#29: Tox Rocks! An Overview of Pediatric Toxic Ingestions with Dr. Diane Calello

July 14, 2021 | By Sam Masur

Summary

Think you may need to call Poison Control? Get right to it! Then listen to this incredible overview of Pediatric Toxic Ingestions with Pediatrician, Medical Toxicologist, and the Executive and Medical Director of the New Jersey Poison Center Dr. Diane Calello. Dr. Calello teaches us about the initial approach to treating pediatric poisonings, when to call Poison Control (anytime!!), the bimodal epidemiology of toxic ingestions, and all about decontamination and prevention.

Credits

• Written and Produced by: Becca Raymond-Kolker MD
• Infographic: Becca Raymond-Kolker MD
• Cover Art: Chris Chiu MD
• Hosts: Chris Chiu MD; Justin Berk MD
• Editor: Justin Berk MD; Clair Morgan of nodderly.com
• Guest(s): Diane Calello, MD

Pediatric Poisoning Pearls

1. Over half of all poisonings called into Poison Centers are children–with the majority of exposures in children under the age of 6 years old. 
2. In an undifferentiated ingestion–always start with your ABCDEs. Airway, Breathing, Circulation, Dextrose and Decontamination, and Exposures
3. Call the Poison Control Center early and often! They are available 24/7 and are happy to support any parent, individual, or clinician. Call: (800) 222-1222. 
4. Children may respond to certain toxins or medications differently than adults! Be aware of the specific dangers that children face
5. If any exposure may not be reversible or fixable with available treatments, this is when you should consider immediate decontamination. 
6. Half-life is not for toxicologists. Half-life is measured in therapeutic conditions, and it’s based on things like the function of enzymes (which get overwhelmed in overdose) or ability of the kidney to excrete it. For these  reasons, knowing the half-life of a drug doesn’t help guide management in an overdose.

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Toxic Ingestion Show Notes 

Epidemiology of Poison Exposures

Dr. Calello shares that over half of all the poisonings called into Poison Centers are kids (under 19 years of age). The majority of those are children under the age of 6. The first toxicologists were pediatricians, and many of the first poison centers were started by pediatricians. In terms of epidemiology, the majority of pediatric poisoning cases are the young 0-6 year olds who are the  “Exploratory Ones”: these are  the kids who get into something that they don’t intend to harm themselves with but haven’t yet acquired the common sense not to ingest it. Then there is a valley from 6-10 years of age where there are fewer cases. Then cases rise again in the teenage years which are more often substance use or suicidal intent which leads to poisoning.

Approach to an Undifferentiated Ingestion

Always start with your ABCDEs! D stands for Dextrose and Decontamination. You’ll never go wrong if you start with the basics. In terms of gathering a history, think of what time of day it is;  if it’s a kid who didn’t wake up in the morning, they might have been exposed the night before; if the kid was last seen well about 30 minutes ago, this was a more recent exposure. Ask what medications are in the house and what health conditions other members of the household have (high blood pressure, diabetes). If the patient was found near pills or have residue on their mouth, these can be helpful clues (you can call the Poison Center to help look up a pill imprint). If anyone else in the house was affected, this suggests an environmental exposure (e.g. carbon monoxide) or siblings who got into a common toxicant. Make sure to ask when the kid last looked okay and ask if something like this has ever happened before (sometimes, inborn errors of metabolism can masquerade as toxic ingestion presentations). Ask in a nonjudgmental and private way, if anyone who lives in the house uses substances. Children who live in homes where there is a substance use disorder are at much greater risk of high mortality from poisoning. 

Labs

For labs, order tests for toxidromes that you wouldn’t be able to pick up on an exam. 

• You can get a urine drug screen (sometimes it is ordered because it just makes us feel better or sometimes it can be helpful in an undifferentiated ingestion), however many substances you can tell by physical exam. 
• You cannot tell if a child is acidotic by exam, and so a Venous Blood Gas (VBG) is helpful to assess pH (no need to do an arterial stick). 
• Electrolytes are helpful. You must always get a glucose- as many ingestions can cause low blood sugar and hypoglycemia can present as anything from an obtunded child to a focal neurologic deficit. 
• An ethanol level is easy to get as well. We get in the habit of ordering an acetaminophen and aspirin level, however the likelihood of occult acetaminophen or salicylate poisoning without some history is less likely. 

