Wzorzec-przegl d lekarski-XX-2001

ORIGINAL PAPERS – PRACE ORYGINALNE
Beata SZKOLNICKA
Ma³gorzata MITRUS
Jowanka MORAWSKA
Leszek SATORA
Dorota TARGOSZ
Children toxic exposure in 2004 – telephone
poison information service
Zatrucia substancjami chemicznymi u dzieci w 2004 roku
– konsultacje toksykologiczne
Chair of the Clinical and Environmental
Toxicology
Jagiellonian University Medical College
Kraków, Poland
Poison Information Centre
Head: Dr Dorota Targosz
Additional key words:
children
poisoning
poison information
Dodatkowe s³owa kluczowe:
dzieci
zatrucia
informacja toksykologiczna
Address for correspondence:
Beata Szkolnicka
Poison Information Centre
31-826 Kraków, os. Z³otej Jesieni 1, Poland
phone: +48 12 64 68 706;
phone/fax: +48 12 64 68 905
e-mail: [email protected]
564
509 toxicological telephone enquires concerning children under 15
years have been provided by Kraków
Poison Information Centre (PIC) in the
year 2004. Medication drugs were involved in almost one half (n=208) the
cases noted. 63.7% of calls concerned
children under 4 years with a two-yearold group predominance. The main
reason for poisoning in children under
4 were pharmaceuticals (42.6%), followed by pesticides (9.8%), corrosives
(8.8%), hydrocarbons (8.1%), plants
(5.5%) and detergents (3.7%); all exposure were accidental. Suicide attempts
reached 32.3% in the 12-14 age group.
In that group also a cases of psychoactive substances overdosing were
noted. Most exposures in children reported to poison centre were accidental (87.2%). Thus, it is absolutely necessary to intensify prevention and education activity both for parents and
primary school children to avoid the
poisoning.
Oœrodek Informacji Toksykologicznej CM UJ w Krakowie w roku 2004
udzieli³ 509 telefonicznych konsultacji
i informacji toksykologicznych dotycz¹cych zatruæ u dzieci poni¿ej 15
roku ¿ycia. W niemal po³owie (208 przypadków) przyczynê zatrucia stanowi³y
leki. Przewa¿aj¹ca czêœæ (63,7%) zatruæ dotyczy³a dzieci do 4 roku ¿ycia.
Wœród nich najwiêcej by³o dwulatków.
G³ówn¹ przyczyn¹ zatruæ w najm³odszej grupie wiekowej by³y nieprawid³owo zabezpieczone leki (42,6%), nastêpnie pestycydy (9,8%), substancje ¿r¹ce (8,8%), wêglowodory (8,1%), roœliny (5,5%) i detergenty (3,7%). Wszystkie zatrucia w tej grupie wiekowej by³y
przypadkowe. Zatrucia samobójcze w
grupie dzieci od 10 do 14 roku ¿ycia
stanowi¹ a¿ 32,3%. W tej ostatniej grupie pojawiaj¹ siê równie¿ przypadki
nadu¿ywania substancji psychoaktywnych. Bardzo niepokoj¹cy jest fakt, ¿e
w ca³ej badanej grupie dzieci zatrucia
przypadkowe stanowi³y 87,2%. W
zwi¹zku z tym konieczne jest podjêcie
bardziej intensywnej akcji profilaktyczno-edukacyjnej dla rodziców oraz dzieci szkó³ podstawowych, co pozwoli³oby na uœwiadomienie istniej¹cego zagro¿enia i unikniêcie w przysz³oœci takich zatruæ.
Introduction
Poison information service and poison
treatment units in Kraków regional toxicology centre (Department of Clinical Toxicology Jagiellonian University Medical College)
are integrated and complimentary to each
other. Poison Information Centre (PIC) in
Kraków provides telephone advice on the
treatment of poisonings to the lay public and
medical professionals. The service is available for consultation 24 hours/day, every day
of the year, and is generally given by doctors on duty. Emergency telephone number
for Kraków PIC is: + 48 12 411 99 99.
Telephone calls are recorded in Wave
files and a documentation chart is completed
for every call. Important role of PIC is public
education and poison prevention conducted
by specialists in poison information (pharmacists and biologists).
In Kraków all inhabitants older than 14
stated or suspected of being poisoned are
treated at the Department of Clinical Toxi-
cology. Children under 14 are treated in paediatric hospitals or wards using via telephone
consulting and toxicology laboratory service.
The aim of the study was to analyse records
of phone calls related to children exposure
in the year 2004.
Przegl¹d Lekarski 2005 / 62 / 6
Material an methods
All telephone enquires to Kraków PIC involving children under the age of 15 years were extracted from our
databases for the year 2004 and analysed for the origin
of phone, children age, agent involved and the route of
exposure. To analyse if the pattern of agent ingested vary
with age the calls were divided into three age clusters
concerning motor skills and psychosocial development
(up to 4 years; 5-9 and 10-14 years old).
Results
In 2004 Kraków PIC received 2263 telephone enquires, of which 509 (22.5%) involved children under the age of 15 years.
Male and females were equally represented.
405 (79.6%) enquiries were obtained from
medical professionals, mostly doctors callB. Szkolnicka et al.
