, for
both). Multivariate analyses showed that BAC is dependent
on gender and age (Table 3). The minimum BAC observed
was 0.05 g/l, and the maximum BAC was 5.0 g/l.
Reduced consciousness varied from several minutes to
24 h. No difference in duration of impaired consciousness
was observed in relation to age (P=0.54), or for boys (P=
0.57) and girls (P=0.86) separately. The average duration
of reduced consciousness was similar for boys and girls, as
shown in Table 2. A moderate correlation was found
between reduced consciousness and BAC (Pearsons r=
0.32; P<0.001). The correlation was slightly stronger for
boys than for girls (Pearsons r=0.36; P<0.001 vs.
Pearsons r=0.27; P=0.001).
Most hospital admissions occurred during the evening
(36.9 %) and at night (55.1%). Girls were hospitalized for a
shorter period than boys (P=0.002). No difference in
duration of hospitalization was observed for age (P=0.14).
Duration of IC facility use was similar for boys and girls.
Increased use of IC devices at a given age could not be
tested because of the small number of persons admitted to
an ICU. A moderate correlation was found between BAC
and the duration of IC facility use (Pearsons r=0.33; P=
0.037), a weak correlation was observed for BAC and
duration of hospitalization (Pearsons r=0.21; P<0.001)
(Table 2). Multivariate analyses showed a dependency
between duration of hospitalization and the variables
gender and BAC (Table 3).
Apart from alcohol, the other most commonly used drug,
for both boys and girls, was cannabis. Cannabis was used
more often by boys than by girls, although not significantly
so. The drug used second-most by both boys and girls was
GHB. In addition to cannabis and GHB, one patient had
used ecstasy. Cocaine, amphetamine/speed, and magic
mushrooms were not seen at all. The average age of
cannabis use was 15.7 years for boys and 15.4 years for
girls (P=0.28), while for GBH, the average age for boys
was 14.9 years and for girls was 15.8 years (P=0.087).
The most common type of alcohol consumed prior to
hospital admission for both boys and girls were spirits
(60.5%). Boys showed a strong preference for drinking beer
(51.5% vs. 21.4%), whereas girls drank more wine (18.5%
vs. 3.5%) and pre-mixed drinks (16.1% vs. 9.6 %). Regular
alcohol consumption on weekdays was similar in boys and
girls (0.25 vs. 0.22 glasses). On weekend days, however,
boys drank more than girls (3.34 vs. 1.98 glasses; P<0.001)
(Table 2). A moderate correlation was tested between age
and alcohol consumption during the weekends (Pearsons
r=0.33; P<0.001). On weekdays, no correlation was found
Eur J Pediatr
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Eur J Pediatr
Table 2 Characteristics of alcohol intoxication by gender
Characteristics Boys (95% CI) Girls (95% CI) Total (95% CI) P
Prevalence per age (years) n=409 n=391 n=800
11 0.2 0 0.1
12 1.5 (0.32.6) 1.8 (0.53.1) 1.6 (0.82.5) 0.72
13 5.4 (3.27.6) 12.5 (9.315.8) 8.9 (6.910.9) <0.001
14 19.8 (15.923.4) 26.9 (22.531.2) 23.3 (20.326.2) 0.018
15 27.4 (23.131.7) 29.2 (24.733.7) 28.3 (25.131.4) 0.58
16 32.5 (28.037.1) 21.0 (16.925.0) 26.9 (23.830.0) <0.001
17 13.2 (9.916.5) 8.7 (5.911.5) 11.0 (8.813.2) 0.042
Average age (years) 15.7 (15.615.8) 15.3 (15.215.4) 15.5 (15.415.6) <0.001
b
BAC per age (average (years)) n=360 (g/l) n=350 (g/l) n=713 (g/l)
11 2.60 2.60
12 1.77 (1.232.31) 1.34 (0.701.98) 1.52 (1.131.91) 0.25
13 1.67 (1.511.83) 1.70 (1.541.87) 1.69 (1.571.81) 0.78
14 1.87 (1.741.99) 1.71 (1.591.82) 1.78 (1.691.86) 0.060
15 1.90 (1.782.02) 1.83 (1.721.95) 1.86 (1.781.94) 0.43
16 2.00 (1.892.11) 1.84 (1.701.99) 1.94 (1.852.02) 0.085
17 2.12 (1.942.29) 1.97 (1.752.23) 2.04 (1.892.19) 0.32
Average BAC 1.94 (1.901.97) 1.79 (1.761.82) 1.86 (1.821.91) 0.001
Characteristics
Average duration of reduced consciousness (hours) n=169 n=159 n=328
2.8 (2.33.1) 2.7 (2.33.1) 2.8 (2.53.1) 0.64
b
Average duration of hospital admission (days) n=364 n=340 n=707
1.0 (1.01.2) 0.9 (0.91.0) 1.0 (1.01.0) 0.002
b
Average duration of using IC facilities (days) n=26 n=17 n=43
1.0 (0.91.1) 1.1 (1.01.3) 1.1 (1.01.2) 0.19
b
Type of alcohol
c
n=396 n=379 n=775
Beer 51.5 (46.656.5) 21.4 (17.325.6) 36.8 (33.640.4) <0.001
Wine 3.5 (1.75.4) 18.5 (14.622.4) 10.8 (8.613.0) <0.001
Distilled 62.4 (57.667.2) 58.6 (53.663.6) 60.5 (57.063.9) 0.28
Pre-mix 9.6 (6.712.5) 16.1 (12.419.8) 12.7 (10.415.1) 0.007
Post-mix 12.6 (9.315.9) 17.4 (13.621.3) 15.0 (12.417.4) 0.062
Other 11.9 (8.715.1) 11.9 (8.615.1) 11.8 (9.614.1) 0.998
