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Hughes K, Overberg A, Satterfield K, Voss H, Rogerson C. Epidemiologic Trends In Children With Toxicologic Exposures Requiring Intensive Care Before and During the COVID-19 Pandemic. J Pediatr Pharmacol Ther 2024; 29:273-277. [PMID: 38863855 PMCID: PMC11163898 DOI: 10.5863/1551-6776-29.3.273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/11/2023] [Indexed: 06/13/2024]
Abstract
OBJECTIVE Pediatric poison exposures are a common reason for pediatric intensive care unit (PICU) -admission. The purpose of this study was to examine the exposure trends and patient outcomes in 2018-2019 compared with 2020-2021 amidst the COVID-19 pandemic. METHODS This was a retrospective cohort study of patients 18 years of age or younger with a suspected toxicologic exposure from January 2018 to March 2021. The primary endpoint was rate of PICU admissions between the 2 cohorts. Secondary endpoints included medical outcome stratified by severity, PICU length of stay, and need for mechanical ventilation. RESULTS Our study included a total of 340 patients with median age 14.5 (IQR, 11.9-16.1) years. There was no significant difference in age, sex, or race between the 2 cohorts. The percentage of patients admitted to the PICU for poison exposures was significantly higher in the COVID-19 cohort compared with the pre-COVID-19 cohort (8.4% vs 3.7%, p < 0.01). Severity of medical outcomes differed between the groups; the COVID-19 cohort had more extreme clinical presentations of no effect or death (p < 0.01). No significant difference was found among the remaining secondary outcomes. Classes of substances ingested were comparable with baseline poison center data. CONCLUSIONS Poisoning-related PICU admissions occurred at more than twice the pre-pandemic rate. This may emphasize the effect of the COVID-19 pandemic on pediatric access and exposure to poisons.
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Affiliation(s)
- Kaitlin Hughes
- Department of Pharmacy (KH), Riley Hospital for Children, Indianapolis, IN
| | - Adam Overberg
- Indiana Poison Center (AO), Indiana University Health, Indianapolis, IN
| | - Kennedi Satterfield
- Pharmacy resident (KS), The Ohio State University Wexner Medical Center, Columbus, OH
| | - Hannah Voss
- Pharmacy resident (HV), Eskenazi Health, Indianapolis, IN
| | - Colin Rogerson
- Division of Pediatric Critical Care (CR), Indiana University School of Medicine, Indianapolis, IN
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2
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Rebbe R, Malicki D, Siddiqi N, Huang JS, Putnam-Hornstein E, Laub N. Child Protection System Interactions for Children With Positive Urine Screens for Illicit Drugs. JAMA Netw Open 2024; 7:e243133. [PMID: 38512254 PMCID: PMC10958236 DOI: 10.1001/jamanetworkopen.2024.3133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/26/2024] [Indexed: 03/22/2024] Open
Abstract
Importance Young children are ingesting illicit drugs at increased rates, but it is unknown what the associated child protection system (CPS) responses are when a child tests positive. Objective To document the child protection system involvement and the characteristics of children who test positive for illicit substances. Design, Setting, and Participants This retrospective cross-sectional study linked medical discharge and child protection system administrative data. The setting was Rady Children's Hospital San Diego, a free-standing pediatric hospital in California. Participants included all emergency department and inpatient medical encounters involving children aged 12 years or younger with a positive urine drug test between 2016 and 2021. Statistical analysis was performed from February 2023 to January 2024. Exposure Drug type, including amphetamines, barbiturates, benzodiazepines, cannabis, cocaine, fentanyl, opiates, and phencyclidine. Main Measures and Outcomes CPS responses associated with the medical encounter including reports, substantiations, case openings, and out-of-home placements. Results A total of 511 emergency department and inpatient medical encounters involving children had a positive drug test (262 [51.3%] were female; 309 [60.5%] were age 6 years or younger; fewer than 10 [<3.0%] were American Indian or Alaska Native; 252 [49.3%] were Hispanic [any race], 20 [3.9%] were non-Hispanic Asian, 56 [11.0%] were non-Hispanic Black, 143 [28.0%] were non-Hispanic White, 36 [7.0%] had other or unknown race and ethnicity; 233 [43.6%] had a CPS report prior to the medical encounter). Following the positive screen, 244 (47.7%) were reported to child protection, and 61 (11.9%) were placed out-of-home within 30 days. Mean (SD) quarterly counts of encounters with positive drug tests doubled after the COVID-19 pandemic onset (32.9 [9.8]) compared with prior to the pandemic onset (16.5 [4.7]); for encounters positive for cannabis, mean (SD) quarterly counts were 3 times as high after the pandemic onset than prior (16.6 [4.7] vs 5.7 [2.9]). Encounters for children under age 1 were significantly more likely to have associated child protection reports (relative risk [RR], 2.91 [95% CI, 2.21-3.83]) and child protection case openings (RR, 1.71 [95% CI, 1.07-2.72]) than encounters involving older children. Conclusions and Relevance In this cross-sectional study of emergency department and inpatient medical encounters, less than half of children with positive urine drug screens were reported to CPS; out-of-home placements were uncommon. With increased encounters for positive drug tests, it is unclear what services these children and families are receiving.
