Nonaccidental poisoning in childhood

Tricyclic antidepressant poisoning: an evidence-based consensus guideline for out-of-hospital management

A review of U.S. poison center data for 2004 showed over 12,000 exposures to tricyclic antidepressants (TCAs). A guideline that determines the conditions for emergency department referral and prehospital care could potentially optimize patient outcome, avoid unnecessary emergency department visits, reduce healthcare costs, and reduce life disruption for patients and caregivers. An evidence-based expert consensus process was used to create the guideline. Relevant articles were abstracted by a trained physician researcher. The first draft of the guideline was created by the lead author. The entire panel discussed and refined the guideline before distribution to secondary reviewers for comment. The panel then made changes based on the secondary review comments. The objective of this guideline is to assist poison center personnel in the appropriate prehospital triage and management of patients with suspected ingestions of TCAs by 1) describing the manner in which an ingestion of a TCA might be managed, 2) identifying the key decision elements in managing cases of TCA ingestion, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This guideline applies to ingestion of TCAs alone. Co-ingestion of additional substances could require different referral and management recommendations depending on their combined toxicities. This guideline is based on the assessment of current scientific and clinical information. The panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and the health professionals providing care, considering all the circumstances involved. This guideline does not substitute for clinical judgment. Recommendations are in chronological order of likely clinical use. The grade of recommendation is in parentheses. 1) Patients with suspected self-harm or who are the victims of malicious administration of a TCA should be referred to an emergency department immediately (Grade D). 2) Patients with acute TCA ingestions who are less than 6 years of age and other patients without evidence of self-harm should have further evaluation including standard history taking and determination of the presence of co-ingestants (especially other psychopharmaceutical agents) and underlying exacerbating conditions, such as convulsions or cardiac arrhythmias. Ingestion of a TCA in combination with other drugs might warrant referral to an emergency department. The ingestion of a TCA by a patient with significant underlying cardiovascular or neurological disease should cause referral to an emergency department at a lower dose than for other individuals. Because of the potential severity of TCA poisoning, transportation by EMS, with close monitoring of clinical status and vital signs en route, should be considered (Grade D). 3) Patients who are symptomatic (e.g., weak, drowsy, dizzy, tremulous, palpitations) after a TCA ingestion should be referred to an emergency department (Grade B). 4) Ingestion of either of the following amounts (whichever is lower) would warrant consideration of referral to an emergency department: an amount that exceeds the usual maximum single therapeutic dose or an amount equal to or greater than the lowest reported toxic dose. For all TCAs except desipramine, nortriptyline, trimipramine, and protriptyline, this dose is >5 mg/kg. For despiramine it is >2.5 mg/kg; for nortriptyline it is >2.5 mg/kg; for trimipramine it is >2.5 mg/kg; and for protriptyline it is >1 mg/kg. This recommendation applies to both patients who are naïve to the specific TCA and to patients currently taking cyclic antidepressants who take extra doses, in which case the extra doses should be added to the daily dose taken and then compared to the threshold dose for referral to an emergency department (Grades B/C). 5) Do not induce emesis (Grade D). 6) The risk-to-benefit ratio of prehospital activated charcoal for gastrointestinal decontamination in TCA poisoning is unknown. Prehospital activated charcoal administration, if available, should only be carried out by health professionals and only if no contraindications are present. Do not delay transportation in order to administer activated charcoal (Grades B/D). 7) For unintentional poisonings, asymptomatic patients are unlikely to develop symptoms if the interval between the ingestion and the initial call to a poison center is greater than 6 hours. These patients do not need referral to an emergency department facility (Grade C). 8) Follow-up calls to determine the outcome for a TCA ingestions ideally should be made within 4 hours of the initial call to a poison center and then at appropriate intervals thereafter based on the clinical judgment of the poison center staff (Grade D). 9) An ECG or rhythm strip, if available, should be checked during the prehospital assessment of a TCA overdose patient. A wide-complex arrhythmia with a QRS duration longer than 100 msec is an indicator that the patient should be immediately stabilized, given sodium bicarbonate if there is a protocol for its use, and transported to an emergency department (Grade B). 10) Symptomatic patients with TCA poisoning might require prehospital interventions, such as intravenous fluids, cardiovascular agents, and respiratory support, in accordance with standard ACLS guidelines (Grade D). 11) Administration of sodium bicarbonate might be beneficial for patients with severe or life-threatening TCA toxicity if there is a prehospital protocol for its use (Grades B/D). 12) For TCA-associated convulsions, benzodiazepines are recommended (Grade D). 13) Flumazenil is not recommended for patients with TCA poisoning (Grade D).

Criminal Poisoning: Munchausen by Proxy

The diagnosis and subsequent prosecution of Munchausen by proxy (MBP) cases require the collaborative teamwork of health care teams, laboratory personnel, law enforcement, and social services. Poisoning occurs in a significant number of the MBP cases with a diverse variety of agents used. To aid laboratory professionals in determining the appropriate toxicology tests to perform in such criminal cases, health care professionals must focus their testing requests on substances that correspond to the victim's signs, symptoms, and ancillary test values. This article reviews MBP, with particular focus on poisoning agents that have been used in past reported cases.

Munchausen by proxy: a case, chart series, and literature review of older victims

The history of an older child victim of Munchausen by proxy (MBP) is described. He was referred for evaluation after repeated sinus surgeries for recurrent sinus infections believed to be related to a falsified history of an immunodeficiency. The perpetrator was the mother of this 14-year-old victim, consistent with the majority of such cases. This case prompted a review of cases of MBP in older children reported in our hospital as well as a literature search for other cases in older children.

