Poisoning in children 2: painkillers

A clinician's guide to self-poisoning with paracetamol in youth: The what, when and why?

AIM

Deliberate self-poisoning or overdose is a common presentation to the paediatric emergency departments (ED) due to a lack of emergency access to child and adolescent mental health services. We overview medical and psychiatric assessment of overdoses in youth with the most commonly implicated drug, paracetamol, as a case study.

METHODS

A what, when and why framework is adopted to guide clinicians on what information should be ascertained, when overdose treatment should be initiated and how to explore why the overdose occurred.

RESULTS

Presentations are often asymptomatic while gastrointestinal symptoms offer an alarm signal for severe hepatotoxicity. A worst-case exposure amount and time elapsed since ingestion should be calculated to determine whether N-acetylcysteine treatment is indicated. Establishing reasons why the young person took the overdose, along with assessing the degree of remorse or regret, is crucial for discharge planning.

CONCLUSION

Given the importance of timely assessment and treatment, paediatric emergency staff need to be familiar with the protocol for care. Attention needs to be focused on both the medical and psychological risk, and staff need to consider the reasons behind the overdose and following a biopsychosocial assessment, ensure that the young person and family are adequately signposted for future mental health care if needed.

Childhood Drug and Non-Drug Poisoning in Nigeria: An Economic Appraisal

Background:

The dearth of information on the economic cost of childhood poisoning in sub-Saharan Africa necessitated this study.

Objective:

This study has investigated the prevalence of childhood drug and non-drug poisoning, treatment modalities and economic costs in Nigeria.

Method:

A retrospective study of childhood drug and non-drug poisoning cases from January 2007 to June 2014 in the University of Port Harcourt Teaching Hospital (UPTH), Port Harcourt, Nigeria was carried out. Medical records were analysed for demographic and aetiological characteristics of poisoned children (0–14 years of age), as well as fiscal impact of poisoning cases.

Findings:

Of the 100 poisoned patients, 46% were male and 54% female, with female/male ratio of 1.17:1. Most of the children were under five years of age. Paracetamol, amitriptyline, chlorpromazine, ferrous sulphate, kerosene, organophosphates, carbon monoxide, snake bite, alcohol and rodenticides were involved in the poisoning. The average cost of poison management per patient was about $168, which is high given the economic status of Nigeria.

Conclusion:

Childhood poisoning is still a significant cause of morbidity among children in Nigeria and accounts for an appreciable amount of health spending, therefore preventive strategies should be considered.

A cross-sectional study of children with acute poisoning: A three-year retrospective analysis

BACKGROUND

There is a lack of evidence on description of burden and cases of childhood poisoning in developing countries. This study aimed to assess the characteristics of children with acute poisoning, and factors for time of presentation to health facility and nature of poisoning.

METHODS

A cross-sectional study was conducted at three major pediatric referral hospitals in Addis Ababa, Ethiopia. Description of demographics of children with acute poisoning and factors associated with time to presentation and nature of poisoning were analyzed. Data were entered to Epi info 3.5.3 and analyzed with SPSS version 20.

RESULTS

Over three years, we retrieved records of a total of 128 children admitted for acute poisoning. The mean age of victims was 5.46 (SD, standard deviation=4.48) years. The majority (29.7%) were poisoned by prescribed drugs. Most poisoning incidents (73.5%) were unintentional in nature. The median time to health facility visit was 15.5 hours. Age less than 2 years was related to earlier presentation to health facility (P=0.010, OR=0.28, 95%CI=0.10-0.74). Children with age more than 5 years was more likely to have intentional poisoning (χ(2)=25.06, P<0.0001). None of the victims was provided psychosocial evaluation and counseling.

CONCLUSION

Most poisoning incidents are unintentional. Prescribed drugs are the commonest causes. Psychosocial counseling and care for the affected children is lacking. Family and community education should be given on prevention of poisoning. We recommend that caregivers take the required action in keeping prescribed drugs at home. Psychosocial support should be part of care and treatment of children with poisoning.

Adult prescription drug use and pediatric medication exposures and poisonings

BACKGROUND AND OBJECTIVES

Nontherapeutic medication ingestions continue to be a major pediatric health problem, with recent increases in ingestions despite a number of public health interventions. It is unknown how changes in adult prescription drug use relate to pediatric medication poisonings. The objective of the study was to measure the association between changing adult prescription drug patterns and pediatric medication exposures and poisonings and identify high-risk classes of medications and pediatric age groups.

METHODS

We measured monthly pediatric exposures and poisonings using the National Poison Data System and prescriptions written for adults using the National Ambulatory Medical Care Surveys for 2000 through 2009. Associations between adult prescriptions for oral hypoglycemics, antihyperlipidemics, β-blockers, and opioids and exposures and poisonings among children 0 to 5, 6 to 12, and 13 to 19 years were analyzed by using multiple time-series analysis. Emergency department visits, serious injuries, and hospitalizations stemming from these associations were described.

