Hypoglycemia and convulsions in children following alcohol ingestion

Ethanol Content of Medications and Its Effect on Blood Alcohol Concentration in Pediatric Patients

OBJECTIVE

Ethanol is a common excipient used in liquid medications to enhance solubility and inhibit -bacterial growth. While the US Food and Drug Administration (FDA) and European Medicines Agency (EMA) have released guidance for how much ethanol is acceptable in medicines, many medications contain more than the recommended amount. The objective of this study was to determine what effect these medications would have on blood alcohol concentration (BAC) for pediatric patients, defined as those medications that would increase the BAC by ≥2.5 mg/dL.

METHODS

A list of medications dispensed to pediatric patients from a single hospital over a period of 4 months was obtained. The package inserts of these medications were reviewed to determine ethanol content. Typical doses were used to determine the amount of ethanol pediatric patients weighing 10, 20, and 40 kg would receive. The theoretical BAC was then calculated for each medication containing ethanol.

RESULTS

Seven hundred ninety-six medications were dispensed for pediatric patients during the study period, of which 33 contained ethanol. Seven medications would be projected to increase the BAC above 2.5 mg/dL with a normal pediatric dose.

CONCLUSION

While most medications do not contain ethanol, we found 7 that contained enough ethanol to potentially raise the BAC above 2.5 mg/dL. Health care practitioners should consider the ethanol content of medications prior to recommending them in children and when assessing overdoses.

Beverage ethanol exposures among infants reported to United States poison control centers

BACKGROUND

Case studies and small series have demonstrated that beverage ethanol may pose a serious poisoning hazard to infants. Intoxicated infants may not present with the classic signs or symptoms of ethanol poisoning. The objective of this study was to describe the epidemiology of beverage ethanol exposures among infants reported to the United States poison control centers.

METHODS

Data from the National Poison Data System were retrospectively analyzed for infants <12 months of age who were exposed to beverage ethanol from 2009-2018.

RESULTS

Over the 10-year study period, 1,818 infant exposures to beverage ethanol were reported. Most exposures were single substance (95.2%), and the most common route of exposure was ingestion (n = 1,738). Infants 9-11 months were the most commonly exposed age group subset (45.3%). The annual number and rate of alcoholic beverage exposure increased by 37.5% and 42.9%, respectively, from 2009 to 2018. Of the 563 infants evaluated at a healthcare facility, 38% of exposures were hospitalized. Infants 0-5 months of age had higher odds of being admitted to a non-critical (OR: 2.35, 95% CI: 1.41-3.92) or critical care unit (OR: 2.39; 95% CI: 1.50-3.79) compared to infants 6-11 months of age. Infants 0-5 months of age were more likely to (OR: 4.65; 95% CI: 3.18-6.79) experience a serious outcome compared to infants ages 6-11 months. Five fatalities in infants <6 months old were documented. An in-depth case review identified improper storage and subsequent formula preparation with beverage ethanol as a common exposure mechanism.

CONCLUSIONS

Beverage ethanol exposures among infants are associated with hospitalization, serious clinical effects, and mortality. Infants may present with atypical signs and symptoms of intoxication, requiring a high index of suspicion. Opportunities exist to reduce exposures by addressing improper storage of beverage alcohols.

Ethanol Intoxication of Young Children

Ethanol intoxication of infants and young children can be a challenging diagnosis in the pediatric emergency department, and features of the poisoning may differ in comparison with adolescents. The sources of ethanol exposures in this age are varied and include unintentional, malicious, and iatrogenic etiologies. Young children exposed to ethanol often present with mixed clinical signs and symptoms that may not fit the traditional ethanol or sedative-hypnotic toxidrome. Pediatric ethanol intoxications are often managed supportively, and recovery is usually rapid. The purpose of this review is to describe the sources of ethanol poisoning among children 6 years and younger, highlight presenting symptoms and pharmacokinetic considerations unique to this age group, and review management strategies. In addition, published cases of ethanol poisoning due to ingestion among young infants are compiled for presentation.

