ETIOLOGY AND INCIDENCE
Approximately 1,400 fatal poisonings occurred in the home in 1954, with a third of these in the 0-four age group.1 In 1970, there were 2,600 fatalities reported from home poisonings, but only 200 of these deaths were in the 0-four year age group.2 Does this reduction indicate that we have an answer to the problem in this age group? While everyone admitted that the exact cause of the decrease was elusive, various assumptions were made (increasing skills of toxicologists and clinicians, cultural changes, safety packaging, education, etc.). In 1971, the fatality rate rose to 250 in this age group with a total increase to only 3,000. 3
Acetylsalicylic acid (aspirin) ingestion and mortality has also shown a dramatic drop in recent years. Ingestions have fallen 30 per cent from 1969 to 1970, but the decrease has been mainly in "baby" aspirin ingestions, which were responsible for severe intoxications in acute single ingestions. The mortality from aspirin has dropped from 140 childhood deaths in 1963 to 61 deaths in 1968. This reduction in poisoning and mortality may be partially explained by the increased use of acetoaminphen products by many physicians in place of aspirin but other assumptions have also been made. With the fall in the incidence of aspirin poisonings, the ingestion of other products such as soaps, detergents, household cleaners and paints has increased.4 The problem of childhood poisoning is far from being solved.
The number of products into which the toddler may sink his newly erupted teeth continues to multiply, and the hazard of a new toxic element being introduced into the marketplace remains with us. It is estimated that over 200 incidents of poisoning occur for each fatality, and there are one-half million products which can be ingested.
Children who poison themselves during daylight hours have an 80 per cent chance of a recurrence. The families of these children need investigation and would benefit most from effective counter measures.
The psychosocial aspects of poisoning are of considerable importance. Sobel5 views these as symptoms of parental psychopathology and family disturbances. However, psychosocial identification of patients at risk must be made much earlier, before the symptom of ingestion has resulted in 250 deaths a year. This appears to be too high a price to pay for identification.
Studies comparing gastric lavage to emesis have shown the latter to be more effective in eliminating the toxic material.6
Syrup of Ipecac has become the princapai first aid to be used in the home. In 1965, an FDA ruling allowed the dispensing of a one ounce bottle over-the-counter for use in accidental poisonings. Its safety as an emetic appears to be proven by its wide use without significant toxicity. However, one should not be led to a false sense of security by the knowledge that the patient has vomited. Cognizance should be taken of the amount of the product taken, its potential toxicity and the amount vomited before considering the patient safe. Fluid Extract of Ipecac, which was previously marketed as an emetic, is more potent, but is highly toxic and should never be used.
Activated charcoal has been advocated as an adsorbent of ingested noxious substances. It is given in doses of five to 10 times the amount of ingested poison and has proven very useful. It must be given after the Syrup of Ipecac has induced vomiting or it will render the Ipecac ineffective and may reduce its own adsorbent capacity.
The table below modified from Decker et al. gives some of the uses and limitations of charcoal.7
Salt has been suggested as a second choice emetic but reports of hypernatremia developing suggest that it is potentially dangerous and should not be used.8
The universal antidote is condemned as being neither universal nor an antidote and should be relegated to an obsolete category.9
In the treatment of corrosive poisonings, Lenoski has suggested that a small plastic tube covered with an anesthetic ointment be inserted through the nose to act as a lifeline for fluids and nutrition and a guide for endoscopy if the edema is severe and the esophagus tight. 10 Poisoning by a corrosive agent was formerly considered a contraindication to intubation.
A new narcotic antagonist, naloxone (Narcan), an N-allyl derivative of oxymorphine, has been introduced for clinical use as a pure narcotic antagonist with no agonist properties. It will probably replace both nalorphine (Nalline) and levallorphan (Lorfan) in the treatment of opiate overdose. It does not cause respiratory depression, which was a possible side effect of these older opiate antagonists. Its disadvantage is its short duration of action. The dosage is 0.01 mg. /kg. in children and 0.4-1.0 mg. in adults, given intravenously.11
The use of physostigmine salicylate (Eserine Salicylate) has been advocated by Durvoisin and Katz in the treatment of atrophine poisoning. Unlike its analog Neostigmine, they feel that this product crosses thebloodbrain barrier and gains access to the central nervous system. The dose in adults is 1.4 mg. every I-IV2 hours.12 This drug has also been suggested to control the supraventricular tachycardia which may be associated with an overdose of the tricyclic antidepressant drugs. These latter drugs are being used with increasing frequency in the treatment of childhood enuresis.
In iron poisoning, the general consensus of opinion appears to be against the use of oral desferrioxamine mesylate (Desferal) as this may increase the absorption of iron across the injured intestinal mucosa.13
The use of adrenocortical steroids in the treatment of corrosive injuries of the esophagus has been questioned. A child recently being treated for such an injury developed thromboembolism during therapy. There is a controversy about whether these agents will even prevent esophageal stricture.14 In hydrocarbon induced pneumonia, two recent studies, one in dogs and the other a cooperative study in children, showed no statistical differences in recovery between those receiving adrenocortical steroids and those that did not receive this medication. It would appear that this therapy is not warranted in the treatment of this poisoning.15,16
Peritoneal dialysis and hemodialysis depend upon protein binding, the fluid compartment, the tissue absorption and the ionization of the toxic agent. These methods are of little use in phenothiazine, digitalis, iron, glutethimide (Doriden), chlordiazepoxide (Librium) and diazepam (Valium) intoxications. More refined techniques such as charcoal dialysis and lipid dialysis are being investigated as a means of increasing the efficacy of this procedure. The addition of albumin and alkali to the dialysate may increase the phénobarbital and salicylate in the dialasance. The use of an anion recirculation (peritoneal dialysate circulated through an anion exchange column for removal of phénobarbital) in dogs is being investigated. Intraperitoneal Tham or bicarbonate may increase salicylate and phénobarbital removal. Gastric dialysis may be helpful where the product is excreted by the gastric mucosa and reabsorbed, as in Imipramine (Tofranil) intoxication.