Vaping liquid

For nicotine poisoning, the best test is the clinical exam. Look for muscle fasciculations, GI symptoms, seizures. A nicotine level or a cotinine is not helpful for the short term. Vaping liquid can contain THC (tetrahydrocannabinol). Vaping associated lung injury (EVALI) is still occurring, and is seemingly linked with mostly THC-containing vapes.

When to Call the Poison Center

When shouldn’t you call the Poison Center?! Call as often and as soon as you need! Many times the Poison Center is already aware of patients seeking medical care, as parents/caregivers may have called first from home.  Unlike other consultants where you may call for a specific question after a thorough workup, the Poison Center is very happy to have the provider call as cases are evolving, and walk the team through the workup and management of patients who are presenting with a concern for ingestion. 

What are Poison Centers? Who works there?

There are 55 Poison Centers across the USA. People on the other end of the phone are nurses, pharmacists, physicians, nurse practitioners, and physician assistants’ who undergo specific training in poisoning and become certified Specialists in Poison Information (SPIs).  Some centers are remote, some are in person. Poison Centers operated 24/7, 365 days a year, with a  relatively small staff (10-15). In addition to specialized training and expertise, SPIs have access to certain databases like  Micromedex to figure out how much of a given exposure is too much and to Material and Safety Data Sheets (MSDS) to determine contents of non-food products. Behind every SPI is a toxicologist for further support in complicated cases. There is a National Poison Center Hotline at 1- 800-222-1222 which will route callers to the Poison Center you are closest to (or area code you are calling from). Many Poison Centers also have chat and text capability. 

Common Ingestions

For young kids, most common calls to the Poison Center are for soap and other household items (cosmetics, cleaning products). Silica gel packs and glow sticks are responsible for a ton of calls and both are non-toxic.  The preponderance of calls are non-toxic ingestions. For teenagers and adults, the most common ingestions are analgesics (acetaminophen, ibuprofen, and then opioids). The frequency of analgesic ingestions follows availability, and since acetaminophen is present in so many households, this is the most common. 

Physical Exam and Toxidromes

Think of the big categories of toxidromes: Cholinergic, Anticholinergic, Opioid, Sedative Hypnotics, and Pathomimetics. To start, ask yourself, “are they up or are they down?” Are they sedated? Think opioids and sedative hypnotics, and cholinergics (eg pesticides with which you will also see bradycardia and bronchorrhea). Are they revved up? Think amphetamine exposure (high blood pressure, fast heart rate) or jimson weed (dry, flushed, with huge pupils). So start by thinking, are they up or down? And then look at pupils, skin moisture, vital signs, and then pattern recognition of other findings. 

Other physical exam findings that do not fit easily into toxidromes include:

•  Hyperthermia (drug induced hyperthermia): can be secondary to stimulants, serotonin syndrome, neuroleptic malignant syndrome, weight loss supplements.
• Cyanosis: hypoxia, dyshemoglobinemia (such as methemoglobinemia)
• Appearance of skin, nails, teeth can be suggestive of more chronic exposures such as lead

Pediatric Population Considerations

There are a few medications that kids react to differently than adults; this is because the kinetics of some drugs are different in pediatric patients than adult patients. 

• Buprenorphine in adults has a “ceiling effect” such that it does not cause respiratory depression until they have very high doses. In kids, they do not have the p-glycoprotein efflux of buprenorphine out of their CNS and so they get sleepy very quickly. When compared with morphine, pediatric patients can have more respiratory depression from buprenorphine. 
• Dextromethorphan (cough syrups) may cause sedation and hallucinations in adults but  should not be used in children under 2 years old. Expert opinion: This is thought to be because in young children, dextromethorphan might be converted into levorphanol which is an opioid. You might see this as a kid who has overdosed on dextromethorphan coming in with pinpoint pupils and not breathing–they can be reversed with naloxone.

There are also physiologic differences between children and adults that have an impact on poisonings. 

