Severe and fatal pharmaceutical poisoning in young children in the UK

A Strategy for Rescuing a Child From Clonazepam Poisoning: A Case Study

BACKGROUND

This report describes the successful rescue of a 12-year-old girl who ingested large quantities of clonazepam tablets.

METHODS

The patient was promptly treated with flumazenil and hemoperfusion to alleviate the symptoms of central depression. Therapeutic drug monitoring was used to evaluate detoxification efficacy. The authors analyzed the rescue protocol for clonazepam poisoning based on the pathophysiology, clinical manifestations, and pharmacokinetics of clonazepam overdose.

RESULTS

The patient responded well to the treatment and was discharged from the hospital without adverse events.

CONCLUSIONS

This case study demonstrated the effectiveness and safety of combining flumazenil with hemoperfusion as a treatment for clonazepam poisoning. This study aimed to provide insights into more effective methods for treating clonazepam overdose and contribute to the ongoing issue of managing this condition.

Poisoning in children and adolescents in Kermanshah city, Iran

BACKGROUND

Poisoning among children and adolescents is a public health problem worldwide. To take preventive measures, the pattern of this problem should be determined. This study aimed to describe the demographic characteristics of poisoning in children and to investigate the relationship between the types of poisoning and demographic factors in children in Kermanshah province.

METHODS

This cross-sectional, descriptive-analytical study was conducted on 250 children and adolescents under 18 years of age who were referred to Mohammad Kermanshahi Pediatric Hospital in Kermanshah province due to poisoning during 2019-2022. The demographic and epidemiological data of patients were extracted from their medical files and analyzed.

RESULTS

Out of 250 cases of poisoning, 173 (69.2%) cases were unintentional, 96 (55.5%) of whom were boys. Further, 77 (30.8%) cases of poisoning were intentional, of whom 49 (63.6%) were girls. There was a significant difference between gender and intentional and unintentional poisonings (p-value = 0.005). The median age of unintentional poisoning was 3 (IQR = 2.5) and that of intentional poisoning was 14 (IQR = 2). Most cases of poisoning were in cities, 145 (83.8%) of them were unintentional and 66 (85.7%) were intentional. Most cases of intentional and unintentional poisonings occurred in spring 2017 (35.1%) and autumn 2016 (34.6%), respectively. The most common causes of poisoning were narcotics (n = 36, 34.3%) and drugs (n = 35, 33.3%) in the age group 0-3 years and drugs (n = 46, 66.9) in the age group 11-18 years.

CONCLUSIONS

The most common causes of poisoning were narcotics and drugs in children and drugs in adolescents. To prevent poisoning in children, parents are required to increase their knowledge of the safe storage of narcotics and drugs, such as not storing methadone in a water bottle. Targeted evaluation and preventive measures are also needed in adolescent poisoning.

Pediatric poisoning deaths in Saudi Arabia: A systematic review

Poisons are potentially harmful substances that can cause damage to the human body. Children are a vulnerable group to poisoning. This article aims to review the deaths due to poisoning among children in Saudi Arabia. A comprehensive search was conducted on 13 January 2022 using PubMed, Scopus, and Web of Science databases to identify articles that reported on pediatric poisoning deaths in Saudi Arabia. Eight articles met the inclusion criteria and were included in this systematic review. Some articles included one city, for instance, Jeddah or Riyadh, while others included different regions of the country. Children got poisoned most commonly at their homes by accidental ingestion. The common substances that caused fatality included drugs and pesticides. Low caregiver awareness and neglect were recognized as risk factors for pediatric poisoning. Further studies should be conducted to provide comprehensive details about the victims, the poisons involved, and the circumstances of pediatric poisonings in Saudi Arabia at the national and sub-national levels. Public awareness campaigns should be organized to raise community awareness about safety measures and risks of neglect to prevent pediatric poisonings.

