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.
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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.
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.
For labs, order tests for toxidromes that you wouldn’t be able to pick up on an exam.
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 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.
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.
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.
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:
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.
There are also physiologic differences between children and adults that have an impact on poisonings.
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.
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).
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.
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.
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.
Tips for prevention!
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
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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.
After listening to this episode listeners will…
Dr Calello reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures.
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.
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