Unintentional paediatric ingestions of angiotensin converting enzyme inhibitors and angiotensin II receptor antagonists

AIMS: There is limited information on safety of angiotensin converting enzyme (ACE) inhibitors and angiotensin II (AII) receptor antagonists in unintentional paediatric ingestions. This study was conducted with the aim of developing referral guidelines for poison information centres. METHODS: Calls to the NSW poison information centre from January 2002 to July 2004 regarding paediatric ingestion of ACE inhibitors and AII receptor antagonists were recruited and prospectively followed up. Information collected included: demographics (age, gender, weight), type of exposure (unintentional, therapeutic error), ingested dose and clinical effects. Dose was reported in defined daily doses (DDD) to compare across and within the two drug classes with respect to the normal adult dose. RESULTS: Nineteen cases of paediatric ingestion of ACE inhibitors and AII receptor antagonists were included. The median age was 2 years (Interquartile range (IQR): 20-33 months) and the median dose ingested was 1 DDD (IQR: 1-2). There were nine ACE inhibitor ingestions and 10 AII receptor antagonist ingestions. One of nine children (11%) observed in hospital developed transient hypotension but required no treatment and recovered without complication. This child ingested an ACE inhibitor and ingested >3 DDD. CONCLUSION: Unintentional paediatric ingestions of ACE inhibitors and AII receptor antagonists resulted in the majority of children remaining asymptomatic. ACE inhibitor ingestions under 2 DDD can be observed at home provided the child is asymptomatic and there is a responsible adult to observe the child. The dose required for observation in AII receptor antagonist ingestions is less clear.     

Prediction of complications following unintentional caustic ingestion in children. Is endoscopy always necessary?

The records of 115 children hospitalized following caustic ingestion over an 18.5-year period from 1976 to 1994 were reviewed. The relationship between types of product ingested, signs and symptoms, degree of esophageal injury and complications was analyzed. All complications were the result of strong alkali ingestion (sensitivity = 1.0). Among the 102 incident patients, 36.8% of lye ingestions resulted in complications, whereas only 2.7% (one) of automatic dishwasher detergent (ADD) ingestions caused any complications (p < 0.01). Endoscopy 6h to 4 days after injury was accurate in predicting or identifying complications in all types of strong alkali ingestions. In lye ingestions, endoscopy was not superior to the test, "one or more signs or symptoms" in predicting complications (predictivity = 1.0). Endoscopy is recommended to establish or confirm a prognosis, or to identify acute respiratory complications, in symptomatic ingestions of lye or ammonia water, in children with respiratory symptoms, and in rare cases of severe symptoms following ADD or strong acid ingestion. It is suggested that children who are non-symptomatic following unintentional ingestions are not at risk of complications and do not need endoscopic examination. Causlic ingestion, children, complication, diagnostic test, endoscopy, esophagus, unintentional     

Prehospital and in-hospital mortality: a comparison of intentional and unintentional traumatic brain injuries in Colorado children

OBJECTIVES: To describe the incidence and case-fatality rates of traumatic brain injury (TBI) in young children in Colorado, to compare these injuries based on intentionality and outcome (prehospital death, in-hospital death, or survival), and to model the association of intentionality with TBI-related mortality. METHODS: Cases were drawn from the 1994-2002 Colorado Traumatic Brain Injury Surveillance System. Incidence and case-fatality rates for intentional and unintentional TBI were calculated. We performed univariate comparisons based on the intentionality and outcome of the TBI. Multivariate logistic regression was used to estimate the association of intentionality and mortality, controlling for injury severity. RESULTS: Of the 1333 children aged 0 to 36 months with TBI, 340 had intentional and 993 had unintentional TBI. Incidence for intentional and unintentional TBI was 16.1 and 47.0 per 100,000, respectively. Children with intentional TBI had a higher case-fatality rate, in-hospital death rate, and injury severity. Intentional TBI deaths were twice as likely to occur in hospital than prehospital, whereas unintentional TBI deaths were twice as likely to occur prehospital. Intentionality was significantly associated with mortality, with the effect increasing with increasing age. CONCLUSION: Intentionality--independent of severity--raises the mortality of TBI in young children.     