An unexpected clinical course in a 29-day-old infant with ethanol exposure

Ethanol exposure can affect all pediatric age groups but occurs most commonly in ambulatory children and adolescents. Infants are less likely to ingest ethanol because they have limited ability to explore their environments. However, ethanol exposures in infants can occur. We report the case of a 29-day-old (3.5 kg) baby girl who presented with a blood alcohol level of 301 mg/dL after ingesting formula that had been prepared with gin. To our knowledge, she is the youngest reported child with such an elevated ethanol level in the medical literature. Despite her markedly elevated blood alcohol level, she had an unexpectedly mild clinical course, exhibiting subtle neurologic symptoms but no hypothermia, hypoglycemia, or cardiorespiratory impairment. This case demonstrates that the ethanol-exposed infant may lack typical or clear symptoms of acute intoxication. Therefore, the clinician must have a low threshold for pursuing blood alcohol testing in infants and young children with altered mental status. A prompt diagnosis of ethanol exposure is important for ensuring the health and safety of the child.

Ackee fruit poisoning: an outbreak investigation in Haiti 2000-2001, and review of the literature

The Centers for Disease Control and Prevention (CDC) provided technical assistance to the Ministry of Health of Haiti during an outbreak of over 100 cases of acute illness and death in the northern region of Haiti during a 4-month period beginning in November 2000. The epidemiologic, clinical, and laboratory findings in this investigation indicated the ingestion of unripe ackee fruit as the most likely cause of this outbreak. This report describes the CDC field investigation in Haiti and gives a brief overview of the current state of knowledge about ackee poisoning.

What are the adverse effects of ethanol used as an antidote in the treatment of suspected methanol poisoning in children?

BACKGROUND

Ethanol used as an antidote is said to have various adverse effects, particularly in children. The rate of these adverse effects is not known.

METHODS

Twenty-one-year retrospective chart review (1980-2000) from suspected methanol poisoning patients treated with ethanol in two large pediatric tertiary care centers.

RESULTS

A total of 60 children (median age of 24 months) received ethanol for suspected methanol poisoning: 39 orally and 21 intravenously. Median initial methanol level was 4.16 mmol/L (13.3 mg/dL) (range 0 to 87.5 mmol/L or 0 to 280 mg/dL). Median duration of ethanol treatment was 16 hours (range 1.5 to 72 hours). None [0% (95% CI 0-5%)] of the 60 patients developed symptomatic hypoglycemia. Of the 50 patients that had a glucose level measured, none [(0% [95% CI 0-6%)] had a serum glucose concentration < 2.78 mmol/L (< 50 mg/dL). Eight patients [16% (95% CI 8-30%)] had at least one serum glucose concentration between 2.78-3.61 mmol/L (50-65 mg/dL), but none of those had symptoms compatible with hypoglycemia. A total of 42 patients [84% (95% CI 70-92%)] had all their serum glucose concentrations > 3.61mmol/L (> 65 mg/dL). There was no identifiable difference in the glucose intake between the serum glucose concentration groups. Six out of the 60 patients [10% (95% CI 4-21%)] were described as more drowsy after ethanol but none was comatose or needed intubation. No child showed signs of hypothermia [0/40 (95% CI 0-8%)] (rectal temperature < 35 degrees C), hepatotoxicity (0/12) (AST or ALT > 100 U/L) or even thrombophlebitis (0/21). None of the 22 patients with toxic levels of methanol (> or = 26.2 mmol/L- > or = 20 mg/dL) died or had ethanol-induced morbidity despite wide variation in ethanol levels.

CONCLUSION

The rate of clinically important adverse effects related to ethanol used as an antidote to treat methanol poisoning in children was either absent or low in a tertiary care pediatric hospital setting. There was no morbidity or mortality associated with ethanol when it was used despite wide variation in ethanol levels. These results suggest that with appropriate monitoring and intravenous glucose intake in a controlled environment such as a pediatric intensive care unit, ethanol therapy does not carry as many risks as currently believed.