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Affiliation(s)
- Rebecca Rebbe
- University of North Carolina at Chapel Hill School of Social Work, Chapel Hill
| | - Denise Malicki
- University of California, San Diego
- Rady Children’s Hospital, San Diego, California
- Chadwick Center for Children and Families, San Diego, California
| | - Nadia Siddiqi
- Nova Southeastern University, Fort Lauderdale, Florida
| | - Jeannie S. Huang
- University of California, San Diego
- Rady Children’s Hospital, San Diego, California
| | | | - Natalie Laub
- University of California, San Diego
- Rady Children’s Hospital, San Diego, California
- Chadwick Center for Children and Families, San Diego, California
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Simpson MD, Watson CJ, Whitledge JD, Monuteaux MC, Burns MM. Intensive Care Interventions Among Children With Toxicologic Exposures to Cardiovascular Medications. Pediatr Crit Care Med 2023; 24:893-900. [PMID: 37133321 DOI: 10.1097/pcc.0000000000003274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
OBJECTIVES Interventions requiring a PICU are rare in toxicologic exposures, but cardiovascular medications are high-risk exposures due to their hemodynamic effects. This study aimed to describe prevalence of and risk factors for PICU interventions among children exposed to cardiovascular medications. DESIGN Secondary analysis of Toxicology Investigators Consortium Core Registry from January 2010 to March 2022. SETTING International multicenter research network of 40 sites. PATIENTS Patients 18 years old or younger with acute or acute-on-chronic toxicologic exposure to cardiovascular medications. Patients were excluded if exposed to noncardiovascular medications or if symptoms were documented as unlikely related to exposure. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 1,091 patients in the final analysis, 195 (17.9%) received PICU intervention. One hundred fifty-seven (14.4%) received intensive hemodynamic interventions and 602 (55.2%) received intervention in general. Children less than 2 years old were less likely to receive PICU intervention (odds ratio [OR], 0.42; 95% CI, 0.20-0.86). Exposures to alpha-2 agonists (OR, 2.0; 95% CI, 1.11-3.72) and antiarrhythmics (OR, 4.26; 95% CI, 1.41-12.90) were associated with PICU intervention. In the sensitivity analysis removing atropine from the composite outcome PICU intervention, only exposures to calcium channel antagonists (OR, 2.12; 95% CI, 1.09-4.11) and antiarrhythmics (OR, 4.82; 95% CI, 1.57-14.81) were independently associated with PICU intervention. No independent association was identified between PICU intervention and gender, polypharmacy, intentionality or acuity of exposure, or the other medication classes studied. CONCLUSIONS PICU interventions were uncommon but were associated with exposure to antiarrhythmic medications, calcium channel antagonists, and alpha-2 agonists. As demonstrated via sensitivity analysis, exact associations may depend on institutional definitions of PICU intervention. Children less than 2 years old are less likely to require PICU interventions. In equivocal cases, age and exposure to certain cardiovascular medication classes may be useful to guide appropriate disposition.
