Special Considerations in the Pediatric Patient

            Poisonings are all too common in the pediatric world. It has been estimated that approximately 6,000,000 children ingest a potentially toxic substance each year nationwide. In children, poisonings are predominately accidental, and occur most frequently in children ages 1-5 years old, namely those who are newly ambulatory and curious about their surroundings. Not surprisingly, the most common exposures in younger children are substances found around the house, such as makeup, household chemicals, over the counter medicines, and houseplants. This group actually constitutes the majority of all calls to poison centers nationwide. Usually, the substances turn out to be either nontoxic or, if toxic, in insufficient amounts to cause significant problems. A second peak of exposures unfortunately occurs in the adolescent population, with most of these representing suicide attempts. The leading causes of fatal pediatric poisonings include iron supplements, TCA’s, cardiovascular medications (Ca2+, Beta blockers), methyl salicylate, and hydrocarbons. 5 The table below illustrates that many common substances can be potentially fatal to children in small amounts

Selected Significant Pediatric Poisons 5

Drug or Poison	Potentially Lethal Dose In 10 kg Child
Camphor	1 teaspoon of 20% oil
Chloroquine	1 tablet (500 mg)
Codeine	3 tablets (60 mg each)
Desipramine	2 tablets (75 mg each)
Hydrocarbons (e.g. gasoline)	One swallow (if aspirated)
Oral Hypoglycemics	2 Glyburide tablets (5mg each)
Imipramine	1 tablet (150 mg)
Iron	10 tablets (Full Adult Strength)
Lindane	2 teaspoons
Methyl Salicylate	Less that 1 teaspoon of Oil of Wintergreen
Theophylline	1 tablet (500 mg)
Verapimil	1 tablet (240 mg)

Prevention

            Careful childproofing of the home is the best way to cut down on child poisonings. This needs to be stressed repeatedly to all parents of young children by not only their pediatricians, but also any physicians with whom they have contact. It is equally important to childproof any other places where the child spends any significant amount of time, including day care facilities and home of relatives. Grandparents’ medications are an all too common source of poisonings, as the grandparents are often unaccustomed to having young children around the house any may often have their prescriptions in easy-open, non childproof containers.

Syrup of Ipecac

            As discussed previously, in past years this was given to all new parents to have on hand in case of “emergency”, often with very little instruction. Now it is known, however, that ipecac may not always be the proper therapy and may be harmful in some cases. Therefore, although it is still a potentially useful therapy that many parents choose to keep on hand, it is imperative that it be stressed to them that ipecac should NEVER be administered before first consulting with a physician or poison control center.

Neonates

            Neonates can be exposed through a variety of routes, including trans-placental prior to birth, dermal, oral via breast milk, or via intentional or accidental misdosing of medications. A detailed discussion of neonatal toxicology well beyond the scope of this presentation. It is very important to remember, however,  that neonates have dramatically different pharmacokinetic profiles than adults, and drugs may behave quite differently in terms of both absorption and elimination. Therefore, in cases of neonatal poisonings, it is highly advisable to seek input from someone with expertise in this field in a timely fashion.

Child Abuse       

            Although most poisonings of young children are accidental, physicians must be vigilant for exposures that may represent abuse. Below are some warning flags that may indicate that further exploration of the events surrounding the exposure may be warranted 5:

1.      Stories that don’t make sense, or change over time

2.      Child is under 6 months of age, and therefore non-ambulatory.

a.       How did they get access to the poison?

3.      Child is over 4-5 years old.

a.       Accidental ingestions, though not impossible, are very rare in older children, and may suggest abuse or neglect

4.      The substance in question is a sedative, tranquilizer, or ethanol

a.       May represent an effort to calm or quiet a crying child

5.      The parents themselves are intoxicated

6.      Delay in seeking care

7.      Other signs of physical or sexual abuse

8.      Repeated episodes of abuse or poisonings.

 

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