Regular alcohol consumption per day (average)
Week n=196 (glasses) n=191 (glasses) n=388 (glasses)
0.22 (0.150.36) 0.25 (0.030.42) 0.23 (0.100.36) 0.78
b
Weekend n=203 (glasses) n=187 (glasses) n=391 (glasses)
3.34 (3.144.22) 1.98 (1.802.48) 2.68 (2.363.00) <0.001
b
Characteristics
Other (illicit) drug use n=392 n=378 n=773
None 89.3 (86.592.6) 90.2 (87.293.2) 89.7 (87.591.8) 0.67
Cannabis 8.2 (5.510.9) 6.3 (3.98.8) 7.4 (5.59.2) 0.33
GHB 1.8 (0.53.1) 2.9 (1.24.6) 2.3 (1.33.4) 0.30
Ecstasy 0.3 0 0.1
Other 0.5 (01.2) 0.5 (01.3) 0.5 (01.0) 0.97
P values calculated by Chi-square test
b
P values calculated by two-sample t test
c
More than one option per person was possible, therefore the total percentage per column >100%
Eur J Pediatr
between age and level of alcohol intake (Pearsons
r=0.060; P=0.24).
Discussion
Our study found a growing number of hospital admissions
due to alcohol intoxication and several differences in
characteristics between alcohol intoxicated boys and girls.
Intoxicated girls had a lower BAC than boys. This finding
is in contrast to the study of Weinberg et al. [46] where
boys and girls had a similar BAC. The prevalence of
hospital admissions was the same for boys and girls, as was
the duration of reduced consciousness. This suggests that
girls become intoxicated from less alcohol consumption
than boys, as a given dose of alcohol results in a higher
BAC in women than in men [15, 40]. This implies greater
sensitivity for girls to the toxic, suppressive effects of
alcohol on the central nervous system, which is in line with
other studies [4, 18, 26, 34]. Girls were hospitalized for
shorter periods than boys, but although this difference is
significant, it is small.
During the week, consumption of alcoholic drinks was
minimal for both boys and girls. However, on weekends,
alcohol consumption increased dramatically, with boys
drinking over 1.5 times as much as girls. This is another
indication that girls drink less than boys, but end up in the
hospital as often as boys. These findings are in line with
studies among adults, where men were found to drink more
excessively than women [13, 47].
Spirits and beer were the favored drinks of intoxicated
adolescents, which is consistent with the results of other
studies [8, 17, 21]. However, our findings show a difference
between boys and girls in their preference for alcoholic
drinks. Boys drank beer about twice as often as girls. Girls
drank over five times more wine and over 1.5 times more
pre-mixed drinks. This is in contrast to the study of Clapp
et al. [8], who reported that wine consumption was not
associated with binge drinking, but made no distinction for
gender. No association was found between alcohol intox-
ication and other, possibly illicit drug use which is in
contrast to other studies [17, 24]. Cannabis was the most
frequently used drug, but the prevalence is lower than the
lifetime cannabis use in the Netherlands, where cannabis
use is legal above the age of 18 years [42]. The use of other
drugs besides cannabis was only rarely seen. However,
drug use was not biochemically tested.
We also found that girls aged 13 and 14 years had a
significantly higher hospitalization prevalence due to
alcohol intoxication than boys of the same ages. This
finding is consistent with the study of Miller et al. [28] in
which binge drinking rates in adolescents aged 12 to
14 years were higher for girls than for boys. In our study,
the average age was, at the time of hospitalization,
significantly lower for girls than for boys. A possible
explanation is that girls enter puberty earlier and, therefore,
begin experimenting with alcohol at a younger age [7].
Puberty is a period when adolescents are extremely
susceptible to peer influence, which is thought to contribute
to engaging in risky activities like binge drinking [38]. This
is especially disturbing because girls may be more
susceptible to the harmful effects of alcohol than boys [4,
18, 26, 33, 34]. At the ages of 16 and 17 years, significantly
more boys were hospitalized than girls. This may be
because the experimentation stage is later for boys, but this
trend also reflects adult drinking patterns, where the
prevalence of binge drinking is higher among men than
among women [30, 47]. Another explanation could be that
girls are catching up with boys, as was seen in rates of
cigarette smoking, which suggests that the prevalence of
binge drinking among older girls will continue to grow.