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Affiliation(s)
- Michael D Simpson
- Harvard Medical Toxicology Program, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
| | - C James Watson
- Department of Emergency Medicine, Maine Medical Center, Portland, ME
| | - James D Whitledge
- Harvard Medical Toxicology Program, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Michele M Burns
- Harvard Medical Toxicology Program, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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4
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Watson CJ, Monuteaux MC, Burns MM. Characterization of pediatric beta-adrenergic antagonist ingestions reported to the National Poison Data System from 2000 to 2020. Acad Emerg Med 2023; 30:1129-1137. [PMID: 37350748 DOI: 10.1111/acem.14769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/15/2023] [Accepted: 06/20/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND When ingested by children, small quantities of beta-adrenergic antagonists (BAA) are described as dangerous and even potentially lethal ("one pill can kill"). We characterize demographics, clinical characteristics, and the rate of serious outcomes among pediatric patients with reported BAA ingestions. METHODS This study was a retrospective review of U.S. patients <20 years old with reported single-agent BAA ingestions presenting to a health care facility between January 2000 and February 2020 for whom a poison control center was consulted. Data were abstracted from the National Poison Data System (NPDS). Medical outcomes were assessed by the NPDS scale of no effect, minor effect, moderate effect, major effect, and death. All relevant NPDS fatality narratives were reviewed. RESULTS A total of 35,436 reported exposures were identified. A total of 29,155 (82.3%) were <6 years old, of which 29,089 (99.8%) were unintentional. Twenty-five patients (<0.1%) <6 years old had major effects. A total of 2316 (8.8%) of patients with no/mild effects were admitted to a critical care unit. Of all cases, 1460 (4.1%) had hypotension and 1403 (4.0%) had bradycardia. One hundred nineteen (0.3%) developed hypoglycemia. The only four fatalities resulted from intentional ingestions in patients >10 years old who sustained cardiac arrest in the prehospital setting. CONCLUSIONS Reported BAA ingestions in this multiyear national pediatric cohort caused infrequent toxicity, and no fatalities resulted from an unintentional ingestion. The frequency of bradycardia, hypotension, and hypoglycemia were low. While severely poisoned patients require aggressive treatment, 8.8% of patients were admitted to a critical care unit despite having no or mild effects, which suggests an opportunity to reduce resource utilization.
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Affiliation(s)
- C James Watson
- Division of Medical Toxicology, Department of Emergency Medicine, Maine Medical Center, Portland, Maine, USA
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Michele M Burns
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Harvard Medical Toxicology Program, Boston Children's Hospital, Boston, Massachusetts, USA
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5
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Smith HL, Branick KA, Free ME, Naegle MS, Laageide LG, Misholy JT. Analysis of ingestion admissions in a midsized pediatric intensive care unit. J Public Health (Oxf) 2022; 44:918-925. [PMID: 34498075 DOI: 10.1093/pubmed/fdab339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 08/18/2021] [Accepted: 08/18/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Pediatric ingestion of toxic substances is a complicated cause of morbidity. Currently, there is limited literature on toxic ingestions resulting in pediatric intensive care unit (PICU) admissions. METHODS A retrospective study was conducted to quantify the number and financial costs of admissions for toxic ingestion. Secondary objectives were to determine common types of ingestions and interventions as well as examine the relationship between intentional ingestion status and patient age. Data were obtained from a retrospective review of records from April 2016 through August 2018 from a PICU located in the Midwestern USA. RESULTS There were 360 unique patient encounters used in primary analyses. Intentional ingestion and suicidal ideation documented in 72% and 54% of patients, respectively.Patients younger than nine had an 87% (95% confidence interval: 80%, 92%) lower risk for intentional ingestion. The median lengths of stay were 1.0 (interquartile range [IQR]: 1.0, 1.0) days with a median cost of $2498 (IQR: $1870, $3592) USD. There was no patient mortality identified in the sample. CONCLUSION The types of ingestions appeared to match those of the National Poison Control Database. Lengths of stay were short and had a non-nominal cost. A greater age was associated with an increased risk of intentional ingestions.
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Affiliation(s)
- Hayden L Smith
- Unitypoint Health, Des Moines, IA 50309, USA.,Iowa Methodist Internal Medicine Residency Program, Des Moines, IA 50309, USA.,Blank Children's Hospital Pediatric Residency Program, Des Moines, IA 50309, USA
| | - Kaitlin A Branick
- Iowa Methodist Internal Medicine Residency Program, Des Moines, IA 50309, USA
| | - Margaret E Free
- Blank Children's Hospital Pediatric Residency Program, Des Moines, IA 50309, USA
| | - Matthew S Naegle
- Blank Children's Hospital Pediatric Residency Program, Des Moines, IA 50309, USA
| | - Leah G Laageide
- Iowa Methodist Internal Medicine Residency Program, Des Moines, IA 50309, USA
| | - Justine T Misholy
- Blank Children's Hospital Pediatric Residency Program, Des Moines, IA 50309, USA
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6
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Balme K, Stephen C. Streamlining referral decisions for childhood poisoning: a cross-sectional study from a tertiary children's hospital in Cape Town, South Africa. Afr J Emerg Med 2022; 12:432-437. [PMID: 36348737 PMCID: PMC9634013 DOI: 10.1016/j.afjem.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 10/10/2022] [Accepted: 10/17/2022] [Indexed: 12/02/2022] Open
Abstract
Poisoning is one of the top five causes of childhood injury-related disease globally, but data in Africa are limited. Low socioeconomic status plays a role in the types of toxins to which children are exposed, some of which may cause significant morbidity and mortality. The far-reaching primary health care system relies on early assessment of all patients, to refer those requiring advanced medical care timeously. Detailed knowledge of age-groups, toxin groups and clinical outcomes of paediatric poisoned patients may allow streamlining of triage and referral systems, in order to optimise the use of limited resources and improve patient outcomes.