Supportive therapy is still the mainstay in the treatment of intoxications. It consists of the treatment of congestive heart failure, the control of seizures and pain, the relief of cerebral edema, the treatment of renal and liver failure. The most important emergency treatment of intoxication is clearing the airway, treating respiratory failure and supporting the circulation. Epinephrine should be used with caution in chlorinated hydrocarbon intoxications and intoxication by organic phosphate pesticides, carbon tetrachloride and chloral hydrates, where it may produce a fatal ventricular fibrillation.
It has been become increasingly apparent that the slogan "out of sight and out of reach" will not prevent the majority of poisoning episodes in children.
The Poison Prevention Packaging Act (PL 91-601) was signed into law on December 30, 1970. The Technical Advisory Committee on Safety Packaging of the FDA is promulgating its standards. Safety packaging has been established for aspirin containing products, controlled drugs (narcotics, amphetamines, barbiturates, etc.), liquid furniture polish and methyl salicylates. In addition, special packaging has been recommended for proprietary drugs, drain cleaners (liquid and solid), kerosene, turpentine, paint thinners, charcoal lighter fluids, household pesticides, high pH detergents and bleach products.
Safety packaging was successful in reducing the number of poisoning episodes when used as a trial in two communities. It is hoped that this proves significant on a nationwide basis. It must be emphasized that this is not a substitute for a good family relationship and parental supervision.
The Product Safety Act has been passed by Congress and signed into law by the President on October 28, 1972. This bill authorizes mandatory standards to guard against "unreasonable" hazards in products used by consumers in households, schools, recreation areas, etc. The measure empowered the newly created commission to ban the sale of products that cannot be made "reasonably" safe.
Poison prevention and accident prevention efforts must be appraised with more scientific data in evaluating their effectiveness. Controlled studies must be available to prove the effectiveness of proposed countermeasures. The psychosocial behavior of families with repeated poisonings and accidents must be investigated in order to predict and identify the child at risk before he becomes a statistic. Only after this identification is made can preventative countermeasures be designed. Multiple barriers may be needed, some physical and others psychological. Retrospective studies have given clues to the characteristics and psychosocial aspects of the families at risk.17,18,19,20 Now we must do a prospective study using these tools. Most of all, we must consider accidents, no matter how trivial, as a symptom of family problems which may or may not be permanent.
Poison and accident prevention attempts are in an embryonic stage. The National Injury Electronic Surveillance System (NlESS), recently inaugurated by the federal government to document product related injuries seen in hospital emergency rooms, may allow better epidemological identification, particularly when it investigates product related injuries in depth under its Phase II Program. Since poisoning is the number one acute emergency that is likely to be encountered in pediatric practice, it is important for the pediatrician to be cognizant of the recent changes in the incidence, etiology and therapy in this field.
1. Press, E. Accidental Poisoning in Childhood. Springfield. III.: Charles C. Thomas. 1955, 9.
2. Accident Facts. Chicago: National Safety Council. 1971.
3. Accident Facts. Chicago: National Safety Council, 1972.
4 Tabulations of 1970 reports. Bulletin, National Clearinghouse For Poison Control Centers (Sept.-Oct , 1971). 1-2.
5 Sobel, R. The psychiatric implications of accidental poisoning in childhood Ped. Clin. N. Amer. 17 (1970). 653-685.
6. Boxer, L. et al.. Ipecac induced vs gastric lavage in salicylate ingestion. J. Ped. 74 (1969). 800
7. Decker, W et al. Adsorption of drugs and poisons by activated charcoal Tox. Applied. Pharm. 13 (1968), 454-460.
8. Digenaro, F. and Nyhan. W, Salt is a dangerous antidote. J. Ped. 78 (1971). 1048.
9. Picchioni, A. et al A preliminary investigation involving relative efficacy of activated charcoal and the universal antidote. Bulletin National Clearinghouse of Poison Control Centers (Jan -Feb 1965).
10. Lenoski, E. Poisoning, head trauma and dog bites Audio Digest Ped. 18: 14 (July 25. 1972). Side B.
11. Nalaxone hydrochloride (Narcan) a new narcotic antagonist. Med. Letter Drugs Therap. 14 (Jan.. 1972). 2.
12. Duvoisin. R. and Katz. R. Reversal of central anticholinergic syndrome in man by physostigmine. J.A.M.A. 206 (1968), 1963.
13. Whitten. C. Studies in acute iron poisoning. Pediatrics 38 (1966), 102-110.
14. Shaw, A. Thromboembolism in a child during therapy for caustic burns of the esophagus J.A.M.A. 217 (1971). 826.
15. Steel. R. et al. Corticosteroids and antibiotics for the treatment of fulminant hydrocarbon aspiration J.A.M.A. 219 (1972). 1434.
16. Marks, M. et a! Ad renocort i costerai d treatment of hydrocarbon pneumonia in children. A cooperative study J. Ped. 81 (1972), 366-369.
17 Scherz, R Prevention of childhood poisoning. Ped. Clin. N. Amer. 17 (1972). 713-727.
18 Breault. H Poisonings are preventable. Presented at the Canadian Pediatric Society Annual Meeting, Saskatoon. June 26, 1968.
19. Husband. P. and Hinton. P. Families of children with repeated accidents. Arch. Dis. Child. 47 (1972), 396.
20 Matheny, A. et al Assessment of children's behavioral characteristics: a tool in accident prevention Clin. Ped. 11 (1972). 437