Gastric evacuation for acute ethanol intoxication in a three year old

A three year old girl presented in a deeply comatose state. She had drunk ethanol four hours previously and her blood ethanol concentration on arrival was 79.8 mmol/litre (3.69 g/litre). Because of her young age, high blood ethanol concentration, time since ingestion, and severe neurological depression on presentation, nasogastric aspiration of the stomach contents was performed and 4.2 g of ethanol were removed. She made an uneventful recovery.

Alcohol intoxication in young children

This article presents two cases of severe ethyl alcohol intoxication in pediatric patients, with one of these cases resulting in the death of a child. A review of the current literature is provided along with a comparison of our regional poison control centers and the national intoxication statistics regarding pediatric alcohol ingestion. Medical evaluation is recommended for all symptomatic children; hourly observations x 6 h are recommended for asymptomatic children.

Acute alcohol intoxication among children and adolescents

Severe toxicity from ethanol, manifested as coma, occurs at lower blood alcohol concentrations in young teenagers than in adults. Coma, vomiting and hypothermia are the commonest symptoms in young teenagers intoxicated by alcohol. The biochemical disturbances in children 11-16 years of age with alcohol intoxication resemble those of adults. Mild acidosis of a respiratory and metabolic origin and mild hypokalaemia are common findings in young teenagers. Young teenagers eliminate ethanol at the same rate as adults, whereas preschool age children are reported to eliminate ethanol twice as fast. The effect of ethanol on the state of consciousness is directly proportional to the blood alcohol concentration. Among small children the risk of hypoglycaemia is increased. Data on family history, social status, drinking habits, and children's motives for getting drunk are also of clinical importance. Fluid replacement with glucose-containing fluids and follow up are generally the only treatments needed for complete recovery. When children and adolescents are healthy, well-nourished and have not fasted, no severe complications are expected.

A report of acute ethanol poisoning in a child: mouthwash versus cologne, perfume and after-shave

The ingestion of ethanol-containing products, such as cologne, perfume and after-shave, in children under six years of age is common, but serious poisoning is rarely reported. Thus, it has been recently suggested that children ingesting up to 3.5 ounces of these products may be safely observed at home as long as they remain asymptomatic. While it may be assumed that products with a significantly lower alcohol content represent a much smaller poisoning hazard, mouthwashes are a relatively frequent cause of serious poisoning in children. In the following case report, 75 milliliters of mouthwash caused hypoglycemia, coma and manifestations of tonic seizure activity. Because of the palatable nature of mouthwash, wine and liquor, it appears that children are more apt to drink large quantities, consuming dangerous amounts of ethanol. The apparent safety of cologne, perfume, and after-shave may be due to a lack of palatability as well as the irritant nature of high concentrations of ethanol. This case suggests that consumer items such as mouthwash should be packaged in child-resistant containers.

Acute alcohol intoxications in children treated in hospital

Cases of alcohol intoxication in children are common; they are encountered every day in Finland. Studies other than case studies of alcohol intoxication in children are few. Metabolic acidosis was a frequent finding in juvenile alcohol intoxication. Capillary or arterial blood pH was below normal (less than 7.36) in 61.4% of patients and bicarbonate (less than 22) in 55.3% of patients. pCO2 was varied; the higher the blood alcohol concentration the higher the pCO2. Metabolic acidosis and blood pH correlated with the blood alcohol concentration and consciousness. The lower the blood pH the higher the serum glucose. Hypoglycemia is the most common reported symptom in children under 5 years of age. In the present study three patients were slightly hypoglycemic. Hypokalemia was the most important change (in 12.2%) in serum electrolytes. Alcohol intoxication causes metabolic acidosis and respiratory depression in children. Metabolic acidosis reduces consciousness.

Hypoglycemia: a pathophysiologic approach

An exploration of the factors that sustain glucose levels in the normal fasting subject reveals that the single major component is conservation of glucose rather than gluconeogenesis. Conservation is achieved by recycling of glucose carbon as lactate, pyruvate and alanine, and a profound decrease in the oxidation of glucose by the brain brought about by the provision and use of ketones. What glucose continues to be oxidized is for the most part formed from glycerol. Gluconeogenesis from protein plays little part in the process. Fasting hypoglycemia results from disorders affecting either one of the two critical sustaining factors--the recycling process or the availability and use of ketones. Individual hypoglycemic entities are examined against this background.