Introduction The study objectives were to report on current paediatric poisoning figures from South Africa, and to better understand this patient population to contribute suggestions for streamlining local triage and referral criteria. Methods A retrospective review of children presenting to Red Cross War Memorial Children's Hospital (RCWMCH) with poisoning between January 2009 and December 2019 was performed. Data were extracted from the Poisons Information Centre's Clinical Poisonings Database. Results There were 3699 incidents, involving 3662 patients; 3011 (81%) patients were under 5 years (median 29 months, IQR 19 to 49 months). There was a slight decline in numbers over the 11-year period. Most patients were referred (n = 2542, 69%), which included a greater proportion that were symptomatic (p < 0.001). There were 8 deaths (case fatality rate 0.2%). Medications were the most common single toxin group (n = 1270, 38%), followed by handyman and industrial (HI) products (n = 889, 27%), household products (n = 451, 14%), and pesticides (n = 445, 13%). There was a significant relationship between toxin type and referral patterns (p < 0.001) as well as clinical severity (p < 0.001): pesticides and HI products (paraffin, n = 486/568, 86%) had a greater proportion of referrals, and pesticides more moderate to fatal poisonings (n = 132/445, 30%), all due to cholinergic (organophosphates and carbamates) and formamidine pesticides. The medication subgroups anticonvulsants (n = 21/78, 27%), anti-infectives (n = 4/34, 12%), multi-vitamin/mineral (MVM) supplements (n = 17/84, 20%), neuropsychiatric medications (n = 50/350, 14%) and substances of abuse (n = 13/47, 28%) had larger proportions of moderate to severe poisonings (p < 0.001), as did the small group of biological toxins (n = 17/55, 31%; p < 0.001). Conclusion Certain medication, pesticide, and biological toxin subgroups, should be flagged for early referral. The goal is to improve patient outcomes as well as optimize the use of limited resources.
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Affiliation(s)
- Kate Balme
- Poisons Information Centre, Red Cross War Memorial Children's Hospital, Rondebosch, Western Cape, South Africa
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, South Africa
- Corresponding author at:
| | - Cindy Stephen
- Poisons Information Centre, Red Cross War Memorial Children's Hospital, Rondebosch, Western Cape, South Africa
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, South Africa
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7
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Modesto MMO, Carvalho de Lima PKG, Gavioli A, Hungaro AA, Modesto GDS, Zani AV, Marcon SS, De Oliveira MLF. Root cause qualitative analysis of acute childhood poisonings as a study of sentinel surveillance. REVISTA CIÊNCIAS EM SAÚDE 2022. [DOI: 10.21876/rcshci.v12i1.1183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Objective: To analyze the root cause of occurrences of severe intoxication in children and adolescents from the perspective of sentinel events. Methods: Observational, retrospective, and qualitative study of a series of cases of seven children and young people with a confirmed clinical picture of intoxication by various agents, treated in a stabilization room of emergency care units or intensive care, and notified to toxicological information and assistance center from January to June 2019. The epidemiological surveillance of sentinel events was used based on a review of hospital documents and in-depth interviews with family members. The Root Cause Analysis (RCA) matrix was used to evaluate the cases and the systematic reconstruction of the cases' antecedents.Results: The age profile of the study population, the pattern of agents and substances involved - poisoning by intentional ingestion in five (71%) cases, indicated critical points and missed opportunities for prevention. The individual and family history analysis indicated as direct causal factors the deviations from norms for preventing poisoning at home or in the family context for all cases.The prevention and health promotion activities in the health services constituted the underlying causes of the occurrences.Conclusion: The root cause analysis identified a deficiency in public policies, but the interface between education, public security, social assistance, economy, and health policies would be preponderant for preventing childhood and youth poisoning.