Acute poisoning among children and adolescents: a narrative review

Background: Acute poisoning is a frequent emergency and a significant health concern in the pediatric population. The pattern of acute intoxication differs between countries and within each country. Poisoning depends on many factors. It can be divided into two categories (accidental and intentional), and each one has its own characteristics. Aim of the study: This study aimed to analyze and discuss the overall patterns of accidental and intentional poisoning among children and adolescents. Material and methods: A systematic literature search was conducted using Google Scholar, Elsevier, and the PubMed database. The following keywords were used: “acute poisoning”, “pediatric poisoning”, “intentional poisonings”, “unintentional poisonings”, and “suicide attempts”. Results: A total of 38 articles were included in the review. Half had been published in the last five years. The analysis focused on the characteristics of the materials and methods, results, and conclusions sections of each study. Conclusions: Unintentional poisonings dominate among younger children, with a slight male predominance. They usually occur at home and occasionally lead to severe harm or even death. The most common causes of intoxication in this population are medications and household products. The majority of poisonings among adolescents are intentional suicide attempts. Among older children, over-the-counter analgesics are the most common cause of acute poisoning. Accidental poisoning can be avoided by providing preventive educational programs to guardians and replacing potentially toxic household products with safer ones. The prevention of intentional poisoning should be based on a community support system and behavioral programs. Healthcare professionals should be familiar with poisoning and be aware of the different patterns of intoxication according to age and gender.

Emotional Intervention and Education System Construction for Rural Children Based on Semantic Analysis

Objective

Under the background of the policy of caring for the healthy growth of left-behind children, the purpose of selecting the topic is to study some common negative emotional problems of left-behind children in rural areas, focusing on the guidance of negative emotions of left-behind children in rural areas. In emotional problems, we analyze and find out the reasons for these negative emotions through observation and research.

Method

In this paper, a platform for acquiring emotional semantic data of scene images in an open behavioral experimental environment is designed, which breaks the limitations of time and place, and thus acquires a large amount of emotional semantic data of scene images and then uses principal component analysis to evaluate the validity of the data analysis. Psychological testing was used to measure parent-child affinity, adversity beliefs, and positive/negative emotion scales, respectively, to examine children whose parents went out, children whose fathers went out, and non-left-behind children. The characteristics of parent-child affinity, adversity beliefs, and positive/negative emotions in three types of children were examined, and the direct predictive effects of parent-child affinity and adversity beliefs on the positive/negative emotions of the three types of children were examined. Results/Discussion. Adversity beliefs played a partial mediating role between children's parent-child bonding and positive emotions. The predictive effect of adversity beliefs on children's emotional adaptation differs by emotional type. The main effects of the left-behind category were significant for both positive and negative emotions. The gender main effect of negative emotion was significant, and the negative emotion level of girls was significantly higher than that of boys. The main effect of the left-behind category of adversity beliefs was significant, and the adversity belief levels of children whose parents went out to rural areas were significantly lower than those of children whose fathers went out and non-left-behind children. The negative emotions generated by left-behind children in rural areas are channeled, and to a certain extent, they are improved and alleviated. Through the emotional counseling and improvement of the rural left-behind children in the research site in the article, the service objects can have better emotions, promote mental health, make them happy and grow up healthily, and also provide a certain theory for the establishment of the local left-behind children care system.

Epidemiological Study of Acute Unintentional Poisoning Among Children in Iran

The occurrence of different types of poisoning and early diagnosis is important for therapeutic measures. In this study, we investigate the epidemiological causes of acute poisoning in children.In this retrospective descriptive study, children presented with acute poisoning during 2010-2019 to Shahid Madani Hospital were included. The Electronic Medical Record system of the hospital was accessed to obtain the data of the patients. The data included was demographic information, type of poisoning, clinical findings, complications, duration of hospitalization, parents' education status, and mortality status.Of 336 patients included in the study, the mean age of patients was 4.90±3.27 years (range: 1-12 years). There was a significant correlation between the age of the child and the type of poisoning, p=0.001. The most frequent age group was 5 years and less (69.6%). The most frequent sex group was male (58.6%). However, there was no significant correlation between the sex of the child and the type of poisoning. Parents' education and ICU admission were also associated significantly with the type of poisoning, p=0.001, respectively. The most common type of poisoning in children was medication (60.6%) which was mainly due to methadone. The mortality rate in the study was 1.2%.Our study showed that pharmacological drugs are the main cause of poisoning in our population. Age of the children is likely to be associated with the type of poisoning however, no gender difference was found in this regard was found in our study.

Public health risks associated with methadone in Iran: A systematic review and meta-analysis

BACKGROUND

There has been a marked growth in methadone maintenance treatment (MMT) in Iran in the past two decades with positive health outcomes. We conducted a systematic review of studies on the prevalence of non-prescribed methadone use, methadone use disorder, and methadone-related poisoning and mortality in Iran.

