Pediatric Annals

Introduction: 'If I Can Stop One Heart From Breaking, I Shall Not Live in Vain...'

Ronald B Mack, MD

Abstract

Although we live in one of the golden ages of medicine, common problems involving the pediatric age group still exist. Certainly, the prospect of managing childhood ingestions faces the pediatrician on a daily basis. In the 1993 survey published by the American Association of Poison Control Centers, 1,751,476 human exposures were reported.1 These data represented the reports of 64 poison centers; a total population of 181.3 million people was served by the participating centers. The data presented represented an estimated 70% of the human poison exposures that precipitated poison center contacts in the United States in 1993. Considering that not all patients involved in exposure to a toxin contact a poison center, the number of toxic encounters in a given year is likely to be at least three times the reported number.

The pediatric contribution to this 1.7+ million human exposure report is remarkably high. Fifty-six percent of the cases involved children younger than 6 years of age and 42% occurred in children younger than 3 years of age. The fatalities reported in this latest survey numbered 626; however, children younger than 6 years of age comprised only 4.3% (27 cases) of these fatalities. In the 6- to 12-year-old age group, there were 9 fatalities, and in the teenage human exposures, fatalities numbered 61. The bad news is that children are still being poisoned; the good news is that the mortality statistics are much improved. Pediatricians and poison centers are stopping "hearts from breaking."

To the readers who were pediatricians before 1970 and who recall that salicylate overdose accounted for 25% of all reported childhood poisoning cases, it is a different era we live in today. In those younger than 6 years of age, acetaminophen products are the most common drug ingestant - more than 46,000 exposures occur annually in this age group. In the same age group, aspirin ingestions are now a distant third in terms of analgesic/antipyretic ingestion. Nonsteroidal anti'inflammatory drugs are in second place but are still way behind acetaminophen products.

I have asked five young toxicology experts to contribute articles to this issue of Pediatric Aramis in an effort to make pediatricians and other primary care front-line health-care providers au courant with some of the major common toxicological challenges that could engage their management skills as early as their next phone call. The first article, "Emergency Department Gastrointestinal Decontamination," was written by Drs Holly Perry and Michael Shannon. These doctors are from the Division of Emergency Medicine and the Program in Clinical Pharmacology/Toxicology, Children's Hospital Department of Pediatrics, Harvard Medical School, and the Massachusetts Poison Control System, Boston, Massachusetts. This article discusses the role of ipecac syrup, gastric ravage, activated charcoal, cathartics, and whole-bowel irrigation in the decontamination of the poisoned patient. There have been remarkable changes in the indication for these procedures in the past few years. It seems as if when you look away for even a moment, the rules change. One of the best examples of this sea of change is the recommendation (except under unusual circumstances) not to administer ipecac syrup in the emergency department. Why, you ask? The answer is rather simple - it delays the administration of activated charcoal, a more efficient tool for gastric decontamination.

The second article is specifically written for the busy, pharmacokinetically challenged pediatrician who wants to know more about some of the basic principles of clinical pharmacology as these precepts interface with the poisoned child. It was written by Dr Milton Tenenbein, Professor of Pediatrics and Pharmacology at the Children's Hospital, University of Manitoba, Canada. Dr Tenenbein discusses, in an easy-to-understand fashion, such toxicokinetic concepts…

Although we live in one of the golden ages of medicine, common problems involving the pediatric age group still exist. Certainly, the prospect of managing childhood ingestions faces the pediatrician on a daily basis. In the 1993 survey published by the American Association of Poison Control Centers, 1,751,476 human exposures were reported.1 These data represented the reports of 64 poison centers; a total population of 181.3 million people was served by the participating centers. The data presented represented an estimated 70% of the human poison exposures that precipitated poison center contacts in the United States in 1993. Considering that not all patients involved in exposure to a toxin contact a poison center, the number of toxic encounters in a given year is likely to be at least three times the reported number.