Restricting cough and cold medicines in children

Aims: Based on concerns about safety and efficacy, international authorities have either advised against the use of cough and cold medication or considering such action. We aimed to systematically review the evidence for the effectiveness and safety of cough and cold medicines in children. Methods: We conducted a systematic review to identify studies relating to the use of products to treat symptoms of the common cold, influenza or allergic rhinitis, and relating to poisoning or toxicity from unintentional ingestion or overdose in children (<12 years). Medline, Embase and the Cochrane database were searched. No meta‐analysis was undertaken because of the paucity of evidence, multiple medicines available, and the need to consider both effectiveness and safety. Results: Seventy two relevant studies or clinical reports were identified. There was little support for the effectiveness of these medicines for acute cough or the common cold in children. However, the majority of these medicines do not appear to be highly toxic in children and are not a major cause of severe effects following unintentional poisoning. The common use of these agents does not appear to be responsible for increased deaths in young children. Many cases of toxicity from cough and cold medications in young children are a result of therapeutic error. Particular medications, including diphenhydramine and codeine, appear to be associated with a high frequency of severe adverse effects and toxicity. Conclusion: Restriction of cough and cold medicines in children is supported by currently available evidence.     

Toxic clonidine ingestion in children

OBJECTIVES: We performed a prospective case series to seek dosage or clinical parameters to better identify patients who need direct medical evaluation. STUDY DESIGN: All clonidine ingestions in children younger than 12 years of age reported to 6 poison centers were followed for a minimum of 24 hours. Exclusion criterion was polydrug ingestion. RESULTS: The study included 113 patients, of whom 63 were male. Mean age was 3.8 years (+/-2.4 SD). Clinical effects were common, but severe adverse effects occurred in <10% of patients. The dose ingested was reported for 90 patients (80%); 61 (68%) children ingested <0.3 mg and none had coma, respiratory depression, or hypotension. The lowest dose ingested by history with coma and respiratory depression was 0.3 mg (0.015 mg/kg). Prior clonidine therapy did not affect outcome. Onset of full clinical effects in all cases was complete within 4 hours of ingestion. CONCLUSIONS: We recommend direct medical evaluation for (1) all children 4 years of age and younger with unintentional clonidine ingestion of >or=0.1 mg, (2) ingestion of >0.2 mg in children 5 to 8 years of age, and (3) ingestion of >or=0.4 mg in children older than 8 years of age. Observation for 4 hours may be sufficient to detect patients who will develop severe effects.     

Mosquito repellents and superwarfarin rodenticides--are they really toxic in children?

PURPOSE OF REVIEW: In many United States households, there are many substances used to control the exposure of our children to mosquitoes, mice and rats. This review provides information on common mosquito repellents and rodenticides used in households and discusses their toxicity, in order to help pediatricians better advise their patients of their proper use. RECENT FINDINGS: A recent study has demonstrated that many continue to have practices of applying DEET (N,N-diethyl-3-methylbenzamide) based repellents that may lead to undesirable effects. Picaridin and oil of lemon eucalyptus are two products that have recently been shown to have an efficacy similar to that of DEET-based repellents. Studies within the last five years show that most unintentional superwarfarin ingestions can be managed at home with close outpatient follow-up. There does not appear to be a benefit of prophylactic vitamin K or gastrointestinal decontamination in patients with relatively small ingestions of superwarfarins. SUMMARY: With education and correct usage, mosquito repellents and the superwarfarin rodenticides can help protect children from significant vector-borne diseases. Not all exposures lead to significant morbidity or mortality. With recognition of the current literature, most of these exposures can be managed safely at home or as an outpatient, ultimately saving healthcare costs.     

Fatal unintentional traumatic asphyxia in childhood

OBJECTIVE: The present study was undertaken to examine specific features of unintentional traumatic asphyxial deaths in childhood. METHODS: Coronial files and records at the Forensic Science Centre in Adelaide, South Australia, were examined over a 35-year period from 1966 to 2000 for all cases of traumatic asphyxial death occurring in children under the age of 17 years. RESULTS: Six cases of unintentional fatal traumatic asphyxia were identified. All of the victims were boys with an age range of 2-15 years (mean 6.8 years) and all were found dead at the scene. Fatal traumatic asphyxia resulted from entrapment beneath a chest of drawers, beneath a table tennis table, between a pile of wooden pallets and a metal fence, between a conveyor belt and its frame, and under a motor vehicle (in two cases). CONCLUSIONS: Fatal traumatic asphyxia in childhood is a rare event, with younger children commonly being trapped by furniture or by industrial equipment while playing, and older children being trapped under motor vehicles in similar circumstances to adult traumatic asphyxial deaths. Unsupervised play of young children around heavy and potentially unstable pieces of furniture may be dangerous, particularly if more than one child is present. Unsupervised play of young children in industrial yards should be avoided.     