• For example, children have a higher minute ventilation so they are more vulnerable to airborne toxins such as carbon monoxide because they just take in more airborne gas.
• It also means that when they have an overdose on salicylates–which requires them to hyperventilate to stay at a neutral pH–kids can’t do it quite as well. So in an adult, we might think of salicylate poisoning causing respiratory alkalosis metabolic acidosis, in young children you might not have that respiratory alkalosis at all and they may just come in acidotic because they can’t keep up the respiratory rate. 

All About Decontamination 

If any exposure may not be reversible or fixable with available treatments, this is when you should consider immediate decontamination. An example exposure is bupropion, a common antidepressant, which is hard to treat in overdose–and so for this overdose you should think of giving activated charcoal or maybe whole bowel irrigation because it is a sustained release preparation. 

Gastric lavage may be appropriate if you: a)  have a patient who just took an overdose b) that could be fatal and c) you have a large bohr tube handy. Gastric lavage fails because it is often hard to find the tube. 

Therefore, it’s usually more efficient to give activated charcoal or passing an NG tube to give whole bowel irrigation (rapid installation of polyethylene glycol to try to flush the drug through, mostly utilized for sustained release preps). Activated charcoal can be used in awake and cooperative patients (must be unlikely to be unconscious soon, and be cautious of aspiration risk) or in intubated patients (because they have a protected airway). The primary risk of activated charcoal is aspiration. Activated charcoal is just charcoal with increased molecular surface area. 

Expert opinion: In a pinch, if you have ingested a toxic exposure in the wilderness (don’t eat the foxglove!), ground up charcoal from a grill would likely work similarly to activated charcoal. 

Ipecac: No longer recommended by the AAP. The rationale for withdrawing support for the use of ipecac is that it can be dangerous to make someone vomit without medical advice/guidance. For example: an agent that is caustic would cause twice as much damage if it is regurgitated. Ipecac can also be misused for weight loss and in excess, can cause cardiomyopathy.

Difficult to Treat Ingestions

• Because acetaminophen now comes in massive bottles, regular N-acetylcysteine (NAC) is not going to be enough for patients that take massive amounts of acetaminophen, and those patients may fail NAC treatment even if it’s given on time. For massive acetaminophen overdoses, the NAC infusion rate may need to be doubled or tripled, and patients may need to be dialyzed. There is also some discussion of using fomepizole in these patients which blocks some portion of acetaminophen metabolism and causes cellular repair. 
• Bupropion is, as discussed, also very hard to treat and can cause status epilepticus and wide-complex dysrhythmias. 
• Salicylate overdose is also very complicated to treat and can cause tinnitus, AKI, and pH must be maintained in a narrow range; there is also delayed absorption which can complicate the timeline of overdose. 
• Button batteries, hydrocarbons (thin petroleum distillates), and caustics are also all non-pharmacologic but very potentially destructive pediatric ingestions. 

How long do we monitor?

The asymptomatic child is the one where we need to decide how long to monitor. Once a kid develops symptoms, you need to monitor them until they are improved. The period for asymptomatic monitoring depends on the ingested substance (Ex: for asymptomatic bupropion ingestions, would need to monitor for 24 hours; for asymptomatic acetaminophen ingestion with no transaminitis and acetaminophen level is 0, would need to monitor for 24-36 hours).  

The Half-life Myth: Clinical Pearl

Half-life is not for toxicologists. Half life is a therapeutic parameter. The half-life is measured in therapeutic conditions, and it’s based on things like the function of enzymes which get overwhelmed in overdose or ability of the kidney to excrete it, which again, gets overwhelmed in overdose. For example, the half-life of a drug might be 6 hours but in an overdose, it might be 46 hours. Expert Opinion: For this reason, knowing the half-life of a drug doesn’t help guide management in the clinical setting of an overdose.

The Teenage Ingestion

A 16 year-old is more likely to have knowingly done something –which could be anything from a suicidal ingestion, drug use, or exploratory behavior. These ingestions are different from the ingestions of younger patients. Get an alcohol level and do a careful physical exam –including looking in patients’ pockets. Teenagers are more likely to take a higher dose of toxins. One protective aspect of ingestions in younger patients is that they usually ingest a smaller quantity of a toxin–this is not true of adolescents. Your level of concern with adolescent ingestions should be high. 