METHODS

We searched International and Iranian databases up to May 2020 and contacted relevant experts. The pooled proportions were estimated through random-effects model. Methadone-related adverse outcomes were evaluated over time.

RESULTS

Sixty-five studies were included. The pooled estimates of non-prescribed methadone use in the last 12-month were 2.7% (95%CI: 0.9-5.4) and 0.1% (95%CI: 0.03-0.2) in the male and female general population, respectively. Among people who use drugs, 8.4% reported daily non-prescribed use in 2018. Four heterogeneous studies in drug treatment centers reported the existence of treatment-seeking for methadone use disorder. Methadone was responsible for 10.4% (95%CI: 4.5-18.3) of cases of acute poisoning in adults and 16.0% (95%CI: 9.3-24.1) in children. Methadone was reported as a cause of death in 53.5% of substance-related deaths referred to the Legal Medicine Organization while being the only cause in 35.8% of all cases.

CONCLUSION

Non-prescribed use of methadone in the general population is much less than opiates and some other available prescription opioids, like tramadol. However, notwithstanding the large and successful MMT program in Iran, increasing trends in methadone-related poisoning and deaths pose serious public health concerns. There is an urgent need to explore these fatal and non-fatal poisoning cases and implement policies to curb the harms associated with methadone use.

Hospitalizations and deaths related to adverse drug events worldwide: Systematic review of studies with national coverage

PURPOSE

Adverse drug events are related to negative outcomes in healthcare, including hospitalization, increased duration of hospital stay and death. The aim of this study was to conduct a systematic review to evaluate hospitalizations and deaths related to adverse drug events worldwide, reported in studies with national coverage.

METHODS

The protocol was registered in PROSPERO (CRD42020157008). We performed a systematic search on Medline, Embase, CINAHL, LILACS, and the Cochrane Library (until March 2020) using pre-specified terms. We included published studies that reported data on hospitalizations and/or deaths related to adverse drug events from a national perspective and the use of secondary data as a source of information. Two reviewers independently extracted and synthesized data. The quality of the studies was assessed using an adapted version of the Joanna Briggs Institute critical appraisal checklist for prevalence studies. Narrative summaries of findings were undertaken.

RESULTS

Among 59,336 citations, 62 studies were included for data extraction and synthesis. Among these studies, 41 studies included the outcome of hospitalization, 16 included the death outcome, and five included both outcomes. Administrative databases regarding discharges and registries of vital statistics were the most common sources of information. The relative frequency of hospitalizations ranged from 0.03% to 7.3%, and from 9.7 to 383.0/100,000 population, whereas mortality rate ranged from 0.1 to 7.88/100,000 population.

CONCLUSION

Our study highlights information about adverse drug events using large administrative databases in a national scenario and provides an overview of databases and methods implemented to detect adverse drug events.

Toxico-epidemiology of acute poisoning; an exploratory study from a tertiary care hospital in South India along with global comparisons and solutions

BACKGROUND

Poisoning has been and still is a major problem faced throughout the globe. But its patterns are different and changing in different parts of the world due to local influences. This calls for a study to explore the issue in this unique South Indian state.

METHODS

A cross-sectional exploratory study was conducted to analyse the patterns of poisoning and the socio-demographic characteristics of the patients. Subgroups were compared using Fisher-Freeman-Halton exact test and further analysed by multivariate logistic regression.

RESULTS

48% of cases were of pharmaceutical drug poisoning. 27.5% of these cases involved polymedication and Paracetamol (Acetaminophen) turned out to be the single most drug used. Suicide was the most common circumstance. 10% of patients had co-diagnoses of psychiatric disorders. Univariate analysis separately showed that females (p < 0.001), higher educated (p = 0.149), higher socioeconomic strata (p = 0.136) and non-addicts (p = 0.002) were more exposed to drugs whereas males, lower educated, lower socioeconomic strata and addicts are skewed to pesticides for poisoning. Most repeat suicide attempts were with the same poisonous agent. 70% of patients with a diagnosed psychiatric disorder have attempted suicide before using some drugs (p < 0.001).