Unintentional household poisoning in children

Despite the major reduction in fatal paediatric poisonings that has been achieved in industrialised countries over the last few decades, unintentional paediatric poisoning remains a major public health issue worldwide. In this article, we aim to provide clinicians dealing with poisoned children an overview of the problem and specific guidance on the identification and management of significant poisoning. Substances most frequently ingested by children in the developed world include household chemicals, medication, and plants. Although the great majority of such poisonings have no or limited clinical effects, it puts substantial burden on health care systems. Importantly, a few poisons can kill after ingestion of very small amounts. Unintentional poisoning in developing countries can be much more serious, following ingestion of kerosene, caustic agents, herbal remedies, insecticides or herbicides. Management of symptomatic patients involves supportive care, if available the administration of antidotes, and the removal of the offending drug from the body. Recent position papers on gastric decontamination indicate that such interventions are only rarely necessary. To further reduce the number of deaths and disabilities in the industrialised world and to begin to have an effect in the developing world, much more work is required to both identify and implement prevention strategies to reduce the number of cases of paediatric poisoning.     

Trends and toxic effects from pediatric clonidine exposures

OBJECTIVE: To analyze the trends, demographics, and toxic effects associated with pediatric clonidine hydrochloride exposures reported to poison centers. DESIGN: Retrospective. SETTING AND PATIENTS: Clonidine-only exposures followed up to known outcome in children younger than 19 years reported to the American Association of Poison Control Center's database from January 1, 1993, through December 31, 1999. MAIN OUTCOME MEASURES: Frequency of exposures over time, acuity, reason, symptoms, management site, treatment, and outcome. RESULTS: There were 10 060 reported exposures with 57% reported for children younger than 6 years, 34% for children between 6 and 12 years old, and 9% for adolescents between 13 and 18 years old. In 1999 there were 2.5 times as many exposures as in 1993. In 6- through 12-year-olds, clonidine was the child's medication in 35% of the exposures, compared with 10% in children younger than 6 years and 26% in adolescents. The proportion of cases involving the child's medication increased over 7 years. While unintentional overdose was most common in children younger than 6 years, therapeutic errors and suicide attempts predominated in 6- through 12-year-olds and adolescents, respectively. In 6042 symptomatic children (60%), the most common symptoms were lethargy (80%), bradycardia (17%), hypotension (15%), and respiratory depression (5%). Most exposures resulted in no effect (40%) or minor effects (39%). Moderate effects occurred in 1907 children (19%), major effects in 230 children (2%); there was 1 fatality in a 23-month-old. CONCLUSIONS: While most of the clonidine exposures resulted in minimal toxic effects, serious toxic effects and death can occur. The trend toward increasing the number of exposures in children, especially with evidence of toxic effects in children receiving clonidine therapeutically, is cause for concern.     

Infant injury deaths with unknown intent: what else do we know?

OBJECTIVES: Strong evidence based on case record reviews indicates that the incidence of child homicide reported from death certificates is under ascertained. The characteristics of infant injury fatalities with undetermined, but suspicious, intent were compared for the probability that they should be considered homicides. METHODS: Using linked birth and death certificates for all birth cohorts in the US from 1983-91, 2345 injury fatalities reported as intentional, 7594 as unintentional, and 431 as undetermined intent were identified. Maternal and infant variables potentially predictive of injury fatalities were selected based on increased bivariate associations. Relative risks of injury death by intentional, unintentional, and undetermined intent were assessed for maternal and infant characteristics. RESULTS: Relative risks were consistently higher across all intent categories for infants of mothers with the least education, no prenatal care, young maternal age, and single marital status, as well as for infants who are second or later born, preterm, black, or American Indian. Fatalities with undetermined intent have larger relative risks in the highest risk categories than either intentional or unintentional injuries. Deaths with undetermined intent have risk profiles that more closely resemble profiles for intentional deaths than unintentional. CONCLUSIONS: Injury homicide rates would be almost 20% greater than official classifications indicate if deaths with undetermined intent were included. In analyses of infant homicide, excluding deaths of undetermined intent may lead to an underestimation of the magnitude of the public health problem of intentional injuries among infants. Other studies based on record reviews from multiple sources indicate that misclassification and under ascertainment of homicides may be even greater.     