RESULTS

Adult medication prescriptions were statistically significantly associated with exposures and poisonings in children of all ages, with the strongest association observed for opioids. Across medications, the greatest risk was among children 0 to 5 years old, followed by 13- to 19-year-olds. Rates of emergency department visits were highest for events related to hypoglycemics (60.1%) and β-blockers (59.7%), whereas serious injuries and hospitalizations occurred most frequently with opioids (26.8% and 35.2%, respectively) and hypoglycemics (19.5% and 49.4%, respectively).

CONCLUSIONS

Increasing adult drug prescriptions are strongly associated with rising pediatric exposures and poisonings, particularly for opioids and among children 0 to 5 years old. These associations have sizable impacts, including high rates of serious injury and health care use.

Poison exposure and outcome of children admitted to a pediatric emergency department

BACKGROUND

This paper reports the characteristics, outcomes and clinical features of children with poisoning treated at an emergency department (ED).

METHODS

This retrospective study at an emergency department consisted of 140 children with poison exposure who were aged under 18 years. Their characteristics were analyzed in order to understand the differences between accidental and non-accidental poisoning. The poisonous materials were divided into two major categories (pharmaceuticals and non-pharmaceuticals) and their associations with patient outcomes were analyzed. Furthermore, the association was analyzed between the incidence of poison exposure and the season in which the poison exposure occurred.

RESULTS

The incidence of poison exposure was highest among adolescents and pre-school age children. Nonaccidental poisoning was more common in older girls and accidental poisoning was more common in younger boys (P<0.001). Neurological system agents were the most common cause of poisoning in the pharmaceutical group and cleansing products were the most common cause of poisoning in the non-pharmaceutical group. Neurological and gastrointestinal symptoms were the most common clinical presentations for the pharmaceutical and non-pharmaceutical groups, respectively. Furthermore, poisoning due to cleansing products and analgesics were associated with the longest duration of hospitalization. March was the highest risk month for pediatric poisoning (P=0.018).

CONCLUSIONS

Cleansing products and analgesics were associated with the longest duration of hospitalization and intentional poison was more common in girls.

Toddlers requiring pediatric intensive care unit admission following at-home exposure to buprenorphine/naloxone

BACKGROUND

Sublingual buprenorphine is an alternative to methadone for office-based treatment of opioid dependence. Recent reports have examined a growing number of unintentional buprenorphine exposures in children resulting in significant toxicity, even after a single lick or taste of a sublingual tablet. Here, we report a series of unintentional buprenorphine exposures in toddlers over a 2.5-yr period that led to admission to the pediatric intensive care unit.

OBJECTIVES

The goals of this study were to determine: 1) the prevalence of symptomatic buprenorphine exposure in children <3 yrs of age; 2) the severity of toxicity associated with such exposures; and 3) effective clinical interventions.

METHODS AND MAIN RESULTS

A retrospective case review was performed on records from the pediatric intensive care unit at an academic medical center located in the northeastern United States. Unintentional buprenorphine/naloxone exposure (n = 9) accounted for the largest single fraction of toxic ingestions among patients younger than 3 yrs within the study period (9/33, 27%). All exposures occurred at the child's place of residence (n = 9, 100%). Clinical signs of opioid toxicity were evident in all nine cases, with the most common symptom being drowsiness or lethargy (n = 9, 100%), followed by miosis (n = 6, 67%) and respiratory depression (n = 5, 56%). Six patients were effectively treated with naloxone (n = 6, 67%).

CONCLUSIONS

The increased use and similarity to candy of the current formulation of buprenorphine pose a special risk to children, especially toddlers. Buprenorphine exposure in children <3 yrs old can cause significant opioid toxidrome. Naloxone is an effective agent for reversal of symptoms; however, given buprenorphine's high affinity and long action, higher doses or continuous infusion may be required. Adults on buprenorphine should be educated on the risks posed to young children in their household and the appropriate storage of medication.

Pharmaceutical poisoning exposure and outcome analysis in children admitted to the pediatric emergency department

BACKGROUND

Pharmaceuticals involved in childhood poisoning vary, and treatment of poison exposure can be a challenge for primary physicians when children are unconscious or histories are lacking. Knowledge of the clinical manifestations and prognosis of poisoning will help primary physicians perform appropriate clinical assessments. In this study, we aim to report on patient characteristics, outcomes, and clinical features of pediatric poisoning in the emergency department.

METHODS

We retrospectively evaluated the medical records of 87 children younger than 18 years of age and presented to the emergency department with pharmaceutical poisoning (2001-2008). The detailed categories of pharmaceutical were reported, and their associations with patient outcomes were analyzed. Furthermore, children were divided into two groups, based on the reasons for poison exposure (accidental or intentional poisoning). Clinical features and outcomes between accidental or intentional poisoning were analyzed, and the cut-off age for high risk of intentional poisoning was also calculated.

