Pediatric poisoning exposures have always comprised the majority of calls to poison control centers nationwide. The American Association of Poison Control Centers (AAPCC), as it is known today, arose in response to the need for timely, accurate advice to parents whose children ingested household products and pharmaceuticals. Originally, there was a loose network of small call centers per state; now there are 55 regional call centers nationwide that serve the United States and its territories, with over 2 million calls annually.1–4 In addition to providing real-time advice to the public, health care professionals, law enforcement personnel, and others, poison control centers participate in local and national toxico-surveillance through the National Poison Data System (NPDS).
Ingestion represents the primary route of poisoning exposures for all ages, and children are no exception. The factors leading up to pediatric poisoning by ingestion are as varied as the substances implicated and the children themselves. In this article, we discuss the developmental factors contributing to exposure as well as the landscape of pediatric poisoning over time, including review of annual data regarding pediatric poisoning fatalities. The pediatric patient, for the purposes of this discussion, will be children age 0 to 19 years in accordance with AAPCC category parameters.
The National Poison Data System: Trends in Pediatric Poisoning
The AAPCC NPDS is derived from a compilation of electronic records generated whenever a call is placed to a regional poison control center. The NPDS provides real-time surveillance as well as annual reporting on the epidemiology of poisoning exposures overall, including in the pediatric population, which consistently represent over one-half of all incidents.1–4 Fortunately, many pediatric exposures have a mild effect and favorable clinical results, although that has changed in recent years as the annual rate of serious outcomes in children who are poisoned has risen.4–11
The Role of Childhood Development
Understanding the sequence of developmental milestones from young childhood through adolescence provides helpful insight into the circumstances leading to poisoning. In the young child, poisoning results from a combination of child-associated, poison-associated, and environment-associated factors. The preponderance of people who are poisoned falls between ages 1 and 5 years, a critical period in which children's increased mobility allows for exploratory behavior. Age 1 year marks a period of development that predisposes children to self-poisoning as hand-to-mouth activity is common. As development continues, the child masters reaching, grasping, and releasing objects, permitting unscrewing of small bottle caps (ie, laundry detergents and household cleaning products). Mobility increases resulting in greater accessibility to objects. Moreover, features of “look-alike” poisons, which may appear similarly to candy or food items, increase the risk. Diminished supervision in the home or increased access to potential poisons, such as prescribed medications, also sets the stage for poisonous exposures. It is not surprising that children younger than age 5 years represent the majority of total reported poisoning ingestions each year.1–8
The period between ages 6 and 12 years has historically been one of lowest incidence for poisoning. This is followed by a rise of incidences into adolescence as the development of mental illness contributes to suicidality, and adolescent risk-taking behaviors and feelings of invincibility lead to substance abuse.9,10 Neurobehavioral changes triggered by puberty may be responsible for the increasing suicide rates in children age 14 years and younger.
The increase in adolescent suicide has also been associated with more widespread use of alcohol and other drugs.11,12 Owing to the heightened vulnerability of the developing adolescent brain, the earlier a person uses any substance, the greater the risk of developing an addiction.13–15 Reports have shown that 1 in 4 youth who use any addictive substance before age 18 years are at risk of developing a substance use disorder, as opposed to only 1 in 25 for those who begin use after age 21 years.9,10
Circumstances of Poisoning by Age Group: Intent
Age 0–5 Years
“Exploratory ingestion” most accurately describes the motives for unintentional/accidental non-food poisonings in the young child.16 As the term implies, this is a period marked by curiosity and blossoming independence when children also become more mobile and potentially pica-prone. As such, there is a high risk of injury including unintentional poisonings. Although the young child can understand the basics of right versus wrong behavior, the ability to understand consequences is not yet present.