Self-inflicted and unintentional firearm injuries among children and adolescents: the source of the firearm.

CONTEXT: The source and ownership of guns used by children to shoot themselves or others is largely unknown. OBJECTIVE: To determine the ownership and usual storage location of firearms used in unintentional and self-inflicted intentional firearm deaths and injuries. DESIGN: Retrospective case series. SETTING: King County, Washington. PATIENTS: Youths aged from birth to 19 years who sought medical treatment at a level I trauma center for a self-inflicted or unintentional firearm injury between 1990 and 1995 or who presented to the county medical examiner with a fatal self-inflicted or unintentional firearm injury between 1990 and 1995. DATA SOURCES: County medical examiner records, regional police investigative reports, medical records from a level I trauma center, and surveys of victims' families. MAIN OUTCOME MEASURES: Source and ownership of the associated firearm. RESULTS: Fifty-six fatal injuries and 68 nonfatal firearm injuries that met the criteria were identified. Of these, 59 were intentionally self-inflicted deaths and injuries and 65 were unintentional deaths and injuries. A firearm owned by a household member living with the victim was used in 33 (65%) of 51 suicides and suicide attempts and 11 (23%) of 47 unintentional injuries and deaths. Additionally, a firearm owned by another relative, friend, or parent of a friend of the victim was used in 4 (8%) of the 51 suicides and suicide attempts and 23 (49%) of the 47 unintentional injuries and deaths. Parental ownership accounted for 29 (57%) of the 51 suicides and suicide attempts and 9 (19%) of the 47 unintentional injuries and deaths. More than 75% of the guns used in suicide attempts and unintentional injuries were stored in the residence of the victim, a relative, or a friend. CONCLUSION: Most guns involved in self-inflicted and unintentional firearm injuries originate either from the victim's home or the home of a friend or relative.     

Unit-dose packaging of iron supplements and reduction of iron poisoning in young children

BACKGROUND: Iron poisoning is a major cause of unintentional poisoning death in young children. The US Food and Drug Administration proclaimed a regulation for unit-dose packaging of iron supplements in 1997. OBJECTIVE: To determine whether the requirement for unit-dose packaging of iron supplements decreases the incidence of iron ingestion and the incidence of deaths due to iron poisoning in children younger than 6 years. METHODS: This is a preintervention-postintervention study of the US federally mandated requirement for unit-dose packaging of iron supplements. The 10 years prior to the intervention were compared with the 5 years after its promulgation. The incidences of iron ingestion and of iron poisoning deaths for children younger than 6 years were obtained from the annual reports of the American Association of Poison Control Centers (Washington, DC). RESULTS: The average number of iron ingestion calls per 1000 of all calls to poison control centers regarding children younger than 6 years decreased from 2.99 per 1000 to 1.91 per 1000 (odds ratio, 1.29 [95% confidence interval, 1.27-1.32]; P<.001). The number of deaths decreased from 29 to 1 (odds ratio, 13.56 [95% confidence interval, 1.85-99.52]; P = .03). CONCLUSIONS: These are the first data that show a decrease in the incidence of nonintentional ingestion of a specific drug by young children and a decrease in mortality from poisoning by this drug after the introduction of unit-dose packaging. There was a decrease in the incidence of iron ingestion and a dramatic decrease in the number of deaths due to iron poisoning. This validates unit-dose packaging as an effective strategy for the prevention of iron poisoning and iron poisoning deaths in young children. This highly effective intervention should be considered for other medications with a high hazard for morbidity and mortality when taken as an overdose.     

Classifying undetermined poisoning deaths.