The pediatric contribution to this 1.7+ million human exposure report is remarkably high. Fifty-six percent of the cases involved children younger than 6 years of age and 42% occurred in children younger than 3 years of age. The fatalities reported in this latest survey numbered 626; however, children younger than 6 years of age comprised only 4.3% (27 cases) of these fatalities. In the 6- to 12-year-old age group, there were 9 fatalities, and in the teenage human exposures, fatalities numbered 61. The bad news is that children are still being poisoned; the good news is that the mortality statistics are much improved. Pediatricians and poison centers are stopping "hearts from breaking."

To the readers who were pediatricians before 1970 and who recall that salicylate overdose accounted for 25% of all reported childhood poisoning cases, it is a different era we live in today. In those younger than 6 years of age, acetaminophen products are the most common drug ingestant - more than 46,000 exposures occur annually in this age group. In the same age group, aspirin ingestions are now a distant third in terms of analgesic/antipyretic ingestion. Nonsteroidal anti'inflammatory drugs are in second place but are still way behind acetaminophen products.

I have asked five young toxicology experts to contribute articles to this issue of Pediatric Aramis in an effort to make pediatricians and other primary care front-line health-care providers au courant with some of the major common toxicological challenges that could engage their management skills as early as their next phone call. The first article, "Emergency Department Gastrointestinal Decontamination," was written by Drs Holly Perry and Michael Shannon. These doctors are from the Division of Emergency Medicine and the Program in Clinical Pharmacology/Toxicology, Children's Hospital Department of Pediatrics, Harvard Medical School, and the Massachusetts Poison Control System, Boston, Massachusetts. This article discusses the role of ipecac syrup, gastric ravage, activated charcoal, cathartics, and whole-bowel irrigation in the decontamination of the poisoned patient. There have been remarkable changes in the indication for these procedures in the past few years. It seems as if when you look away for even a moment, the rules change. One of the best examples of this sea of change is the recommendation (except under unusual circumstances) not to administer ipecac syrup in the emergency department. Why, you ask? The answer is rather simple - it delays the administration of activated charcoal, a more efficient tool for gastric decontamination.

The second article is specifically written for the busy, pharmacokinetically challenged pediatrician who wants to know more about some of the basic principles of clinical pharmacology as these precepts interface with the poisoned child. It was written by Dr Milton Tenenbein, Professor of Pediatrics and Pharmacology at the Children's Hospital, University of Manitoba, Canada. Dr Tenenbein discusses, in an easy-to-understand fashion, such toxicokinetic concepts as volume of distribution, the timing of blood sampling, and drug half-lives. These simple adjuncts to your education can add greatly to the ease with which you manage a poisoned child. Certainly, since I began pediatric practice, toxicology is no longer an arcane art practiced by 20th century alchemists but rather a scientific discipline with logic and rules that make sense.

Poisoning due to iron-containing medications has been the bete noire of pediatricians and toxicologists called on to manage these often terribly ill patients. During the past few years, there has been an annual average of 22,000 reported exposures to medications containing iron.2 The majority of patients involved in these exposures were less than 6 years of age who ingested the relatively benign pediatric multivitamin preparations. However, during the same period, there was a 20% increase in reported exposures to concentrated iron supplement with an amazing quadrupling in reported deaths. The adult formulations of iron supplements and adult vitamins with iron have become significant killers. And yet the lay public and too many health-care practitioners are not sufficiently cognizant of the dangers contained in these products if ingested at too high a dose.

The Food and Drug Administration (FDA)3 has become aware of this problem. In an effort to avert further tragedies due to iron poisoning, the FDA recently has issued proposed regulations to require warning statements on the label of tablets and caplets that contain iron as well as unit dose packaging for iron-containing products with 30 mg or more of iron in each dosage unit. The FDA remarks that since 1986, more than 110,000 incidents of children ingesting iron medications have been reported to poison control centers, with at least 33 deaths.