Features of the poison itself and the child's environment also set the stage for exploratory ingestion. Easy access and product attractiveness increase the risk to a curious toddler. For example, in recent years, the introduction of visually appealing laundry detergent pods has resulted in a large increase in detergent exposures.17 Inadequate safeguards and a lack of preventive practices in the home also play a role in accidental exposures in the home environment. In some cases, risk increases with the underestimation of a child's will/physical ability to successfully gain access, as well as the inability of the caretaker to recognize what constitutes a potentially harmful product (eg, vitamins are “natural”).15
Poisonings secondary to child abuse are an unfortunate reality, although significantly less common than exploratory poisonings. Abuse may be in the form of intentional (malicious) or unintentional (neglectful) abuse. However, abuse in general as compared to exploratory poisonings is significantly less prevalent.14,17
Finally, parental or iatrogenic medication errors are common and preventable.18 Various scenarios may result in medication errors. Double dosing and incorrect dosing account for many medication errors and are usually a result of incorrect weight- or age-based dosing.16,18 Multiple factors may contribute to this increased risk, including caregiver experience, education level, stress level/fatigue at time of dosing, medical complexity, and clarity of instructions. Formulation errors also contribute to medication errors. For example, cardiac medications (eg, verapamil and labetalol) and some immunosuppressant drugs (eg, tacrolimus) have multiple available concentrations.19 Although medication errors are less prevalent (up to 6%) as compared to exploratory ingestion, the mortality reaches approximately 12% in this age group.18
Age 6–12 Years
Most poisonings in children age 6 to 12 years are attributable to unintentional overdoses1–4,20,21 (Table 1). In fact, unintentional poisonings are almost 10 times that of intentional causes.1–4 Although misuse accounts for the most intentional overdoses, suicide represents only a small proportion of intentional overdoses.4 However, a trending increase in the rate of suicidal poisonings in this group is alarming.1–4 Societal expectations, advancement and easier access to technology, and the gradual decrease of pubertal age of onset are likely some factors in play.
Common Agents that Cause Pediatric Fatalities
Age 13–19 Years
The circumstances of poisoning in adolescence resemble the adult population, with an increase in suicidal self-poisoning and substance abuse/misuse. According to the NPDS data, most ingestions in young people age 13 to 19 years remain intentional, with the most frequent reason being suspected suicide and abuse (Table 1).1–4 Suicidal poisonings account for most reported toxicities, and to a lesser degree accidental recreational drug overdose.1–4 For example, data from the NPDS in 2015 revealed that for all age groups, intentional exposures were significantly less as compared to unintentional except in young people age 13 to 19 years.4 Of these cases, suicidal intent was significantly more prevalent than intentional misuse or abuse.4 Although beyond the scope of this article, both adolescent suicide and substance abuse are most ominously on the rise in recent years according to the Centers for Disease Control and Prevention.9–11
Pediatric Poisoning by Substance Class
The agents implicated in poisoning by ingestion are diverse and fall into a few broad categories. Household products, including cosmetics and cleansers, are the most common source of exposure in the young child, followed by nonprescription medications, such as cough and cold preparations and analgesics.1–4 Prescription pharmaceuticals, including opioid analgesics, antidepressants, and antihypertensives, are often responsible for the most serious of exposures.1–4 Environmental poisoning by lead is another perennial issue.
Household products have long been a common cause of poisoning in the young child, and include products such as cleansers, disinfectants, detergents, bleach, and ammonia. In 2013, the distribution of these agents changed as the relative proportion of laundry detergent exposures demonstrated a significant rise—from 10.2% of total household exposures to 15.4%, with a continued increase to 18.1% reported in 2015.1–4 This surge is undoubtedly due to the emergence on the market of single-use laundry detergent packets (or pods), which became available in the United States in 2011. The highest proportions of laundry detergent pod ingestions were found in children younger than age 5 years, most likely due to the large amount of time they spend at home, newfound mobility, and curiosity leading to exploratory and mouthing behavior.20
Approximately 4 million children younger than age 12 years are treated with nonprescription or over-the counter medications each week in the US, with the most commonly implicated agents being analgesics (eg, acetaminophen, aspirin, and ibuprofen), cough and cold preparations, and diphenhydramine.1–4,22 The overall incidence of exposures and fatalities in children younger than age 5 years has declined somewhat since 2012, when NPDS reported a total of 26,488 single-substance exposures; of those, 4 (0.015%) were fatal.1 In 2015, NPDS reported a total of 20,667 single-substance exposures, with only 1 case associated with death.4 Prevention of potential poisoning lies in both the caregivers' and manufacturers' hands, and prevention strategies have been implemented. However, these public health interventions are unlikely to effectively deter intentional exposures, whether malicious or suicidal.22
The circumstances leading to a prescription pharmaceutical exposure are often similar to those with nonprescription agents, with the exception of addictive substances such as opioids. The implicated agents have some interesting features by age. Children younger than age 5 years are less likely to have prescription drug ingestions as over-the-counter medications are more accessible. In children age 6 to 12 years, the most frequently reportedingestions include antihistamines, vitamins, stimulants and street drugs, cardiovascular drugs, antimicrobials, and sedatives (hypnotic, antipsychotics).1–4,23 Of note are the appearance of stimulant exposures; methylphenidate is the most common. This likely reflects both increased prescribing in this age group as well as the beginning of stimulant abuse in the young adolescent.
