Ingestion of any poisonous substance in children is called poisoning in children. Accidental poisoning in home is common. When young children explore the world, they use all their senses including taste. They put everything in mouth to find out what it is and how it tastes? So, adults must make sure that children do not have access to anything poisonous.
Common poisonous household materials
In kitchen
- Detergent and cleaning products
- Caustic soda
- Kerosene oil
In living rooms
- Alcohol
- Cosmetics, creams and lotions
- Medicines
In bathrooms
- Dettol
- Phenyl
- Savlon
In garden
- Fertilizers
- Insecticide and pesticide
- Paint
- Poisonous plants such as datura, mushrooms etc.
Risk factors
The risk factors that increase the risk of poisoning are as follows:
- Age- About 40% of all cases of accidental poisoning in children are reported in second year of life. About 20% cases are reported in third year of life and 12% in first year of life.
- Environment- Children living in that areas where there are workshops or lead poisoning is common.
- Large families- In large families, mother is not able to supervise the child because mother is often occupies with household chores. Lack supervision increases the chances of poisoning.
Clinical Features
The clinical features of poisoning are as follows:
- Respiratory problems such as breathlessness and cyanosis
- Gastrointestinal disturbances such as vomiting, diarrhea and abdominal pain
- Convulsion
- Unconsciousness in child.
Management
The management of poisoning are as follows:
Risk assessment
Risk assessment is a distinct cognitive process through which the clinician attempts to predict the likely clinical course and potential complications for the individual patient at that particular presentation.
Risk assessment should be quantitative and take into account agent, dose, time of ingestion, current clinical status and individual patient factors (for example, weight and co-morbidities).
The risk assessment is essential to determine the course of the poisoning and will guide treatment, investigations, period of observation and disposition.
Attempt to elucidate and clearly document:
- What substance(s) have been ingested?
- How much of each substance has been ingested – including a calculation of amount of substance per kg?
- What time the ingestion occurred?
- What clinical features have occurred thus far?
- What other relevant patient factors (patient weight, other medical problems etc) are present?
Then discuss with senior staff and/or consult poisons information
If the ingestant is unknown:
Consider all possible medications or toxins accessible in the house
- All family members medications
- Non-pharmaceutical agents
- Drugs of abuse
Conduct tablet counts of missing medication
Consider the worst case scenario, including:
- That all the missing tablets were taken
- That the ingestion time is the latest time possible
- That there has not been significant spillage
- That one child has ingested all of the missing poison.
Focused clinical examination
- Especially important if ingestant is unknown
- Toxidromes
Screening tests
No tests are routine. These will be determined by risk assessment and may include:
- Blood sugar level
- ECG
- Paracetamol level should be requested in all children/young people following any intentional ingestion
- Other screening tests should be guided by risk assessment
- Other drug levels
- Blood gases
- Radiology
Supportive care
For most children the only treatment required is good supportive care:
- Observation
- Hydration
- Nutrition
- Sedation
- Treatment of
- Hypothermia /hyperthermia
- Hypoglycemia / hyperglycemia
- Agitation
- Seizures
Decontamination
This is rarely required and must not distract from resuscitation and supportive care
Eyes
Irrigate with 0.9% NaCl until pH is <8.0
GI Tract
- Dilution with milk/water is generally not recommended
- Emesis should never be induced
- Gastric lavage is not recommended as no demonstrated benefit compared to a single dose of activated charcoal.
- Activated charcoal (AC) Is rarely indicated in paediatric poisoning. The use of AC carries a risk of aspiration and subsequent chemical pneumonitis. Indicated only if ALL of the following are true:
- Presentation within 1 hour of Ingestion
- Toxin is adsorbed by AC
- Patient is currently maintaining own airway and risk assessment determines that their GCS will remain normal
- Otherwise only give if airway is protected
- The substance has significant toxicity and is not easily treatable
Dose = 1g/kg
Can be made more palatable by mixing with ice-cream
| Toxins not adsorbed by activated charcoal Acids/alkalis Alcohols Metals and ionic compounds (iron, potassium, lithium) Hydrocarbons |
- Whole bowel irrigation (WBI) is very rarely performed. Indicated if:
- Ingestion of a slow release or extended release substance or a substance not bound to AC and
- Presentation prior to symptom onset
- Ingestion is likely to result in significant toxicity despite supportive care or antidote therapy
- Polyethylene glycol (Golytely) – 30ml/kg/h until effluent runs clear)
| Possible indications for WBI Iron (>60mg/kg elemental iron ingested) Sustained release diltiazem/verapamil Slow release potassium chloride |
Antidotes
- Pharmacological antagonists and chelating agents
- Only useful in a small minority of poisonings
- Administered when the potential therapeutic effect outweighs the adverse effects
Examples of some available antidotes
| POISON | ANTIDOTE |
| Paracetamol | N-acetylcysteine |
| Opioids | Naloxone |
| Benzodiazepines | Flumazenil |
| Sodium channel blockers | NaHCO3 |
| Iron | Desferroxamine |
| Glipizide | Octreotide |
| Digoxin | Digoxin fab-fragments (Digi-bind) |
| Organophosphates | Pralidoxime, atropine |
| Beta blockers, Ca2+ channel blockers | Insulin/dextrose euglycaemic therapy |
Prevention
- The prevention of unintentional poisoning should be promoted throughout the community.
- Child resistant packaging and safe storage has been shown to decrease the incidence of childhood poisoning.
- Other measures include:- Smaller volume prescribing- Child resistant lids- Education about safe storage of medications, out of reach of children- Store in cupboards with child resistant latches- Home visits to target this advice.
- Poison control centers must be established to collect, compile and the disseminate information on poisons and their management.