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8
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Li H, Dodd-Butera T, Beaman ML, Pritty MB, Heitritter TE, Clark RF. Trends in Childhood Poison Exposures and Fatalities: A Retrospective Secondary Data Analysis of the 2009-2019 U.S. National Poison Data System Annual Reports. Pediatr Rep 2021; 13:613-623. [PMID: 34842797 PMCID: PMC8628925 DOI: 10.3390/pediatric13040073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/06/2021] [Accepted: 11/10/2021] [Indexed: 11/28/2022] Open
Abstract
Despite significant prevention efforts, childhood poison exposures remain a serious public health challenge in the United States. This study aimed to assess annual trends of pharmaceutical vs. non-pharmaceutical poison exposures in the US among children 0-19 years and compare the odds of death by children's age group. Poison exposure and fatality data were retrospectively extracted from 2009 to 2019 National Poison Data System (NPDS) annual reports for children in all reported age groups. Overall, there was a significant reduction in the annual population-adjusted poison exposures in children (annual percentage change = -2.54%, 95% CI = -3.94% to -1.15%, p < 0.01), but not in poisoning-related fatalities. Children 0-5 had similar odds of dying from exposure to non-pharmaceuticals vs. pharmaceuticals. The odds of children 6-12 dying from non-pharmaceuticals vs. pharmaceuticals was 2.38 (95% CI = 1.58, 3.58), χ2 = 18.53, p < 0.001. In contrast, the odds of children 13-19 dying from pharmaceuticals vs. non-pharmaceuticals was 3.04 (95% CI = 2.51, 3.69), χ2 = 141.16, p < 0.001. Suicidal intent accounted for 40.63% of pharmaceutical deaths in children 6-12, as well as 48.66% of pharmaceutical and 31.15% of non-pharmaceutical deaths in children 13-19. While a significant decline in overall childhood poison exposures was reported, a decrease in poisoning-related fatalities was not observed. Children in different age groups had contrasting relative odds of death from pharmaceutical and non-pharmaceutical exposures. Among older children, a greater proportion of poisoning-related deaths was due to intentional suicide. These findings provide evidence of age-specific trends in childhood poison exposure risk and directions for future poison prevention efforts and behavioral health partnerships.
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Affiliation(s)
- Hong Li
- Biobehavioral and Health Research Center, Department of Doctoral Studies, School of Nursing, Azusa Pacific University, Monrovia, CA 91016, USA
| | - Teresa Dodd-Butera
- Biobehavioral and Health Research Center, Department of Public Health and Doctoral Studies, School of Nursing, Azusa Pacific University, San Diego, CA 92108, USA
| | - Margaret L Beaman
- Department of Nursing, California State University, San Bernardino, CA 92407, USA
| | | | - Thomas E Heitritter
- Pharmacy Informatics, Eisenhower Medical Center, Rancho Mirage, CA 92270, USA
| | - Richard F Clark
- California Poison Control System, San Diego, CA 92103, USA
- Department of Emergency Medicine, University of California San Diego Medical Center, San Diego, CA 92093, USA
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9
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Burns MM, Renny MH. Pediatric Poisoning Fatalities: Beyond Cough and Cold Medications. Pediatrics 2021; 148:peds.2021-052189. [PMID: 34607933 DOI: 10.1542/peds.2021-052189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/20/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Michele M Burns
- Harvard Medical Toxicology Fellowship, Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Madeline H Renny
- Departments of Population Health, Emergency Medicine, and Pediatrics, Grossman School of Medicine, New York University, New York, New York
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10
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Ko Y, Jeon W, Choi YJ, Yang H, Lee J. Impact of drug formulation on outcomes of pharmaceutical poisoning in children aged 7 years or younger: A retrospective observational study in South Korea. Medicine (Baltimore) 2021; 100:e27485. [PMID: 34622880 PMCID: PMC8500666 DOI: 10.1097/md.0000000000027485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/22/2021] [Indexed: 01/05/2023] Open
Abstract
Pharmaceutical poisoning in children is almost unintentional and there are various types of drug out of curiosity. Understanding the attractive features and formulation of drugs related to poisoning in younger children may be helpful in treatment and prevention of poisoning. To investigate the impact of drug formulation on outcomes of pharmaceutical poisoning in young children.We retrospectively reviewed the data of pharmaceutical exposures among children who were registered in a Korean 23-center, emergency department (ED) based registry from 2011 to 2016. Our study was conducted on preschool children aged 0 to 7 years. According to the formulation and category of the ingested drugs, the exposures were divided into the "tablet and capsule (TAC)" and "syrup" groups. In the TAC group, we additionally recorded data on the shape, color, and size of the drugs. The ED outcomes, such as hospitalization and length of stay, were compared between the 2 groups.Among the 970 enrolled exposures, 674 (69.5%) were classified into the TAC group. In this group, hormones/hormone antagonists (18.5%) were the most commonly ingested, followed by central nervous system drugs (17.1%). In the syrup group, antihistamines (28.4%) were the most commonly ingested, followed by respiratory drugs (24.3%). The TAC group showed a higher hospitalization and transfer rate to tertiary centers than the counterpart (TAC, 18.0% vs syrup, 11.5%, P = .03) without a significant difference in the length of stay (TAC, 173.5 minutes [interquartile range, 95.0-304.0] vs syrup, 152.5 [77.5-272.0]; P = .08). No in-hospital mortality occurred in the exposures. Round-shaped and chromatic TACs, accounting for 91.7% (618) and 56.1% (378), respectively, were more commonly ingested. The median size of the TACs was less than 1.0 cm.Young children who visited the ED ingested TACs more frequently than syrups, particularly small, round-shaped, or chromatic drugs, leading to a higher hospitalization rate. Our findings can contribute to prevention strategies and safety education on childhood drug poisoning.