I have asked Dr Michael A. McGuigan to discuss the subject of iron poisoning, including clinical presentation and management. Dr McGuigan is the Medical Director of the Ontario Regional Poison Information Centre at the Hospital for Sick Children in Toronto, Ontario. After reading his article, you will feel more confident about managing a patient with acute iron overdose. There have been many changes in the management of such patients eg, no more intragastric administration of bicarbonate or phosphate or deferoxamine and the new therapeutic modality for decontamination in iron poisoning - whole-bowel irrigation.

"The Nontoxic Ingestion" by Dr Gary S. Wasserman deals with the opposite end of pediatric potential poisoning problems. This is not a frivolous concept. Such ingestions can occupy a large amount of your time and somebody's money unless you are aware that such ingestions are common and can usually be dismissed provided you use some simple principles and pediatric common sense. These precepts are presented to us by Dr Wasserman, Clinical Toxicologist and Director, Poison Control Center and Chief, Section of Clinical Toxicology, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine.

Dr Wasserman reminds us that the preschool child will ingest anything that will not ingest them first. Approximately 75% of accidental ingestions are virtually nontoxic exposures. His article offers many examples of which substances do and do not cause trouble when ingested by a child. His offering is so practical that the wise and prudent health-care professional should keep a copy by the telephone in the office and at home.

The final article in this issue of Pediatric Annak deals with a disturbing and common problem - "inhalant abuse" as practiced by adolescents. Inhalant abuse is the leading cause of poisoning deaths among teenagers, accounting for 31% of the fatalities.4 The substances used are solvent and aerosol propellant chemicals that are intentionally inhaled to produce a "high."5 These preparations are readily available, inexpensive, and rapidly mind-altering. The experts remark that these substances often are overlooked as agents with abuse potential, and not much suspicion is raised when these items disappear from the home. Included in the long list of volatile substances of abuse are: butane, propane, gasoline, freon, naphtha, nail polish remover, typewriter correction fluid, and on and on. The danger is similar to Russian Roulette - the unknown inhaler can experience an acute "sudden sniffers death syndrome" due to hypoxia or fatal arrhythmia. Chronic usage can lead to progressive organic brain syndrome, peripheral neuropathy, or other organ-specific pathology.

This subject is discussed by yet another preeminent pediatric toxicologist, Dr Fred M. Henretig. Dr Henretig is the Director of the Section of Clinical Toxicology at the Children's Hospital of Philadelphia. Practicing in a large city has given the author upclose experience with these potential death-causing chemicals. If you do not believe how common this problem, ask your teenage children or grandchildren how many of their peers are "baggers," "huffers," or "sniffers." The children involved are often the young experimenters, ie, seventh, eighth, and ninth graders. Do not be too shocked at their answers.

I believe that the perusal of these articles will provide readers with an informative and interesting addition to their knowledge of the ubiquitous conundrum of pediatric poisoning problems. With "better living through chemistry," the problem will not die in the foreseeable future. We can only hope that less of the victims will die, because of our proper management. As Emily Dickinson said, "If I can ease one life the aching, or cool one pain, or help one fainting robin unto his nest again, 1 shall not live in vain."

REFERENCES

1. Litovitz TL, Clark LR, Soloway RA. The annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. 1994;12:546-584.

2. Milk KC, Curry SC. Acute In» poisoning in concepts and controversies in toxicology. Emerg Med Clin North Am. 1994;12:397-413.

3. FDA proposes special labeling and packaging to prevent childhood iron poisoning. JAMA. 1994;272:1488.

4. Krenzelok EP. Alternatives to the usual drugs of abuse. Cimicai Toxicology Forum. 1993;6:1-6.

5. Linden CH. Volatile substances of abuse, emergency aspects of drug abuse. Emergency Medial Clinics of North America. 1990;8:559-578.

10.3928/0090-4481-19960101-05

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