KANSAS CITY, Mo. (AP) — Fentanyl deaths among Missouri babies, toddlers and teens spiked as child welfare officials struggled to adequately investigate the cases, a state panel found in a newly released report.

Forty-three youth died — 20 of them under the age of 4 — in 2022 alone from the infamously powerful drug, according to a new state report. That reflected an overall doubling of child fentantly deaths, with the spike among the youngest victims even steeper, according to the Missouri Department of Social Services, which convened the panel of social workers, health officials, law enforcement and child advocates.

Called the Fentanyl Case Review Subcommittee, the group’s report said that child welfare “missed warning signs and left vulnerable children at risk” as fentanyl became a main driver of the U.S. overdose epidemic in recent years.

Children are especially vulnerable to overdosing, as ingesting even small amounts of the opioid’s residue can be fatal.

“The loss of a child to a drug-related incident is a heartbreaking occurrence that should never transpire,” said DSS Director Robert Knodell in a letter included in the report. “It is imperative that we collectively strive for improvement on both a personal and communal level.”

Knodell formed the subcommittee after The Kansas City Star reported late last year in a series titled, “Deadly Dose,” that babies and toddlers in Missouri were dying from fentanyl at an alarming rate.

The group’s report also described a lack of substance abuse treatment options, inconsistency in drug testing, gaps in training and inadequate integration between the mental health and child welfare system.

Among the changes the panel is recommending is better debriefing after something goes wrong so policies and practices can be tweaked. The panel also stressed the need to remove children out of environments in which there is a potential for exposure because of how lethal the drug is.

Emily van Schenkhof, executive director of the Children’s Trust Fund, was a part of the subcommittee and told The Star she was surprised by much of what she read in the case reports. The Children’s Trust Fund is the state’s foundation for child abuse prevention.

“There were cases where we knew at the birth of the child that there was a serious substance abuse problem,” she said. “And I think those cases were not handled the way they should have been. … So those were very hard to see.”