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Affiliation(s)
- Yura Ko
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Woochan Jeon
- Department of Emergency Medicine, Inje University, Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Yoo Jin Choi
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Heewon Yang
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Jisook Lee
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Republic of Korea
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11
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Bishop-Freeman SC, Young KA, Aurelius MB, Hudson JS. Pediatric opioid fatalities: What can we learn for prevention? J Forensic Sci 2021; 66:1410-1419. [PMID: 33893645 DOI: 10.1111/1556-4029.14725] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/11/2021] [Accepted: 03/23/2021] [Indexed: 11/27/2022]
Abstract
The aim of this study was to highlight 19 cases investigated by the North Carolina Office of the Chief Medical Examiner over the last 12 years involving accidental or undetermined manner of death opioid ingestions leading to fatalities in young children. These pediatric ingestions have closely mirrored the opioid epidemic in adults transitioning from prescription medications to illicit drugs including fentanyl and fentanyl analogues. Unlike a typical adult ingestion for purposes of self-harm or pleasure, poisonings in toddlers and infants are usually the result of curiosity, exploration, a decreased sense of danger, or imitation of adult or older sibling behavior. Eleven of the decedents were between the ages of 8 and 24 months. Among the cases were 12 prescription opioid exposure deaths and 7 illicit drug poisonings. A majority of the decedents were found unresponsive in an unkept home and/or in unsafe sleeping spaces with easy access to drugs or drug materials, which stresses the importance of safe pediatric sleeping conditions. After a complete pathological investigation, several of the cases had physical or scene evidence demonstrating that foil, plastic, or paper small enough to be ingested can contain enough potent opioid to cause death. Details from the toxicological investigation are included for each case to provide postmortem whole blood drug concentrations for forensic practitioners. Accidental pediatric poisonings are preventable. Risk reduction through improving awareness and education of the dangers of opioids is a key factor in mitigating these tragedies.
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Affiliation(s)
- Sandra C Bishop-Freeman
- North Carolina Office of Chief Medical Examiner, Raleigh, NC, USA.,Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Kerry A Young
- North Carolina Office of Chief Medical Examiner, Raleigh, NC, USA
| | - Michelle B Aurelius
- North Carolina Office of Chief Medical Examiner, Raleigh, NC, USA.,Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Jason S Hudson
- North Carolina Office of Chief Medical Examiner, Raleigh, NC, USA
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12
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O'Donnell EP, Canares TL. Accidents Waiting to Happen: A Review of Unintentional Household Injuries in Children. Pediatr Rev 2021; 42:109-122. [PMID: 33648990 DOI: 10.1542/pir.2019-0169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Erin P O'Donnell
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Therese L Canares
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Lee JH, Lee DH. Acute chemical ingestion in the under 19 population in South Korea: A brief report. PLoS One 2020; 15:e0242430. [PMID: 33186400 PMCID: PMC7665788 DOI: 10.1371/journal.pone.0242430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/02/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Most people are frequently exposed to chemicals and chemical products. This study provides basic information on the outcomes of acute chemical ingestion of patients aged under 19 years. METHODS Patients aged under 19 years who had ingested chemicals and thus visited the emergency department between January 2011 and December 2016 were included in this study. RESULTS In all, 1,247 patients included (1,145 in the unintentional group and 102 in the intentional group). The mean age was 3.27±4.77 in the unintentional ingestion group and 16.49±1.94 in the intentional group. In the unintentional group, detergents were most frequently ingested (by 219 patients), followed by hypochlorite-based agents, ethanol, sodium hydroxide, acetone, silica gel, and citric acid. Cases of boric acid (odds ratio [OR] = 6.131), ethylene glycol (OR = 6.541), glacial acetic acid (OR = 7.644), other hydrocarbons (OR = 4.496), hypochlorite-based agent (OR = 2.627), nicotine (OR = 5.635), and sodium peroxocarbonate (OR = 6.783) ingestion was associated with a significantly high admission rate. In the intentional group, there were 54 cases of ingestion of hypochlorite-based agent, followed by detergent, ethylene glycol, ethanol, methanol and sodium peroxycarbonate. The significant risk factors for admission in the intentional group were ingestion of ethylene glycol (OR = 37.333) and hypochlorite-based agent (OR = 5.026). There was no mortality case. CONCLUSION The most commonly ingested substances were sodium hypochlorite (hypochlorite-related agent), surfactants (detergent and soap), and ethanol. The ingestion of hypochlorite or ethylene glycol was the main risk factor for admission. Intentional ingestion was higher in adolescents than in children.
