Pediatric Annals

editorial 

Poisonings

Stanford T Shulman, MD

Abstract

The number of poisonings, accidental or intentional, in the United States annually is very impressive, with more than twothirds of the almost 2.4 million calls to Poison Control Centers involving childhood exposures. In this issue of Pediatrie Annals you will find six articles that cover this topic comprehensively, each with practical information that you will find helpful.

I recently learned that the "6-hour rule" (that patients who are stable 6 hours after ingestion can be sent home safely) is not as firm as thought previously. Because of slow-release or extended-release preparations, or delayed metabolism or activation of some drugs by some individuals, it has become clear that longer periods of observation are frequently appropriate. In addition, the emerging field of pharmacogenomics is highlighting the fact that individuals vary considerably in their ability to metabolize pro-drugs to their active form and to metabolize active drugs to inactive metabolites. For example, the hepatic enzyme CYP2D6 converts the inactive compound codeine to the active drug morphine. Apparently, about 10% of Caucasians are deficient in CYP2D6 and have impaired ability to convert codeine to the active compound. In contrast, about 25% of Ethiopians possess double the normal amount of the CYP2D6 enzyme and are thus hypersusceptible to therapeutic (and ingested supratherapeutic) amounts of codeine. The implications of this and other genetic variations in enzyme systems upon management of patients with ingestions are now evolving.

Prevention of pediatrie toxic exposures is not given as much attention in this issue as the responses to the situation once an exposure has occurred. Prevention is an aspect that should be covered in a subsequent issue. Of particular interest to me here is the article by Drs. Kostic, Rose, and Bebarta that reviews the history of the poison control centers, their current status, and their prospects for the future. It certainly seems clear that secure funding of this highly effective and valuable system is necessary and probably should come from a governmental source. It would be incredibly short-sighted not to develop secure and stable funding for the poison control centers.…

The number of poisonings, accidental or intentional, in the United States annually is very impressive, with more than twothirds of the almost 2.4 million calls to Poison Control Centers involving childhood exposures. In this issue of Pediatrie Annals you will find six articles that cover this topic comprehensively, each with practical information that you will find helpful.

I recently learned that the "6-hour rule" (that patients who are stable 6 hours after ingestion can be sent home safely) is not as firm as thought previously. Because of slow-release or extended-release preparations, or delayed metabolism or activation of some drugs by some individuals, it has become clear that longer periods of observation are frequently appropriate. In addition, the emerging field of pharmacogenomics is highlighting the fact that individuals vary considerably in their ability to metabolize pro-drugs to their active form and to metabolize active drugs to inactive metabolites. For example, the hepatic enzyme CYP2D6 converts the inactive compound codeine to the active drug morphine. Apparently, about 10% of Caucasians are deficient in CYP2D6 and have impaired ability to convert codeine to the active compound. In contrast, about 25% of Ethiopians possess double the normal amount of the CYP2D6 enzyme and are thus hypersusceptible to therapeutic (and ingested supratherapeutic) amounts of codeine. The implications of this and other genetic variations in enzyme systems upon management of patients with ingestions are now evolving.

Prevention of pediatrie toxic exposures is not given as much attention in this issue as the responses to the situation once an exposure has occurred. Prevention is an aspect that should be covered in a subsequent issue. Of particular interest to me here is the article by Drs. Kostic, Rose, and Bebarta that reviews the history of the poison control centers, their current status, and their prospects for the future. It certainly seems clear that secure funding of this highly effective and valuable system is necessary and probably should come from a governmental source. It would be incredibly short-sighted not to develop secure and stable funding for the poison control centers.

I have chosen four stamps for this column. I was inspired by the quote by Paracelsus (1493-1541) at the beginning of the article by Kostic and colleagues. Aureolus Theophrastus Bombastus von Hohenheim, known as Paracelsus, is portrayed on the green stamp from Germany and the brown and white stamp from Hungary (Magyar). He is considered to be the most original medical thinker of the 16th Century, and his personality was suchthat his middle name (Bombastus) has become a very important adjective for certain kinds of behavior. Paracelsus was born in Switzerland, and he pioneered early chemical pharmacology and therapeutics. The quote chosen by Kostic and colleagues, "What is there that is not poison? All things are poison and nothing is without poison. Solely, the dose determines that a thing is not a poison," shows great insight into the use of therapeutic agents and the concept of the margin of safety.

The other two more colorful stamps from Spain (darker brown) and Israel (multicolored) honor Moses Maimonides (11351204) of Cordova, Spain, the Rabbi Moses ben Maimón, who was court-physician to Sultan Saladin. Maimonides, among his other contributions to medicine, wrote a treatise on poisons that remained influential for centuries, translated into Latin in 1305, French in 1865, and German in 1873.

10.3928/0090-4481-20051201-03

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