Advocacy Morning Report:

Unintentional Pediatric Ingestions

Laura Williams, MD MPH PGY-1 20 July 2012

Once upon a time on night float

2 y.o. boy w mild intermittent asthma presents w acute onset AMS, difficult to awake from nap, increasingly lethargic

Clinical Case
Outside Hospital ED/PCMC ED: difficult to arouse even w sternal rub hypoxic to 40s, BP/HR nml CBC/CMP WNL serum/UDS negative head CT, CXR, EKG nml

Clinical Case
PMH/PSH:
32 wk dizygotic twin mild intermittent asthma dx 4 mo ago, has been asymptomatic

Imm: UTD Meds: singulair, flovent, albuterol PRN All: eggs Soc Hx: twin brother, 5 yo sister, both parents were home that day, grandparents in town Tox:

metformin, warfarin, prozac, trazadone, xanax, glyburide, labetolol, left-over narcotics, vitamins, OTCsall kept in high cupboard cleaners/solventsall kept behind childproof door and on top of fridge

Clinical Case
What was the culprit? Grandmas Ambien

Poison Control Center

50 centers nationwide 1.5 million calls annually for pediatric poisonings
90% of calls can be managed at homehelps to eliminate unnecessary ED visits most frequent calls are about cleaning product and analgesic exposures used more by higher SES families

Call for plant, insect, and snake exposures as well Important to note which database the information is coming from

Utah Poison Control Center

UPCC, Annual Report, 2011.

Utah Poison Control Center

Age Distribution

Top Exposures in Children <6 yo

UPCC, Annual Report, 2011.

Epidemiology of Poisoning
>500,000 exposures in children under 5 yo annually 824 deaths in 2009

CDC, 2012. http://www.cdc.gov/ vitalsigns/ChildInjury/ index.html

Epidemiology of Poisoning
>50,000 ED visits annually
28% increase from 2001 to 2008 60% increase in direct presentation to ED without calling the poison center first generates more annual visits than for motor vehicle occupant injuries

Most implicated exposures leading to admission and harm are:

oral hypoglycemics opioids sedative-hypnotics cardiovascular meds

Why the increase in exposures?

Increase in the avg number of meds taken by adults Difficult to poison-proof a home
inconvenient for adults to lock away all harmful substances self-generated behavior leads to successful performance 90% of the time guests in the home/children visiting other adults

Imitating is part of development

Piaget observed that complicated imitative behaviors begin around 18-24 mo increase in oral drug exposures instead of non-oral drug exposures occurs at 20-30 mo

Imitative Behavior
Probability of an oral drug ingestion poisoning, given that an ingestion poisoning has occurred, for girls, 20045.

Rodgers G B et al. Inj Prev 2012;18:103-108

What can we do?

3 Es of injury prevention Educational initiatives
educating families educating the general public

Engineering modifications
child-resistant closures child-proof doors bittering agents

Enforcement actions

Education: One Pill can Kill

An average toddler weighs 10kg Using the lowest described or estimated lethal dose:
TCAS amitriptyline imipramine desipramine Antipsychotics loxapine thioridazine chlorpromazine Antimalarials chloroquine hydroxychloroquine quinine Anti-arrhythmics quinidine disopyramide procainamide flecainide Ca channel blockers nifedipine verapamil diltiazem Theophylline Narcotics codeine hydrocodone methadone morphine Oral hypoglycemics chlorpropamide glibenclamide glipizide Methyl salicylate Podophylline 25% Camphor

Education
Global problemnot just a pediatricians job! Grandparents
involved in 10-20% of exposures keep medications in childresistant containers only 45% of the time

Educating parents
Dont
take meds in front of children let children see where you keep medicines refer to medicine as candy assume your children cant access high cabinets leave pills in unlabeled containers assume pill bottles are child-proof

Do
Call the poison center!

Engineering Modifications
Child-resistant closures introduced in 1950s studies in late 1960s showed their efficacy Poison Prevention Packaging Act passed in 1970
have reduced poisoning rates by 40% test protocol requires that 80% of children <5 are unable to open package

Child Resistant Closures

Issues
up to 20% of children under 5 can still get into them theres still access to the whole bottle of medication once the cap is off doesnt apply to all medications

Improvements
largest potential benefit in reducing exposures should limit the amount of medication dispensed flow restriction or one-at-a-time tablet dispensers

References
Bar-Oz B, Levichek Z, Koren G. Medications that can be fatal for a toddler with one tablet or teaspoonful. Pediatr Drugs 2004; 6: 123-126. Bond GR, Woodward RW, Ho M. The growing impact of pediatric pharmaceutical poisoning. J Pediatr 2011; 160: 265-270. Braydon RM, MacLean WE, Bonfigli JF, Altemeier W. Behavioral antecedents of pediatric poisonings. Clin Pediatr 1993; 32: 30-35. Budnitz DS & Lovegrove MC. The last mile: Taking the final steps in preventing pediatric pharmaceutical poisonings. J Pediatr 2011; 160: 190-192. Finkelstein Y, Hutson JR, Wax PM, Brent J. Toxico-surveillance of infant and toddler poisonings in the United States. J Med Toxicol 2012. DOI 10.1007/s13181-0120227-1. Franklin RL, Rodgers GB. Unintentional child poisonings treated in United States hospital emergency departments: National estimates of incident cases, population-based poisoning rates, and product involvement. Pediatrics 2008; 122: 1244-1251. Rodgers GB, Franklin RL, Midgett JD. Unintentional paediatric ingestion poisonings and the role of imitative behaviour. Injury Prevention 2011; 18: 103-108. Utah Poison Control Center. 2011 Annual Report. http://uuhsc.utah.edu/poison/about/reports/2011.pdf Vilke GM, Douglas DJ, Shipp H, et al. Pediatric poisonings in children younger than five years responded to by paramedics. J Emergency Med 2011; 41: 265-269.