RESULTS

Age groups of adolescents (48.3%) and preschool age (32.2%) children were the major representation. Neurologic system agents (48.3%) and analgesics (18.4%) were the most common causes of poisoning. Among the two major agents above, anxiolytic/hypnotic drugs (lorazepam) and acetaminophen were the most frequent causes. Of all children, 70.1% had duration of major symptoms for ≤1 day, and intentional poisoning caused significantly longer duration of hospital stay than accidental poisoning did (p=0.008). Moreover, female gender (p<0.001), older age (p<0.001), and analgesics (p=0.008) were more predominantly associated with intentional poisoning in children, and the cut-off age for high risk of intentional poisoning was over 10.5 years.

CONCLUSION

Neurologic system agents and analgesics were responsible for the majority of cases. Intentional poisoning caused longer hospital length of stay than accidental poisoning, and the factors associated with intentional poisoning were older age, female, and neurologic system agents.

Adsorption of Paracetamol and Acetylsalicylic Acid onto Commercial Activated Carbons

The adsorption of paracetamol (PAR) and acetylsalicylic acid (ASA) onto high-surface-area, commercial activated carbons was investigated at 26°C via adsorption isotherms at different pH values, including pH 1.5 to simulate conditions existing in the stomach. A wide-ranging characterization of the carbons, including analysis of their morphology and surface chemistry, was undertaken, with the actual surface areas of the carbons available for PAR and ASA adsorption being estimated by taking the molecular sizes of the drugs into account. This provided an understanding of the differences in the drug adsorption behaviour of the carbons.

Emergency visits for childhood poisoning: a 2-year prospective multicenter survey in Spain

OBJECTIVES

To describe the characteristics of childhood poisoning leading to consultation to 17 pediatric emergency departments in Spain.

METHODS

During a 2-year period (January 2001 to December 2002), accompanying people of 2157 children with acute intoxication who visited consecutively at the emergency room were prospectively surveyed.

RESULTS

Childhood poisoning accounted for 0.28% of all emergency visits during the study period. The median (interquartile range, 25th-75th percentile) age was 24 months (22-60 months); 67% of children were younger than 4 years. Drug ingestion was involved in 54.7% of cases (paracetamol was the most frequent drug), domestic products in 28.9%, alcohol in 5.9%, carbon monoxide in 4.5%, and illicit drugs in 1.5%. A total of 61.3% of patients were admitted within 1 hour after exposure to the toxic substance, and 10.3% had been already treated before arrival; 29.1% of patients were referred for clinical manifestations which were mostly neurological symptoms. Laboratory tests and other investigations were performed in 40.7% of cases. Gastrointestinal decontamination was used in 51.7% of patients, with activated charcoal in 32.3%. Treatment varied significantly according to the individual hospitals. A total of 83.3% of patients were treated as outpatients, 15.2% were hospitalized, and 1.5% were admitted to the intensive care unit. One 11-month-old boy with carbon monoxide intoxication died. Six patients had permanent sequelae (esophageal stenosis in 5 and partial blindness in 1).

CONCLUSIONS

Young children who accidentally ingested drugs and, less frequently, domestic products accounted for most cases of intoxication who presented at the pediatric emergency department.

Thyroid storm induced by aspirin intoxication and the effect of hemodialysis: a case report

Thyroid dysfunction is one of the serious consequences of an overdose of acetaminophen, aspirin, or nonsteroidal antiinflammatory drugs. The management of such consequences remains a medical challenge. A variety of thyroid abnormalities are common in clinical practice and can, in many cases, be accurately diagnosed and managed by the primary care physician. This case study covers an aspirin overdose causing thyroid storm that was treated successfully with hemodialysis.

Childhood and adolescence poisoning in NSW, Australia: an analysis of age, sex, geographic, and poison types

OBJECTIVE

This study aims to investigate whether there is any association between the types of poison substances and geographic locations for different age groups and sex.

DESIGN

This is a population based epidemiological study utilising routinely collected inpatient statistics.

SETTING

Data are collected as part of the routine vital health information system via all hospitals in New South Wales (NSW), Australia.

PATIENTS

All patients aged between 0-19 years who were admitted to a hospital because of poisoning by the four major types of substances that were defined in the study in NSW in 2000.

MAIN RESULTS

The standardised incidence ratios of poisoning related hospitalisation between metropolitan and rural areas varied across different poison types when compared with the NSW average. While there are few differences between metropolitan and rural areas for analgesic and chemical related poisoning admissions across different age groups and sex, differences in the standardised incidence ratios between geographic locations for psychotropic and venom related poisoning admissions were found. No significant difference in standardised mortality ratios were found between metropolitan and rural areas except for females in the 10-14 years age group (standardised mortality ratio 3.24, 95% confidence interval 1.69 to 6.21).

CONCLUSIONS

The results obtained in this study, on the whole, provide some evidence for an association between poison types and geographic locations for psychotropic and venom related poisoning.