METHODS

This study was a chart review of children over 6 years of age who had been evaluated by social services at the Children's Hospital at the Cleveland Clinic and reported as cases of Munchausen by proxy to Child Protective Services between January 2001 and June 2003. Also, an OVID, Psychline, and Pubmed literature review of published cases of Munchausen by proxy were identified, and cases occurring in the older child were selected for review.

RESULTS

Older children who are the victims of Munchausen by proxy may have an induced illness, but falsified reports of symptoms and medical history to coerce the child to undergo medical procedures may be more common. Collusion of the victim with the perpetrator may also become a factor as the child ages and adopts the deception. Given the complex relationship that exists between the parent and child, it is difficult to predict whether the victim either will assist the caregiver in maintaining the factitious illness or be able to recognize the falsification.

CONCLUSIONS

Older children who are the victims of Munchausen by proxy may fear consequences of revealing the factitious illness. Physicians must consider the possibility of this diagnosis whenever there are discrepancies in a child's illness that makes a factitious illness a consideration.

Factitious illness by proxy. Munchausen syndrome by proxy

BACKGROUND

Since 1977 a literature has grown describing examples of factitious illness by proxy (FIP).

METHOD

The literature in English was searched using MEDLINE and supplemented by a manual search. Extracted data focused on terminology of a spectrum of behaviours, clinical features and psychopathology of perpetrators.

RESULTS

There has been difficulty with the use of terminology and classification of psychiatric disorders.

CONCLUSIONS

The spectrum of FIP is wide. Suggestions are made for the use of terminology and classification when FIP is identified.

The ethics of cardiopulmonary resuscitation. II. Medical logistics and the potential for good response

Mismatches between provision of paediatric cardiopulmonary resuscitation (CPR) and potential to benefit are examined. Deficiencies are most likely to occur in peripheral maternity units but futile CPR is more common in emergency departments where the child is unknown. Decision making in individual cases is best retained by the medical profession for the sake of the child and family. American style intervention by the legislature is likely to dissipate scarce resources and perhaps harm infants not capable of benefiting.

Severe failure to thrive and diarrhoea caused by laxative abuse

We report a case of chronic administration of Epsom salts leading to diarrhoea and severe weight loss in 7 month old girl.

Caustic ingestions and foreign body aspirations: an overlooked form of child abuse

Caustic ingestions and foreign body aspirations are common occurrences in the pediatric population. The high association between caustic ingestions and foreign body aspirations and family stress with social problems may result in significant morbidity and mortality. It is the purpose of this article to increase physician awareness concerning the possibility that these events may be a form of child abuse. It is hoped that by recognizing the risk of child abuse in these cases the physician can make the appropriate referrals in order to avoid serious injury to the child.

Three forms of factitious illness in children: when is it Munchausen syndrome by proxy?

Examples of fabrication of illness in children are described. Primarily uncomplicated cries for help are differentiated from two major subtypes (the Active Inducer and the Doctor Addict) which define the spectrum of Munchausen syndrome by proxy. Primary differences involve the form of deception, age of the victim, and maternal affect. Five histories are presented and it is suggested that doctor addiction is more common than has thus far been recognized.

Munchausen syndrome by proxy

Information is presented about 19 children, under age 7 years, from 17 families, whose mothers consistently gave fraudulent clinical histories and fabricated signs so causing them needless harmful medical investigations, hospital admissions, and treatment over periods of time ranging from a few months to 4 years. Episodes of bleeding, neurological abnormality, rashes, fevers, and abnormal urine were commonly simulated. Often the mothers had had previous nursing training and some had a history of fabricating symptoms or signs relating to themselves. Two children died. Of the 17 survivors, 8 were taken into care and the other 9 remained at home after arrangements had been made for their supervision. Study of these children and their families has enabled a list of warning signs to be compiled together with recommendations for dealing with suspected acts. The causes and the relationship of this form of behaviour to other forms of non-accidental injury, iatrogenic injury, and parental-induced illness are discussed.

Value of toxicological investigation in the diagnosis of acute drug poisoning in children

In the 2 years 1978 and 1979 specimens from 287 children aged between 10 days and 14 years were received for general toxicological investigations. Of the 95 (33%) cases of confirmed poisoning, the diagnosis was established as a direct result of the analyses in 48 patients. No diagnosis was made in at least 85 (30%) of the remaining cases. Benzodiazepines were the drugs most commonly encountered (33%), followed by barbiturates, glutethimide, and meprobamate (15%), salicylate and paracetamol (15%), tricyclic antidepressants (12%), and ethanol (11%). 36 patients were severely poisoned (grade 3 or 4 coma, or convulsions), although only 1 patent died. There was evidence that drug(s) had been administered without authorisation in at least 7 instances, and in 51 (54%) of the poisoned patients there was sufficient concern about the safety of the child or the mode of administration of the drug(s) to institute legal proceedings (8 cases), involve the social services (25 cases), or arrange further medical appointments (18 cases). Drugs are readily available in most households and offer a means of inflicting injury that is less easily detectable than physical assault. For this reason, comprehensive toxicological investigations should be considered in children not only when they may assist in management but also in the presence of unusual or unexplained symptoms which could be drug-induced.

Nonaccidental poisoning: the elusive diagnosis

Although nonaccidental poisoning in childhood is now more often recognised, it is still difficult to establish a diagnosis despite correct investigative procedures. In 1978 we were unable, initially, to establish the cause of intermittent episodes of loss of consciousness in a boy admitted to Sheffield Children's Hospital. Subsequently it was conclusively shown that his mother systematically poisoned him with Tuinal (amylobarbitone and quinalbarbitone) both before admission and while he was being treated in the hospital.