In adolescents age 13 to 19 years, the most frequently reported ingestions include antidepressants, sedatives (hypnotics, antipsychotics), stimulants and street drugs, antihistamines, and anticonvulsants.1–4 Antidepressant use has seen a slight increase each year since 2012, accounting for 10.1% of all pharmaceutical ingestions in 2012 to 13.6% in 2015.1–4 Stimulants and street drugs continue to be a common ingestion in this age group, and substance abuse is a significant issue. Amphetamine-related compounds were found to be the most commonly reported stimulant across these years.1–4 Atypical antipsychotics and benzodiazepines are also common in this age group. Trends in the misuse of these addictive prescription central nervous system depressants and stimulants highlight the vulnerability of this age group to future substance abuse.24 In addition, most exposures were reported as intentional, emphasizing reports that 50% of mental health disorders emerge by age 14 years and placing this age group at a higher risk for suicide.25
Environmental exposures by ingestion are less common than other agents discussed in this article, but are still a perennial problem. Common ingestants include heavy metals (most notably lead), plants, and pesticides. Pediatric lead exposure, which can lead to long-term irreversible neurocognitive sequelae, predominantly results from exposure to lead-based residential paint. Poisoning may result from chronic ingestion via hand-to-mouth, overt pica behaviors, inadvertent ingestion, or inhalation of lead dust.25 Likewise, placement of household chemicals and pesticides in the reach of children can result in unintentional exposures.
Pediatric Poisoning Fatalities
Although fatalities in the pediatric population are far less common than in adults, the etiology of pediatric poisoning fatalities is most often preventable. Similar to nonfatal exposures, the circumstances vary somewhat predictably by age group. A few important agents warrant special mention. Table 1 shows the most common agents involved in pediatric fatalities.
Opioid analgesics continue to be among the most common responsible substances in pediatric fatalities secondary to different scenarios.23,24,26–28 Opioid-induced respiratory depression is of special concern in newborns and infants due to their higher metabolic rate and decreased respiratory reserve.29,30 Additionally, mouthing behavior by small children enhances buprenorphine sublingual and buccal mucosa absorption, resulting in toxicity simply by placing the drug in their mouth. Lastly, developmental age-related increase in P-glycoprotein (P-gp) gene polymorphism or inhibition may explain children's extreme vulnerability to opioids as P-gp performs a key protective role in the efflux of opioid substrates/metabolites at the blood-brain barrier.23
As methadone maintenance treatment programs have gained popularity in the wake of the opioid epidemic, there has been a concomitant rise in pediatric methadone poisonings.23,24,27,28 Methadone is a long-acting synthetic opioid agonist used to treat opioid dependency, and is potentially lethal in children even when ingested in small doses (0.5 mg/kg). 23,24,27,28 Not only do adults require higher doses, but programs may dispense concentrated liquid preparations that contain as much as 10 mg/mL and, when reconstituted, are similar in appearance to orange juice. Safer storage of opioids in the home, specifically take-home methadone, would save lives.
Foreign body ingestions are a choking hazard in the young child, but some foreign bodies pose additional serious hazards. Although many foreign bodies pass through the gastrointestinal tract without any serious consequences, button-battery ingestions can become lodged in the esophagus. Increasing use of the large 20-mm lithium coin cell battery has resulted in serious and fatal outcomes—ranging from tracheoesophageal fistulas, strictures, and vocal cord paralysis to exsanguination from perforation into major vessels. Often, this is due in part to delayed removal, misdiagnosis, and failure of caregivers to seek medical attention in a timely matter.6,29
Small magnets, which saw an increase in incidence of ingestions during the mid-2000s, have the potential for forming enteroenteric fistulas between magnets in adjacent loops of bowel, which is associated with perforation and bowel ischemia and necrosis.30 Small laundry detergent “pod” ingestions, as discussed previously, may have severe clinical effects including coma, respiratory arrest, pulmonary edema, and cardiac arrest.14,19
Pediatric poisoning may occur at all stages of a child's development because of varied milestones, environmental factors, and features of the poison itself. The intent of exposure changes over time, as do the responsible agents and targets of prevention. The pediatric provider can recommend valuable anticipatory guidance throughout a child's life to guard against this increasingly common problem. In addition, regional poison centers are a useful resource for prevention and management of poisoning exposures, as well as real-time toxico-surveillance and epidemiology.