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Affiliation(s)
- Jae Hee Lee
- Department of Emergency Medicine, Ewha Womans University, Seoul, South Korea
| | - Duk Hee Lee
- Department of Emergency Medicine, Ewha Womans University, Seoul, South Korea
- * E-mail:
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Le Roux G, Buisset A, Leruez S, Puskarczyk E, Gohier P, Descatha A. Agents Involved and Severity of Acute Ocular Exposure Reported at a Poison Control Center. Ophthalmic Epidemiol 2020; 27:468-476. [PMID: 32500787 DOI: 10.1080/09286586.2020.1773871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE The aim was to identify severity factors useful in the initial management of patients with acute ocular exposure while considering both categories of products involved and circumstances of exposure. METHODS A retrospective study over a one-year period that included patients who benefited from the poison center services for eye exposure to a chemical substance. RESULTS Within a year, 1582 patients were identified. The sex ratio (M/F) was 0.8. The mean age was 28.5 ± 20.3 years. Among children, those under 4 years represented the most significant age category (n = 277; 50.1%). Exposure to chemicals were mild (n = 1342, 84.8%). Adults over 65 years appeared to be more likely to have severe ocular damage (OR: 4.75; [2.26; 9.98]). Unintentional exposures were the most frequent (n = 1548; 97.8%). Ocular exposure primarily occurred at home (n = 937; 59.2%), and at the workplace (n = 396; 25%) which was associated with a higher risk of severe injury (OR: 2.93 [2.16; 3.97]). Cleaning products accounted for 31.2% of exposure cases (n = 457). Exposure to disinfectants is a risk factor of more severe injuries (OR: 1.48 [1.002; 2.19] p = .0472) whereas pH and severity of injuries were not statistically significant. CONCLUSIONS Our study showed the very wide variety of products involved in ocular exposures. Clinicians should pay attention to factors associated with severe injury, including young and old age, work-related injury, substances such as disinfectants, in addition to previously known factors such as acids and bases.
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Affiliation(s)
- Gaël Le Roux
- Grand Ouest Poison Control and Toxicovigilance Center, University Hospital , Angers, France
| | - Adrien Buisset
- Ophthalmology Department, University Hospital , Angers, France
| | | | - Emmanuel Puskarczyk
- Est Poison Control and Toxicovigilance Center, French National Database of Products and Compositions, University Hospital , Nancy, France
| | - Philippe Gohier
- Ophthalmology Department, University Hospital , Angers, France
| | - Alexis Descatha
- Grand Ouest Poison Control and Toxicovigilance Center, University Hospital , Angers, France.,Irset (Institut De Recherche En Santé, Environnement Et Travail) - UMR_S1085, University Angers, CHU Angers, University Rennes, Inserm, EHESP , Angers, France
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15
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Carbamazepine Toxicity Masquerading as Complex Febrile Seizures in a Pediatric Patient. Case Rep Emerg Med 2020; 2020:1790310. [PMID: 32257458 PMCID: PMC7102487 DOI: 10.1155/2020/1790310] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 02/25/2020] [Indexed: 11/23/2022] Open
Abstract
Carbamazepine is an antiepileptic drug that can cause seizures in overdose. In certain patient populations, this may be misdiagnosed as a seizure disorder. We describe a case of a 20-month-old female who presented with fever and seizure-like activity who was initially thought to have complex febrile seizures. Further historical information prompted carbamazepine level to be checked, which was found to be 29 mcg/ml (therapeutic range of 4–12 mcg/ml). Her carbamazepine levels downtrended with multidose activated charcoal. Her condition improved, and she was discharged without evidence of permanent neurologic sequelae. This case illustrates that xenobiotic exposure should often be considered, even if historical clues are not present, as they can often present as other conditions leading to misdiagnosis and delayed treatment.