CONCLUSION

Our study highlights the importance of a region-wise, targeted approach in policymaking to curb poisoning.

Paediatric poisoning exposures in schools: reports to Australia's largest poisons centre

OBJECTIVE

To describe poisoning exposures occurring at school in a large sample of Australian children.

DESIGN

A population-based retrospective cohort study.

SETTING

Cases reported to the New South Wales Poisons Information Centre (NSWPIC), Australia's largest poisons information centre, taking 50% of the nation's poisoning calls.

PATIENTS

Poisoning exposures occurring in children and adolescents while at school were included, over a 4.5-year period (January 2014 to June 2018).

MAIN OUTCOME MEASURES

Time trends in poisonings, demographics, exposure characteristics, substances involved, disposition.

RESULTS

There were 1751 calls relating to exposures at school made to NSWPIC. Most calls concerned accidental exposures (60.8%, n=1064), followed by deliberate self-poisonings (self-harm, 12.3%, n=216). Over a quarter of cases were hospitalised (n=468), where the call originated from hospital or patients referred to hospital by NSWPIC. Disposition varied by exposure type, and hospitalisation was highest with deliberate self-poisonings (92.6%, n=200), recreational exposures (57.1%, n=12) and other intentional exposures (32.6%, n=45). The median age was 12 (IQR 8-15 years), and 54.7% were male (n=958). The most common pharmaceutical exposures were to paracetamol (n=100), methylphenidate (n=78) and ibuprofen (n=53), with the majority being deliberate self-poisonings. Copper sulfate was responsible for 55 science class cases, 45% of which were hospitalised. Cases may be increasing, with 81.3 (±8.2) calls per quarter, 2014-2016, and 129.3 (±24.3) calls per quarter, 2017-2018.

CONCLUSIONS

Poisoning exposures occurring at school are common, with disposition and substances involved varying considerably by exposure reason. The relatively high number of referrals to hospital highlights the need for investigation into preventative measures.

A study of the effectiveness of naltrexone in preventing recurrence of methadone poisoning in opioid-naive children

BACKGROUND

The prevalence of poisoning from methadone and prescription opioids is increasing in pediatric populations. Naloxone is the main antidote for treatment. Long-acting opioid toxicity may need close observation in the intensive care unit (ICU). In our previous study, naltrexone prevented re-narcotization in methadone-poisoned adults. Here, we aim to share our experience with the use of oral naltrexone for preventing recurrence of toxicity in opioid-naïve children.

METHODS

In a single-center, retrospective case series, children (age ≤12 years) admitted to a poison center in Tehran (Iran) between March 2014-March 2016 were included if they presented with methadone poisoning and received naltrexone treatment in hospital. Naltrexone (1 mg/kg) was administrated orally after initial administration of 0.1 mg/kg naloxone intravenously. Children were monitored for level of consciousness, cyanosis, respiratory rate, VBG results, and O2 saturation for ≥48 h during their hospitalization.

RESULTS

Eighty patients with methadone poisoning were enrolled, with median age of three years (range: 0.2-12.0). None involved polysubstance poisoning. Following naltrexone treatment, none experienced recurrent opioid toxicity during hospitalization, and hospital records indicated no readmission within 72-h post-discharge.

CONCLUSION

Oral naltrexone could be a potential substitute for continuous naloxone infusion in methadone-poisoned children and reduce the need for ICU care.

Accidental and Deliberate Self-Poisoning with Medications and Medication Errors among Children in Rural Sri Lanka