- Mowry JB, Spyker DA, Cantilena Jr, . LR, et al. 2012 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 30th annual report. Clin Toxicol (Phila). 2013;51(10):949–1229. doi:. doi:10.3109/15563650.2013.863906 [CrossRef]
- Mowry JB, Spyker DA, Cantilena Jr, . LR, et al. 2013 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 31st annual report. Clin Toxicol (Phila). 2014;52(10):1032–1283. doi:. doi:10.3109/15563650.2014.987397 [CrossRef]
- Mowry JB, Spyker DA, Brooks DE, et al. 2014 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 32nd annual report. Clin Toxicol (Phila). 2015;53(10):962–1147. doi:. doi:10.3109/15563650.2015.1102927 [CrossRef]
- Mowry JB, Spyker DA, Brooks DE, et al. 2015 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 33rd annual report. Clin Toxicol (Phila). 2016;54(10):924–1109. doi:. doi:10.1080/15563650.2016.1245421 [CrossRef]
- Gerber RJ, Wilks T, Erdie-Lakena C. Developmental milestones: motor development. Pediatr Rev. 2010;31(7):267–277. doi:. doi:10.1542/pir.31-7-267 [CrossRef]
- Calello DP, Henretig FM. Pediatric toxicology: specialized approach to the poisoned child. Emerg Med Clin N Am. 2014;32(1):29–52. doi:. doi:10.1016/j.emc.2013.09.008 [CrossRef]
- Scharf RJ, Scharf GJ, Stroustrup A. Developmental milestones. Pediatr Rev. 2016;37(1):25–38. doi:. doi:10.1542/pir.2014-0103 [CrossRef]
- Sibert JR, Newcombe RG. Accidental ingestion of poisons and child personality. Postgrad Med J. 1977;53(619):254–256. doi:10.1136/pgmj.53.619.254 [CrossRef]
- Kaplan DW, Feinstein RA, Fisher MM, et al. Suicide and suicide attempts in adolescents. Pediatrics. 2000;105(4):871–874. doi:10.1542/peds.105.4.871 [CrossRef]
- Pompili M, Serafini G, Innamorati M, et al. Substance abuse and suicide risk among adolescents. Eur Arch Psychiatry Clini Neurosci. 2012;262(6):469–485. doi:. doi:10.1007/s00406-012-0292-0 [CrossRef]
- Bridge JA, Astl L, Horowitz LM, et al. Suicide trends among elementary school-aged children in the United States from 1993 to 2012. JAMA Pediatrics. 2015;169(7):673–677. doi:. doi:10.1001/jamapediatrics.2015.0465 [CrossRef]
- Darvishi N, Farhadi M, Haghtalab T, et al. Alcohol-related risk of suicidal ideation suicide attempt, and completed suicide: a meta-analysis. PLoS One. 2015;10(5):e0126870. doi:. doi:10.1371/journal.pone.0126870 [CrossRef]
- Brown RT. Risk factors for substance abuse in adolescents. Pediatr Clin North Am. 2002;49(2):247–255. doi:10.1016/S0031-3955(01)00002-5 [CrossRef]
- Spiller HA, Beuhler MC, Ryan ML, et al. Evaluation of changes in poisoning in young children: 2000 to 2010. Pediatric Emerg Care. 2013;29(5):635–640. doi:. doi:10.1097/PEC.0b013e31828e9d00 [CrossRef]
- Beuhler MC, Gala PK, Wolfe HA, et al. Laundry detergent “pod” ingestions: a case series and discussion of recent literature. Pediatr Emerg Care. 2013;29(6):743–747. doi:. doi:10.1097/PEC.0b013e318294f3db [CrossRef]
- Yin S. Malicious use of pharmaceuticals in children. J Pediatr. 2010;157(5):832–836. doi:. doi:10.1016/j.jpeds.2010.05.040 [CrossRef]
- Valdez AL, Casavant MJ, Spiller HA, et al. Pediatric exposure to laundry detergent pods. Pediatrics. 2014;134(6):1127–1135. doi:. doi:10.1542/peds.2014-0057 [CrossRef]
- Fine JS. Pediatric principles. In: Nelson LS, Lewin NA, Howland MA, eds. Goldfrank's Toxicologic Emergencies. 9th ed. New York, NY: McGraw-Hill; 2011:447–460.
