A Call For Help
Monday June 28, 2004
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Most people would finish that statement with "Superman." But many parents believe a more appropriate response is "Superchild." Toddlers quickly learn problem-solving skills, including how to reach high places or pry open "childproof" cabinet locks and medication caps. Active youngsters can figure out how to get to the bottle of cleanser on the kitchen shelf or a pill vial in the bathroom cabinet before Mom can say, "Where is Clark Kent?"
About 53% of all poison exposure cases involve children under 6.1 Sandra Sheen, RN, BSN, CSPI, a poison information specialist at the Poison Control Center at The Children's Hospital of Philadelphia, estimates that the center receives more than 75,000 calls each year. Most calls to poison control centers occur between 4 PM and 10 PM; in fact, these peak hours are so busy that some poison centers call this time of day "the arsenic hour."2
"We also get a concentration of calls after children are put to bed," Sheen says, "when parents may find them in the bathroom with pills or cough [syrup] on the floor."
Common Culprits
More than 90% of all poison exposures occur in homes.2 Wilma Pomerantz, RN, BSN, MA, CSPI, specialist in poison information for the New Jersey Poison and Information Center at the University of Medicine and Dentistry in Newark, N.J., says the five most common poisonings that she receives calls about result from ingestion of bleach and other cleaning supplies, plants, magic markers and crayons, diaper preparations, and flavored medications. "Toddlers often eat crayons," Pomerantz says, "but the real danger lies mainly in off-brand crayons ... because they may contain lead." Parents should look for the word "nontoxic" on crayon labels.
Many parents view over-the-counter preparations as less dangerous than prescription medications. This is not always true, says Pomerantz. For example, prenatal vitamins can be harmful to children if swallowed, depending on the amount of iron in the tablet, she says.
Help Is a Phone Call Away
When parents call a poison control center, they often fear the worst outcome. "Our first rule is to calm the caller," says Sheen, "because we must be able to rely on them to get accurate information." One of the challenges for poison information specialists is doing an assessment without seeing the patient. This underscores the need to ask the right questions, Sheen says.
For example, if a parent calls to say a 2-year-old ingested acetaminophen, "We need to know the child's weight and the type and amount the child may have swallowed," Sheen says. "We ask the parent to count what's left [in the bottle] and whether they can recall the amount left in the bottle before the ingestion. If the parent is unsure how many [pills] have been taken, we treat the child as if whatever is missing may have been taken."
Traditionally, syrup of ipecac has been the treatment to remove some of a poisonous substance from a child's system. But in 2003, the American Academy of Pediatrics (AAP) reversed its policy regarding the use of ipecac, questioning its efficacy. The AAP also expressed concern that ipecac might be abused by individuals with eating disorders or, on rare occasions, by adults with Munchausen syndrome by proxy, a disorder in which they intentionally make a child ill to gain attention.2
Despite this change in the AAP policy, most poison centers still recommend that families keep syrup of ipecac on hand. But Pomerantz stresses that parents should always call the poison center before initiating any treatment.
This is particularly important for parents to adhere to when children ingest household products that have antidote instructions listed on the labels, Sheen says. "These suggestions often create more damage," she warns. She cites the example of a drainpipe-unclogging agent that contains a caustic substance like lye: "If a child swallows lye, we don't want him to vomit. But if you follow the instructions on the box, they often suggest using vinegar and water or raw egg whites to inactivate the lye. These antidotes, however, will almost always induce vomiting."
EDs See Share of Kid Poisoning
Debra Westcott, RN, MSN, CRNP, staff nurse at the Abington Memorial Hospital in Abington, Pa., says distraught parents often bring children who have ingested toxins directly to the ED. "Parents should call the poison center first," Westcott says, "because the poison center may suggest some treatment that the parent can start, or avert the wrong treatment." Statistics estimate that about 77% of exposures to toxins can be treated via phone guidance from the poison center, thus not requiring an ED visit.3
Each week, Abington Memorial's ED sees 10 to 12 cases of pediatric poisoning, Westcott says. "That number can vary, and we do see more on holidays," she says.
"Although acetaminophen is the most prominent accidental poisoning that we see in young children, we also see children who have ingested cosmetics, gasoline, rat poison, pesticides, and household cleaners," she says. Because rat poison has a vile taste, children generally swallow only a small quantity. Still, this can put a 2-year-old at risk. "These products contain Coumadin [warfarin]," says Westcott. "So if we suspect a child has swallowed rat poison, we do prothrombin times and observe the child for any side effects."
Many parents are surprised by poisonings caused by herbal remedies, including teas, Westcott says. "Although ephedra has been taken off the market, some herbal teas have ephedralike qualities," she says. "Some can have profound effects, causing hallucinations or tachycardia."
Many adults do not consider herbal remedies to be medicine, Westcott says. "We still don't know a lot about herbal preparations, so we should keep all of them out of the reach of children."
The long-term effect of childhood poisoning depends on what and how much the child swallows. "An overdose of acetaminophen can have a long-term effect, for example, because it is very hepatotoxic," says Westcott, "and can possibly require a transplant or even cause death."
Activated charcoal is the antidote of choice when a toxic drug like acetaminophen is ingested. Although Westcott describes the black liquid as "smooth, with a nonsweet licorice taste," some small children still refuse to take it. In those instances, the charcoal is administered via nasogastric tube. "We also do an acetominophen level," she says, "and Mucomyst [acelylcysteine] is given every four hours for 17 doses if the level is toxic."
Prescription drugs commonly used by older adults, such as antihypertensives, cardiac drugs, and oral hypoglycemics, are another cause for concern. "Kids find those daily pill-reminder boxes, with all the little spaces, fascinating," says Pomerantz. "Especially dangerous are the oral hypoglycemics because even a small amount can lower the blood sugar dramatically in a child. And since glucose is needed to feed the brain, a child can lapse into a coma from which he or she may never recover." When a child is found playing with these types of pills and there is uncertainty as to whether any were swallowed, Pomerantz advises taking the child immediately to the ED.
An Ounce of Prevention
Although the most effective preventive tool is constant vigilance, it is important to be prepared in the event of a poisoning. Sheen suggests posting the universal poison center telephone number (800-222-1222) on the refrigerator. Dialing this number from anywhere in the U.S. will route the call to the closest center.
"Never leave anything [hazardous] on a counter, even for a few minutes," Westcott says, "and be 150% sure about where you keep medications and what you keep in your purse." And never underestimate the superpowers of little "Clark Kents."
Margaret Hawke, RN, MA, is a contributing writer for Nursing Spectrum.
References
1. Poison Facts. Finger Lakes Regional Poison Center website. Available at: www.stronghealth.com/services/poison/poisonfacts.cfm. Accessed on April 28, 2004.
2. Common Childhood Injuries and Poisonings. The Medical Center of Central Georgia website. Available at: www.mccg.org/childrenshealth/poison/factpois.asp. Accessed on April 28, 2004.
3. Ipecac Policy Change SF7-3. Healthy Childcare website. Available at www.healthychild.net/articles/sf39ipecac.html. Accessed on May 29, 2004.
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