The dose is the poison. The poison control center has information on what dose is concerning for all different kinds of ingestions. The vast majority of medications that are double-dosed accidentally are not that dangerous, unless they are drugs with a very narrow therapeutic index. 

Cannabis Ingestions

For young kids, the cannabis ingestions are usually poisoning from cannabis edibles (packaged candy or home-made foods like brownies). Oils can also be a hazard for kids. There are a lot of cannabis candy look-alikes which is a set up for accidental pediatric ingestions. This is an increasing exposure: there has been a 600% increase in edible cannabis exposures at the New Jersey Poison Control Center since 2018. 

New trends in Toxicology

• Modified NAC dosing for acetaminophen. 
• Fomepizole (previously used for toxic alcohols) can also be used for massive acetaminophen ingestions. 
• There is a resurgence of physostigmine which is a pretty effective antidote for anticholinergic delirium. 
• There are  some new snake antivenoms which have emerged. 
• Toxicologists have modified treatment for cyanide poisoning using hydroxocobalamin which is a change from the age-old cyanide poisoning kit. 
• The use of methylene blue for shock. 

Ingestion Prevention

Tips for prevention! 

• There is no such thing as child-proof. Children should never be left alone for any extended period of time with something “child-proof” as given time, kids can usually figure out how to open bottles and containers. Keep things up and away and out of sight. 
• For teenagers, prevention is harder. It requires talking about drug use and abuse, talking about suicidal prevention, and keeping the lines of conversation open. For teens at risk of these behaviors, lock up high risk medications. 

Disparities in Toxic Ingestions 

Kids who live in high poverty areas, particularly children of color, are overrepresented in poisoning fatalities. Additionally, children living in homes where there is drug manufacturing, distribution or use are also at higher risk of ingestions as well as greater stigma in seeking care. Pediatric environmental lead poisoning is also a huge disparity issue due to older, dilapidated housing. The COVID19 pandemic has exacerbated lead poisoning for multifactorial reasons including: more children have been staying home, children have had less access to routine lead testing, delays in lead remediation, and shortages of chelation agents. Areas for potential improvement is making sure to do routine lead screens on all pediatric patients and providing family and patient education around preventing dangerous ingestions

Key Takeaways 

1. Call the Poison Center, Call the Poison Center, Call the Poison Center!
2. Don’t forget the basics –ABCDEs are always first.
3. Prevention is always better than treatment.

Links*

1. Libby App: Free access to ebooks and audiobooks from your local public library
2. Toxicology in a Box Cards
3. Transcendent Kingdom by Yaa Gyasi
4. The Tox and Hound Blog, especially Dr. Calello’s post on Small Poisoned Humans
5. Calello DP, Henretig FM. Pediatric toxicology: specialized approach to the poisoned child. Emerg Med Clin North Am. 2014 Feb;32(1):29-52. doi: 10.1016/j.emc.2013.09.008. Epub 2013 Nov 7. PMID: 24275168.

*The Cribsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on our Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.

Goal

Listeners will develop a clinical approach to evaluating and managing the undifferentiated pediatric toxic ingestions, incorporating the value of collaboration with Poison Control Centers, the role of decontamination and the importance of prevention in pediatric poisonings. 

Learning objectives

After listening to this episode listeners will…  

1. Develop a clinical approach to evaluating and managing the undifferentiated pediatric toxic ingestion. 
2. Describe the bimodal epidemiology of pediatric poisonings and their unique features
3. Recognize the importance of Poison Control Centers as resources for both clinicians and families in the community 
4. Describe the role of decontamination in an acute pediatric ingestion
5. Learn about certain pediatric differences in toxidromes and responses to specific toxins
6. Debunk the half life myth! Takeaway: Half life is not relevant in an overdose setting
7. Develop an understanding of the disparities in pediatric poisonings and opportunities for improvement

Disclosures

Dr Calello reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Raymond-Kolker R, Calello D, Lee N, Masur S, Chiu C, Berk J. “Tox Rocks! An Overview of Pediatric Toxic Ingestions with Dr. Diane Calello”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ July 14, 2021.