OBJECTIVE: To classify poisoning deaths of undetermined intent as either suicide or unintentional and to estimate the extent of underreported poisoning suicides. METHODS: Based on 2002 statewide death certificate and medical examiner data in Utah, the authors randomly selected one half of undetermined and unintentional poisoning deaths for data abstraction and included all suicides. Bivariate analyses assessed differences in demographics, death characteristics, forensic toxicology results, mental health history, and other potentially contributing factors. Classification and regression tree (CART) analysis used information from unintentional and suicide poisoning deaths to create a classification tree that was applied to undetermined poisoning deaths. RESULTS: The authors analyzed 41 unintentional, 87 suicide, and 84 undetermined poisonings. Undetermined and unintentional decedents were similar in the presence of opiates, physical health problems, and drug abuse. Although none of the undetermined decedents left a suicide note, previous attempt or intent to commit suicide was reported for 11 (13%) of these cases. CART analysis identified suicidal behavior, drug abuse, physical health problems, depressed mood, and age as discriminating between suicide and unintentional poisoning. It is estimated that suicide rates related to poisoning are underreported by approximately 30% and overall suicide rates by 10%. Unintentional poisoning death rates were underreported by 61%. CONCLUSIONS: This study suggests that manner of death determination relies on circumstance dependent variables that may not be consistently captured by medical examiners. Underreporting of suicide rates has important implications in policy development, research funding, and evaluation of prevention programs.     

Fire deaths in children in South Australia from 1989 to 1998

A study was undertaken of childhood deaths caused by fires in South Australia over a 10-year period from 1989 to 1998. A total of 23 deaths of children occurred with an age range of 2 months to 16 years (mean 5 years 10 months; M:F = 13:10). Fourteen deaths were associated with house fires, four with fires in cars and four were miscellaneous or unspecified. While house fire deaths remained the major cause of childhood fire deaths (65%), deaths in car fires accounted for a significant proportion of cases (17%). Although the numbers are small, cars represented a specific danger because of their confined space with highly flammable interiors, lockable doors, and built in non-childproof lighters. Cars should not be regarded as suitable places to leave young children, or for children to play in unsupervised.     

Lignocaine and chlorhexidine toxicity in children resulting from mouth paint ingestion: a bottling problem

BACKGROUND: A pharmaceutical product was marketed in Australia for 'teething' in an almost identical container to a popular paediatric paracetamol preparation. The product contained lignocaine and chlorhexidine. The similarity of the packaging resulted in large number of therapeutic errors in which the 'teething' preparation was given in error for paracetamol. As the exact dose of the erroneously administered mouth paint was known this provided an opportunity for outcome assessment of lignocaine ingestion. METHODS: Calls to two state poison information centres regarding this product were prospectively followed up. Information collected included: demographics, type of exposure, details of the exposure and adverse effects. A systematic review of the literature was used to identify all previous reported cases of lignocaine and chlorhexidine ingestion. RESULTS: There were 28 cases with complete follow up where the product was given in therapeutic errors (10 girls and 18 boys; median age 11 months; range 2 months-4 years). The mean ingested dose of lignocaine was 2.7 mg/kg (standard deviation 1.3 mg) and chlorhexidine was 0.06 mg/kg (standard deviation 0.03 mg). The largest ingested lignocaine dose was 5.9 mg/kg. Two children developed minor symptoms: one vomited twice and the other was reported to have increased salivation and difficulty with solid food for 20 min. No other adverse effects were reported. The literature review suggested that severe effects occurred with doses more than 15 mg/kg. CONCLUSION: No major adverse effects occurred with lignocaine ingestions of less than 6 mg/kg and it would be appropriate to observe these patients at home. Chlorhexidine did not appear to cause clinical effects in this low concentration.     

Hair relaxers: a benign caustic ingestion?