Indeed, binge drinking rates among adult women have
already increased [45].
It is important to begin alcohol prevention programs
with a particular focus on girls in primary school, and to
continue in high school with special emphasis on boys. For
girls, it is important to focus prevention on sexual issues,
besides focussing on other risks such as brain damage,
because binge drinking increases risky sexual behavior [5].
In the study by Cuijpers et al., the effects of school
intervention programs were small, but given the wide range
of these programs, they can still have a substantial impact
[10]. Since 2007, special policlinics for children with
alcohol intoxication have been established in the Nether-
lands. These policlinics offer a multidisciplinary approach
between pediatricians and child psychologists with the aim
of detecting psychosocial problems and preventing recur-
rences. Some studies showed that this is an effective
approach to treating and preventing alcohol intoxication
among adolescents [37].
This study found that the NSCK monitored a consider-
able rise in hospital admissions due to alcohol intoxication
among adolescents between 2007 and 2009. This sends an
Table 3 Regression results using BAC and duration of hospitalization
as dependent variable
Beta P
BAC
Age (years) 0.108 <0.001
Gender 0.154 0.004
Duration of hospitalization
BAC (gram/liter) 0.192 <0.001
Gender 0.096 0.015
Standardized regression coefficient
Eur J Pediatr
alarming message, because these numbers are probably an
underestimation of the actual number of cases of alcohol
intoxication. Not all cases will have been reported by
pediatricians, nor will all adolescents have visited a hospital
or a pediatrician when intoxicated [42]. Part of the increase
might be explained by assuming that pediatricians have
learned more about the alcohol intoxication through the
monitoring system and have improved their reporting
routine over time. An argument against this supposed
learning curve, however, is the fact that they did not
report fewer cases in the first couple of months of the study.
The response rate of pediatricians reporting one or more of
the listed diseases to the NSCK is stable over the last
couple of years. Thus, there is no increase in the number of
responding pediatricians. Therefore, an actual increase in
the number of incidents of adolescent alcohol intoxication
is indisputable.
The duration of reduced consciousness, measured in
hours due to alcohol intoxication rose significantly in 2009
compared with 2007. One reason may be that the severity
of alcohol intoxication increased over these years. Howev-
er, there is no evidence of this in the present study, because
duration of hospitalization decreased and BAC levels
remained the same. It is more likely that the longer
reduction of consciousness reported is explained by
growing public awareness. This is to say that children
may have been hospitalized at an earlier stage of their
alcohol coma, and that therefore the duration of coma in the
hospital was longer.
Strikingly, a significant increase of the mean age of
intoxicated children was observed in 2009 compared with
2007. The prevalence of alcohol intoxication before the age
of 15 years decreased as well, but this reduction was not
significant. At the ages of 16 and 17 years an increasing
prevalence was found, with a significant increase at 17 years
of age. As a result, the average age increased significantly
to 15.7 years in 2009. Conversely, Kuzelova et al. [22] and
Weinberg et al. [46] found a lower average age of
adolescents admitted to hospitals with alcohol intoxication.
Considering that alcohol intoxication at 17 years increased
significantly, and that alcohol consumption is permitted at
this age in the Netherlands, we advise to raise the legal
drinking age from 16 to 18 years by Dutch law. Studies
have already shown that it is beneficial to increase the legal
age to prevent drinking alcohol [31, 43].
A limitation of this study is the use of questionnaires.
Self-reporting by the adolescent could lead to underestima-
tion, e.g. of drug use, as was shown before in studies
among adults [27]. Moreover, not all parts of the question-
naire were filled in by all respondents, and some of the
reported characteristics, especially durations (hospitaliza-
tion, reduced consciousness) will have been estimates
rather than the exact values. On the other hand, the only
way to investigate these characteristics is by retrospective
analysis, and we designed the questionnaire in such a way
as to make this retrospective analysis as reliable as possible.
Another limitation of this study is the fact that only children
admitted to hospital and treated by a pediatrician were
included. This could lead to information bias. Therefore,
conclusions should be drawn with caution. Nevertheless the
characteristics reported provide a deeper understanding of
alcohol intoxicated adolescents.
In conclusion, this study clearly demonstrates differences
between boys and girls in terms of their susceptibility to
alcohol intoxication. Alcohol intoxication among adoles-
cents is a growing problem, and more research is needed on
the differences between boys and girls. In future more
research is necessary to investigate long-term effects of
alcohol intoxication and to investigate underlying psycho-
social problems. These data will be collected from the
special alcohol policlinics.
Acknowledgements We thank TNO-NSCK for facilitating the data
collection. We also thank Tjeerd van der Ploeg for his assistance in
statistical data analysis and Ben van de Wetering, Rob Rodrigues
Pereira, and Wim van Dalen for supporting this research. Finally, we
thank all the participating Dutch pediatricians who contributed to this
study by sharing their patients.
Conflicts of interest The authors declare that they have no conflicts
of interest.
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