Context. Pharmaceutical products are the leading cause accidental poisoning in middle- and high-income countries. Patterns of poisoning with medicinal drugs change across different geographic regions and over decades owing to variability in prescription practice, sociocultural factors, safe storage of medicines, and free availability of over the counter medications. Methods. This multicentre descriptive study was conducted over a seven-year period (February 2007 to January 2014) to assess patterns and trends of medicinal drug-related poisoning among children less than 12 years of age in thirty-six hospitals across rural Sri Lanka. Children with both accidental and deliberate medication poisonings and medication errors were recruited to the study. Data on poisoning events and medication errors were gathered via patient/parent interviews using multistructured questionnaires that assessed demographic factors, first aid measures, location and circumstances of poisoning, clinical management, and complications. In addition, focus group discussions were performed on all children and their families who had deliberate poisoning events and medication errors. Results and Conclusions. Among 1621 children presented with acute poisoning over seven years of age, 410 children had acute poisoning with medications. Male children (225, 54.9%) outnumbered female children. Paracetomol (137, 35.6%), salbutamol (55, 14.3%), and chlorpheniramine (35, 9.1%) were the most commonly poisoned medications. Prospective data at Anuradhapura teaching hospital (n = 112) revealed that unsafe first aid measures were practiced on 22 (19.6%) children. Although the majority of children remained asymptomatic (61, 54.5%), neurological symptoms (34, 67%) were predominantly seen in symptomatic children. The majority of poisonings took place within home premises (76, 67.9%). There were 16 reports of medication errors (14.2% of acute poisoning events) either due to erroneous administration by caregivers or erroneous issue of medicines by health workers. The current study did not observe mortality following medication poisonings. This study brings to light the burden of medicinal drug-related poisoning morbidity among children in rural Sri Lanka. Potentially, interventions such as community educational initiatives, written safety warnings, increased use of child resistant containers, and enforcement of laws to bring down accidental medication poisonings need to be implemented, and their effectiveness should be evaluated.

[Availability in Spain of "one pill killers" and other highly toxic drugs in infants]

OBJECTIVE

To prepare a list of highly toxic drugs in infants (HTDs) marketed in Spain, comparing those that reach the lethal dose in a child of 10kg with the ingestion of 1 to 3 units.

METHOD

HTDs are defined as those capable of causing severe or lethal poisoning in children less than 8-year-old. Severe poisoning is considered as that corresponding to Grade 3 in the Poisoning Severity Score classification and to the "major effects" category in publications in the American Association of Poison Control Centers. A literature review was carried out on the annual reports of the American Association of Poison Control Centers, as well as in PubMed, between January 2000 and February 2019 (Keywords "severe", "fatal", "life-threatening", "poisoning", "child", "paediatric", "toxicological emergency"). An observational, retrospective study was also conducted on infants less than 8-year-old that were seen in a Paediatric Emergency Department due to suspected drug poisoning between July 2012 and June 2018. The active ingredients responsible marketed in Spain were selected, and the lethal or highly toxic doses were determined. The number of units (pills) necessary to reach this dose in children of 10kg was calculated.

RESULTS

A total of 7 HTD groups were identified: analgesics; psychotropics and other medication used in neurological disorders; catarrh decongestants - cough -antihistamine - asthma drugs; cardiovascular drugs; antibiotics, topical preparations, and other drugs. In 29 active ingredients, the ingestion of a single pill could cause death in 10kg infant, in another 13, the ingestion of 2 pills could cause death, as well as the ingestion of 3 pills in 10 cases.

CONCLUSION

There are numerous HTDs marketed in Spain, some of which are available in potentially fatal presentations with few pills.

Epidemiology of pediatric buprenorphine and methadone exposures reported to the poison centers

BACKGROUND

Buprenorphine prescriptions have increased dramatically within the United States, whereas methadone continues to be used widely. We investigated the trends and characteristics of buprenorphine and methadone exposures in the pediatric population.

METHODS

We identified pediatric exposures to buprenorphine and methadone using the National Poison Data System from 2013 to 2016. We descriptively assessed characteristics of the exposures. Trends in exposures were evaluated using generalized linear mixed models.

RESULTS

Pediatric buprenorphine exposures increased from 2013 (1097) to 2016 (1226) while methadone calls decreased (486 to 396). After adjusting for the random effects of the geographical region, the mean number of pediatric buprenorphine exposures (per 100,000 pediatric population) increased from 1.3 to 1.5 (P = .05). Conversely, the mean number of methadone exposures decreased from 0.6 to 0.4 (P = .03). Children aged ≤3 years constituted the highest percentage of both exposures. Unintentional exposures accounted for most of the buprenorphine (86.9%) and methadone (62.4%) exposures. Major clinical effects were demonstrated in 2.3% of buprenorphine exposures and were more frequent with methadone (13%). West Virginia and Maryland demonstrated the highest incidence of buprenorphine and methadone exposures, respectively.

CONCLUSIONS

Pediatric buprenorphine exposures increased but demonstrated less severe effects compared to methadone exposures, which decreased during the study period.