BACKGROUND: Despite federally legislated safety regulations, caustic ingestions remain a significant problem in the pediatric population. The current standard of care for caustic ingestion includes upper gastrointestinal endoscopy in most cases. Hair relaxers are a common caustic ingestion at our institution, yet few data have been published describing the clinical or endoscopic outcome. We explored the relative frequency of hair relaxer ingestion, the incidence of associated upper gastrointestinal injury, and the adverse clinical sequelae resulting from these ingestions. METHODS: Consecutive caustic ingestions admitted to our institution between January 1990 and January 2001 were identified. The data were collected through retrospective physician chart review, were analyzed, and were pooled with the existing literature to evaluate for the presence of esophageal injury. RESULTS: 96 charts were reviewed, 29 (30%) of which were hair relaxer ingestions that underwent esophagogastroduodenoscopy; these ingestions served as our study cohort. The median age of the cohort was 14.0 months and patients were evenly divided in gender. The most common symptoms at presentation were drooling and emesis. At endoscopy, lip and oropharyngeal mucosa were most commonly affected. While six patients (20.7%) had Grade I esophageal mucosal injury and five patients (17.2%) had Grade I gastric mucosal injury, none had greater than Grade I mucosal damage. No adverse clinical events were identified. When our data were combined with all previously published cohort data, the findings were similar and no adverse clinical outcomes were reported. CONCLUSIONS: Hair relaxer is the most common childhood caustic ingestion presenting to our large metropolitan tertiary care center. Symptoms are common at presentation. However, despite the high pH of these products, no clinically significant esophageal or gastric mucosal injuries and no long-term sequelae were identified.     

Varicella-related deaths in children and adolescents – Germany 2003–2004

Aim: Although varicella is acknowledged as a rare cause of death in children, there are few comprehensive data with respect to the clinical course leading to death.
Methods: A nationwide, active surveillance was carried out in Germany for children up to age 17 years who were admitted to a paediatric hospital for varicella or associated complications, including deaths.
Results: A total of 10 children with varicella-associated death were reported over period of 2 years, yielding a mortality rate of 0.4/1 000 000 children per year. Three deaths occurred in children diagnosed with acute lymphocytic leukaemia and disseminated varicella, two shortly after diagnosis of leukaemia and therefore not preventable, and one during remission with an untypical presentation. Two children died with a congenital varicella syndrome. There was no death in children with neonatal varicella. Four other cases were related to varicella pneumonia or septicaemia and one to myocarditis.
Conclusion: In a population with no general varicella vaccination programme, varicella accounted for a small but not negligible risk for death in immunocompetent and immunocompromised children. Together these data point to the importance of a thoroughly implemented, general varicella vaccination programme.     

儿童重症监护室儿童慢性危重症的病因组成及预后分析北大核心CSCD

目的探讨儿童重症监护室儿童慢性危重症(pediatric chronic critical illness,PCCI)的病因组成和转归。方法以2017年1月—2022年12月在广东医科大学附属东莞儿童医院儿童重症监护室住院并达到PCCI诊断标准的患儿为研究对象。根据患儿的病历资料及出院诊断,对其病因进行分类。收集并分析其住院期间相关临床资料。结果2017年1月—2022年12月儿童重症监护室3955例住院患儿中,有321例(8.12%)符合PCCI诊断标准。321例PCCI患儿中,最常见的病因为感染(71.3%,229例),其次为意外伤害(12.8%,41例)、手术后(5.9%,19例)、肿瘤/免疫系统疾病(5.0%,16例)、遗传/染色体疾病(5.0%,16例)。321例PCCI患儿中,好转出院249例(77.6%),家属要求出院37例(11.5%),在院死亡35例(10.9%)。死亡病例中,感染占74%(26/35),意外伤害占17%(6/35),肿瘤/免疫系统疾病占6%(2/35),遗传/染色体疾病占3%(1/35)。2017—2022年PCCI在儿童重症监护室疾病中的占比呈逐年上升的趋势(P<0.05)。321例PCCI患儿中,婴幼儿148例(46.1%),学龄前儿童57例(17.8%),学龄期儿童54例(16.8%),青春期儿童62例(19.3%),其中婴幼儿组占比最高(P<0.05)。以上4个年龄组在院病死率分别为14.9%(22/148)、8.8%(5/57)、5.6%(3/54)、8.1%(5/62),其中婴幼儿组病死率最高,但4个组比较差异无统计学意义(P>0.05)。结论PCCI在儿童重症监护室疾病中的占比越来越高,其主要病因为感染及意外伤害,引起PCCI患儿死亡最常见的病因为感染。PCCI患病人群以婴幼儿为主,婴幼儿患者在院病死率相对较高。