childhood poisoning

Am Fam Physician. 2009;79:397-403.

Management of Common Childhood Poisonings Reviewed
Medscape Medical News
Clinical Context

In 2003, more than 2.4 million reports of toxin exposures were received by poison control centers in the United States. Children younger than 6 years accounted for 51% of exposures; of these, 38% involved children 3 years or younger. Most exposures involved oral ingestion (76%), occurred in the home (93%), and were unintentional (> 80%). In addition, most ingestions involved nontoxic substances and were managed at home.
The aim of this article was to review the evaluation and treatment of unintentional toxin ingestions in children younger than 12 years.

Study Highlights
The history of patients with suspected toxin ingestions should include age and sex, time and type of probable exposure, and all medications present in the home (evidence rating, C).
Initial evaluation involves determining whether the patient is symptomatic; any patient who has ingested a toxin and who has respiratory, circulatory, or neurologic symptoms should be transported by ambulance to the nearest emergency department (evidence rating, C).

If the ingestion was witnessed, a nontoxic substance was involved, and the patient appears asymptomatic, a prompt examination by the clinician in the office or a period of observation at home may be appropriate; otherwise, poison control should be consulted, and the patient should be evaluated in the clinician's office or in the emergency department.

In the emergency department, rapid triage is crucial, including airway, respiration, and circulation stabilization.

The most toxic substances to a child include iron, antidepressants, hypoglycemics, cardiovascular drugs, salicylates, anticonvulsants, and illicit drugs.

Iron poisoning is one of the most fatal in children younger than 6 years, especially because as few as 5 to 10 adult ferrous fumarate tablets can kill or seriously harm a child.
An asymptomatic child with suspected toxin ingestion may have ingested a delayed-action medication and should be monitored for a longer period (evidence rating, C).

Identifying toxidromes or symptoms that point to toxin exposure is crucial; therefore, the patient's mental status, vital signs, pupil reactivity, skin moisture and color, bowel sounds, powder or vomit around the mouth, and any unusual breath odors should be noted.

Useful laboratory tests usually include bicarbonate levels, blood glucose levels, electrocardiography, electrolytes, prothrombin time, pulse oximetry, serum acetaminophen levels, and urine human chorionic gonadotropin levels in women of childbearing age.
Appropriate supportive or toxin-specific treatment should be initiated with all childhood poisonings.

Gastric decontamination, such as activated charcoal and gastric lavage, is no longer routinely recommended. It is only recommended when performed by a clinician with experience placing orogastric tubes and when administered within 1 hour of the ingestion (evidence rating, C).
Activated charcoal decreases the absorption of toxins in the stomach and intestinal tract. It is most likely to help children who have ingested carbamazepine, dapsone, phenobarbital, quinine, theophylline, salicylates, phenytoin, or valproic acid.

The American Academy of Clinical Toxicology discourages the routine use of activated charcoal except within 1 hour of ingestion (evidence rating, C). If used, a charcoal-to-drug ratio of 10:1 is recommended or a dose of 1 to 2 g/kg is recommended for children with ingestions of an unknown quantity. Sorbitol is used to improve taste and transit through the intestinal tract.
Syrup of ipecac is no longer recommended (evidence rating, C).

Hemodialysis may be appropriate for lithium, salicylate, theophylline, methanol, atenolol, phenobarbital, or valproic acid toxicity.
Psychiatric consultation is appropriate in the setting of intentional ingestion.

Pearls for Practice
In 2003, reports of toxin exposure usually involved children younger than 6 years, were unintentional, involved oral ingestion, and occurred in the home.
Gastric decontamination, such as activated charcoal and gastric lavage, is no longer routinely recommended and should be reserved for the most severe cases, with poison control center support. Management options should consider the type and amount of substance ingested, potential toxicity, time elapsed since ingestion, and symptoms exhibited.