Ethyl alcohol ingestion in children. A 15-year review

Information on ethyl alcohol intoxication in children is scarce. A retrospective study was conducted by chart reviews of 27 patients with documented ethanol ingestion admitted to the Alberta Children's Hospital, Foothills Provincial Hospital, Calgary General Hospital or Holy Cross Hospital from 1969 to 1984. Six patients had hypoglycemia and one experienced a convulsion. The rate of alcohol elimination was found to be greater than 6.2 mM/L/hr (28.4 mg/dl/hr), approximately twice the rate seen in adults. Six patients had hypokalemia, and two had severe metabolic acidosis.

Effects of ethanol, fructose, and ethanol plus fructose infusions on plasma glucose concentration and glucose turnover in monkeys (Macaca fascicularis) as measured by [6-3H]glucose

Six adult, female, cynomolgus monkeys were fasted for 64 hr and then continuously infused with [6-3H]glucose to determine the rates of glucose turnover and clearance while they were also being infused with ethanol (110 mumol/min/kg), 1,3-butanediol (110 mumol/min/kg), fructose (30 mumol/min/kg) or ethanol plus fructose (110 and 30 mumol/min/kg) respectively. Both ethanol and 1,3-butanediol infusions decreased the glucose turnover rate (the steady-state input-output rate from the plasma glucose pool) and the plasma glucose concentration by halving the glucose production rate. In contrast, fructose infusions increased the glucose turnover rate and glucose concentration by increasing the glucose production rate by 20%. The plasma clearance rate of glucose was lowest when the animals were infused with ethanol plus fructose; this suggests that acetate from ethanol oxidation may have a glucose-sparing effect if normoglycemia is maintained.

Ethanol-induced hypoglycemic coma in a child

Reported is a case of ethanol-induced hypoglycemic coma in a 33-month-old boy after accidental ingestion of ethanol. Blood glucose was 10 mg% and blood ethanol was 71 mg%. He responded promptly to an IV bolus of 50% dextrose. The pathophysiology and clinical presentation of this not uncommon metabolic disorder are discussed. A plan for early recognition and management is presented.

Experimental studies on the "cow's urine mixture"

Samples of the "Cow's Urine Mixture" (a traditional remedy for convulsions) administered intraperitoneally to fasting grey rabbits were found to produce significant depression of their plasma glucose. A similar effect on the plasma glucose was produced by a sample of Cow's Urine Mixture given by the nasogastric route. These findings confirm that the mixture has a significant hypoglycaemic effect when given both parenterally and enterally, the latter being the usual mode of administration of this concoction. The probable nature of the hypoglycaemic agents contained in the mixture is discussed.

Hypoglycemia in children

The factors that sustain postabsorptive glucose concentrations have been analyzed and the adverse effects of various hypoglycemic disorders on these factors examined. The role of alanine has been reviewed and the importance of glycerol as a precursor of glucose and of ketones as a fuel substitute for glucose emphasized. Finally, we have suggested that fasting functional hypoglycemia replace ketotic hypoglycemia as a descriptive term and that we relinquish the concept of leucine-sensitive hypoglycemia as a specific entity.

ALCOHOL-INDUCED HYPOGLYCAEMIA

The clinical manifestations that may result from abuse of alcohol are numerous. Profound, sometimes fatal, hypoglycaemia, first described a little over 20 years ago (Brown and Harvey, 1941), is among them although as far as we are aware, not previously described in this country. This may be due partly to differences in drinking habits here and abroad where “bootleg” liquor is more readily available, and partly to failure to recognize this complication of alcohol. Many cases of alcohol induced hypoglycaemia may well go undiagnosed, alcoholaemia alone being held responsible for bizarre behaviour or alteration in consciousness following the drinking of alcohol-containing beverages. In some cases, a patient brought into the casualty department with a provisional diagnosis of “drunkenness” is found to have a low blood sugar and the diagnosis hastily altered to the more socially acceptable one of “hypoglycaemia”, but without the cause of the hypoglycaemia ever being determined.