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Dorney K, Dodington JM, Rees CA, Farrell CA, Hanson HR, Lyons TW, Lee LK. Preventing injuries must be a priority to prevent disease in the twenty-first century. Pediatr Res 2020; 87:282-292. [PMID: 31466080 DOI: 10.1038/s41390-019-0549-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 08/03/2019] [Accepted: 08/13/2019] [Indexed: 02/08/2023]
Abstract
Injuries continue to be the leading cause of morbidity and mortality for children, adolescents, and young adults aged 1-24 years in industrialized countries in the twenty-first century. In this age group, injuries cause more fatalities than all other causes combined in the United States (U.S.). Importantly, many of these injuries are preventable. Annually in the U.S. there are >9 million emergency department visits for injuries and >16,000 deaths in children and adolescents aged 0-19 years. Among injury mechanisms, motor vehicle crashes, firearm suicide, and firearm homicide remain the leading mechanisms of injury-related death. More recently, poisoning has become a rapidly rising cause of both intentional and unintentional death in teenagers and young adults aged 15-24 years. For young children aged 1-5 years, water submersion injuries are the leading cause of death. Sports and home-related injuries are important mechanisms of nonfatal injuries. Preventing injuries, which potentially cause lifelong morbidity, as well as preventing injury deaths, must be a priority. A multi-pronged approach using legislation, advancing safety technology, improving the built environment, anticipatory guidance by clinical providers, and education of caregivers will be necessary to decrease and prevent injuries in the twenty-first century.
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Affiliation(s)
- Kate Dorney
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - James M Dodington
- Department of Pediatrics, Yale-New Haven Hospital, New Haven, CT, USA
| | - Chris A Rees
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Caitlin A Farrell
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Holly R Hanson
- Division of Pediatric Emergency Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Todd W Lyons
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Lois K Lee
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA.
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17
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Kazanasmaz H, Kazanasmaz Ö, Çalık M. Epidemiological and sociocultural assessment of childhood poisonings. Turk J Emerg Med 2019; 19:127-131. [PMID: 31687610 PMCID: PMC6819726 DOI: 10.1016/j.tjem.2019.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 06/17/2019] [Accepted: 06/17/2019] [Indexed: 12/01/2022] Open
Abstract
Objectives Poisoning occurring in childhood still continues to be an important public health issue. The aim of the study is to socio-demographically and clinically examine poisoning cases consulted to emergency department. Methods The findings of 121 patients between the ages of 1 month and 17 years consulting to the pediatric emergency department with the suspicion of poisoning were examined retrospectively in the study. Results The mean age of the patients was 6.60 ± 5.70 (min-max: 0–17) years and 49.6% of the patients were male and 50.4% were female. The most common causes of poisoning were corrosive chemicals in 35 patients (28.9%), poisonous animals in 24 patient's (19.8%) and prescription medications in 24 patients (19.8%). While 103 (85.1%) of the cases were exposed to the factor accidently, 18 of the cases (14.9%) had attempted suicide. The mean monthly family income levels of accidently poisoned cases were significantly higher than those who attempted suicide (p < 0.001). The father's education level was lower in cases who were poisoned by suicide attempt than in those who were accidently poisoned (p < 0.001). Conclusion Poisoning rates in childhood and varieties of factors differentiate among the regions. The rate of poisoning cases due to poisonous animals was found to be quite high in the region where this study was carried out. In addition, the study showed that poisoning rates due to suicide attempt in children of families with low income level and/or father's education level have increased.
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Affiliation(s)
- Halil Kazanasmaz
- Harran University Faculty of Medicine, Department of Pediatrics, Sanliurfa, Turkey
| | - Özlem Kazanasmaz
- Harran University Faculty of Medicine, Department of Pediatrics, Sanliurfa, Turkey
| | - Mustafa Çalık
- Harran University Faculty of Medicine, Department of Pediatric Neurology, Sanliurfa, Turkey
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