ACCIDENTAL POISONING IN CHILDREN AND ADOLESCENTS ADMITTED TO A REFERRAL TOXICOLOGY DEPARTMENT OF A BRAZILIAN EMERGENCY HOSPITAL

Objective:

To describe the profile of children and adolescents admitted for exogenous unintentional poisoning in the emergency room and analyze factors associated with subsequent in-hospital admissions.

Methods:

This is a cross-sectional study based on hospital records of all subjects up to 19 years-old admitted in 2013 at a specialized toxicology service on a major public emergency hospital due to unintentional intoxication (as reported). Accidents with poisonous animals and insects were excluded. Percentages and frequencies were calculated for the qualitative variables, and measures of central tendency and dispersion for the continuous quantitative variables. Multivariate analysis was performed using binary logistic regression to identify variables associated with subsequent in-hospital admissions.

Results:

In 2013, 353 cases were reported. Poisonings were more frequent in children 0-4 years-old (72.5%) and in boys (55%). The vast majority was of dwellers of the Metropolitan Region of Belo Horizonte (83%), and 90% of the accidental poisonings occurred at home. 82.7% of the poisonings occurred by oral ingestion, especially of medicinal (36.5%) and cleaning products (29.4% of all poisonings). Only 12.2% of the cases resulted in hospitalization, and only one resulted in death. Residing outside Belo Horizonte (OR=5.20 [95%CI 2.37-11.44]) and poisoning by two or more products (OR=4.29 [95%CI 1.33-13.82]) were considered risk factors for hospitalization.

Conclusions:

Accidental poisonings occurred most frequently by ingestion of household medications and cleaning products, especially among children under 4 years-old. Preventive strategies should be primarily directed for this prevalent profile.

Risk of poisoning in children and adolescents with ADHD: a systematic review and meta-analysis

Poisoning, a subtype of physical injury, is an important hazard in children and youth. Individuals with ADHD may be at higher risk of poisoning. Here, we conducted a systematic review and meta-analysis to quantify this risk. Furthermore, since physical injuries, likely share causal mechanisms with those of poisoning, we compared the relative risk of poisoning and injuries pooling studies reporting both. As per our pre-registered protocol (PROSPERO ID CRD42017079911), we searched 114 databases through November 2017. From a pool of 826 potentially relevant references, screened independently by two researchers, nine studies (84,756 individuals with and 1,398,946 without the disorder) were retained. We pooled hazard and odds ratios using Robust Variance Estimation, a meta-analytic method aimed to deal with non-independence of outcomes. We found that ADHD is associated with a significantly higher risk of poisoning (Relative Risk = 3.14, 95% Confidence Interval = 2.23 to 4.42). Results also indicated that the relative risk of poisoning is significantly higher than that of physical injuries when comparing individuals with and without ADHD (Beta coefficient = 0.686, 95% Confidence Interval = 0.166 to 1.206). These findings should inform clinical guidelines and public health programs aimed to reduce physical risks in children/adolescents with ADHD.

Suspected Methadone Toxicity: from Hospital to Autopsy Bed

High mortality rates have been reported for methadone in both adults and children. We aimed to determine the pattern of toxicity, possible underlying diseases and treatment challenges in patients referred to our centre with early diagnosis of methadone toxicity and who later died. Medical files of all methadone-poisoned patients who had been admitted to a referral centre of toxicology between March 2011 and March 2016, died during the hospital stay and sent for autopsy to Legal Medicine Organization were retrospectively evaluated. In a total of 94 patients, autopsy findings and laboratory evaluations showed that cause of death was pure methadone toxicity in 57 (60.6%). Other causes of death were ischaemic heart disease in ten, co-ingestions (toxicities including methadone) in eight, brain haemorrhage, multi-organ failure and pneumosepsis (each in four), meningitis/encephalitis in three and head trauma and other toxicities (other than methadone but including an opioid, each in two) patients. Time of cardiopulmonary arrest was significantly different between those with pure methadone toxicity and those who died due to other causes (p = 0.01). Patients who had died due to co-ingestions and other toxicities were younger (p = 0.029) and took more bolus doses of naloxone (p = 0.042). In methadone users, especially in older ages and those with trivial response to naloxone administration, loss of consciousness should not be strictly attributed to methadone toxicity. In such patients, thorough evaluation for other possible causes of loss of consciousness is mandatory.