- Wang GS, Tham E, Maes J, et al. Flecainide toxicity in a pediatric patient due to differences in pharmacy compounding. Int J Cardiol. 2012;161(3):178–179. doi:. doi:10.1016/j.ijcard.2012.06.028 [CrossRef]
- Davis MG, Casavant MJ, Spiller HA, et al. Pediatric exposures to laundry and dishwasher detergents in the United States: 2013–2014. Pediatrics. 2016;137(5):e20154529. doi:. doi:10.1542/peds.2015-4529 [CrossRef]
- Schoenewald S, Ross S, Bloom L, et al. New insights into root causes of pediatric accidental unsupervised ingestions of over-the-counter medications. Clin Toxicol (Phila). 2013;51(10):930–936. doi:. doi:10.3109/15563650.2013.855314 [CrossRef]
- Dart RC, Paul IM, Bond GR, et al. Pediatric fatalities associated with over the counter (nonprescription) cough and cold medications. Ann Emerg Med. 2009;53(4):411–417. doi:. doi:10.1016/j.annemergmed.2008.09.015 [CrossRef]
- Megarbane B, Alhaddad H. P-glycoprotein should be considered as an additional factor contributing to opioid-induced respiratory depression in paediatrics: the buprenorphine example. Br J Anaesth. 2013;110(5):842. doi:. doi:10.1093/bja/aet082 [CrossRef]
- Miech R, Johnston L, O'Malley PM, et al. Prescription opioids in adolescence and future opioid misuse. Pediatrics. 2015;136(5):e1169–1177. doi:. doi:10.1542/peds.2015-1364 [CrossRef]
- Kessler RC, Amminger GP, Aguilar-Gaxiola S, et al. Age of onset of mental disorders: a review of recent literature. Curr Opin Psychiatry. 2007;20(4):359–364. doi:. doi:10.1097/YCO.0b013e32816ebc8c [CrossRef]
- O'Donnell KA, Osterhoudt KC, Burns MM, et al. Toxicologic emergencies. In: Shaw KN, Bachur RG, Chamberlain J, , eds. Fleisher & Ludwigs's Textbook of Pediatric Emergency Medicine. 7th ed. Philadelphia, PA: Wolters Kluwer; 2016:1061–1114.
- Orliaguest G, Hamza J, Couloigner V, et al. A case of respiratory depression in a child with ultrarapid CYP2D6 metabolism after tramadol. Pediatrics. 2015;135(3):753–755. doi:. doi:10.1542/peds.2014-2673 [CrossRef]
- Kim HK, Smiddy M, Hoffman RS, et al. Buprenorphine may not be as safe as you think: a pediatric fatality from unintentional exposure. Pediatrics. 2012;130(6):1700–1703. doi:. doi:10.1542/peds.2012-1342 [CrossRef]
- Fuentes S, Cano I, Benavent MI, et al. Severe esophageal injuries caused by accidental button battery ingestion in children. J Emerg Trauma Shock. 2014;7(4):316–321. doi:. doi:10.4103/0974-2700.142773 [CrossRef]
- Kramer RE, Lerner DG, Lin T, et al. Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee. J Pediatr Gastroenterol Nutr. 2015;60(4):562–574. doi:. doi:10.1097/MPG.0000000000000729 [CrossRef]
Common Agents that Cause Pediatric Fatalities
|Pediatric Age Group
||Antifreeze (ethylene glycol), fumes (gases, vapors, carbon monoxide, smoke), disc battery, lithium, analgesics, morphine, hydromorphone, fentanyl, oxycodone, tramadol, methadone, amitriptyline, cleaning substances (household), antihistamines
||Carbon monoxide, smoke, acetaminophen, salicylates, methadone, freon, benzonatate, nortriptyline, ethanol, butane, aluminum (sulfate, borax, calcium chloride), verapamil
||Pharmaceuticals: methadone, buprenorphine, heroin, fentanyl, oxycodone, oxymorphone, acetaminophen (hydrocodone), morphine, tramadol, salicylate, acetaminophen, phenylethylamine, diphenhydramine, metformin, methamphetamine, amphetamines, methylenedioxymethamphetamine, tetrahydrocannabinol homolog, amitriptyline, 4-acetoxy-n, n-dimethyltryptamine, doxepin, quetiapine, bupropion, alprazolam
Nonpharmaceuticals: carbon monoxide, chemical (inhalation), unknown agent, smoke, helium, Freon, ethanol, methanol, selenous acid, cyanide, aldicarb, dinitrophenol, hydrogen sulfide, lysergic acid diethylamide, hyperthermia, butane, Taxus baccata