Przegl¹d Lekarski 2005 / 62 / 6
160
140
120
Number of calls
100
80
60
40
unknown
14
13
12
11
10
9
8
7
6
5
4
3
0
2
20
1
ing for toxicological advice, and 104 (20.4%)
from parents or care providers. Most the
exposures reported to PIC were accidental
(87.2%).
In figure 1 a number of information concerning age of the children is presented. Of
the 509 calls, 324 (63.7%) involved youngest children (up to 4 years). Of them, 153
concerned 2 years, 86 concerned 3 years
and 42 concerned 4 years old children. 43
were younger than one year. Decrease in
number of enquires concerning the 5 - 9 age
group (n= 56) was noted. Increasing tendency was noted again in the 10 to 14 years
group (n=99). The age of 30 children was
not exactly stated.
All incidence in those aged under 10
were accidental, and the majority took place
at home or in areas nearby. Of 99 incidence
concerning older children (10-14 yrs), 52
were accidental, 32 were due to suicidal attempts and 15 due to intentional drug abuse.
The most common cause of enquiries
was ingestion of pharmaceuticals (42.6%)
followed in frequency by pesticides (9.8%),
corrosives (8.8%), hydrocarbons (8.1%),
plants (5.5%), detergents (3.7%), mushrooms (3.3%) metals (3.1%) and others
(4,5%). Venoms, psychoactive substances,
alcohols were rarely involved. In 17 calls
toxic exposure was excluded (figure 2).
85.6% of pharmaceuticals incidence
were accidental. In 42.1% a specifics commonly believed to be safe (vitamins formulation, anti-emetics, antacids, iron specimens, nasal drops, homeopathic and herbal
specifics) were the reasons for poisoning
enquiries. They were followed by poisoning
with more than one medication drug (14.8%)
and non-opioid analgesics (13%). Neuroleptics and endocrine drugs (mostly contraceptives ingested accidentally by youngest
children) were also relatively frequent reason for poisoning enquires (8.8% and 5.1%
respectively) in 2004 (figure 3).
The pattern of agent ingested varied with
age reflecting mobility and psychosocial
development of the children. Medication
drugs were the most common cause of enquires about the children in all the age clusters. In 32.3% of the 10 - 14 age group they
were taken for suicidal attempt; neuroleptics,
antiepileptics, non-opioid analgesic drugs
and opioid analgesics were mainly involved.
In 28% benzodiazepines as second pharmaceutical were co-ingested. Drug abuse
(mostly amphetamine and THC) was a reasons for 15.2% of poisoning enquires and
concerned also only the children in the 10 14 age group. In that group one case of intoxication with Datura stramonium seeds
chewed intentionally was noted. In the
younger age groups an intentional overdosing was not stated at all.
The most common cause of enquiries
about the 5-9 age children were pesticides
(14.3%) followed by mushrooms (8.9%),
hydrocarbons (8.9%), corrosives (7.1%),
plants (7.1%), and detergents (5.4%). Enquiries about children up to 4 concerned
mostly corrosives (11.4%), pesticides
(9.6%), hydrocarbons (9.3%), plants (5.9%),
and detergents (4.3%). In the youngest
group 8 enquires (2.5%) about mushroom
were also noted (figure 4).
Age (years)
Figure 1
Number of calls about children concerning age in 2004 (Poison Information Centre in Kraków).
Liczba informacji/konsultacji toksykologicznych dotycz¹cych dzieci udzielona przez Oœrodek Informacji Toksykologicznej
CM UJ w roku 2004.
other gases
other alcohols
venoms
MetHb forming agents
ethanol
carbon monoxide
drugs
metals
mushrooms
exluded exposure
detergents
other substances
plants
hydrocarbons
corrosives
pesticides
pharmaceuticals
0
50
100
150
200
250
Number of calls
Figure 2
The pattern of agent ingested concerned poisoning enquires in 2004 (Poison Information Centre in Kraków).
Rozk³ad nara¿enia na poszczególne ksenobiotyki wœród dzieci w 2004 roku (dane z Oœrodka Informacji Toksykologicznej
CM UJ w Krakowie).
other anxiolytics
nootropics
opioid analgesics
anticonvulsants
cardiovascular drugs
respiratory drugs
antidepressants
benzodiazepines
endocrinologic drugs
neuroleptics
non-opioid analgesics
mixed pharmaceuticals
others
0
5
10
15
20
25
30
35
40
%
45
Figure 3
The pattern of medication drugs in telephone enquires in 2004 (Poison Information Centre in Kraków).
Rozk³ad nara¿enia na poszczególne leki wœród dzieci w 2004 (dane z Oœrodka Informacji Toksykologicznej CM UJ w
Krakowie).
565
exluded exposure
other substances
venoms
10-14 yrs
plants
mushrooms
5-9 yrs
metals
0-4 yrs
detergents
corrosives
hydrocarbons
pesticides
CO and other gases
ethanol and other alcohols
drugs
pharmaceuticals
0
10
20
30
40
50
%
60
Figure 4
The pattern of agent ingested concerning children age in 2004 (Poison Information Centre in Kraków).
Rozk³ad nara¿enia na poszczególne ksenobiotyki w zale¿noœci od wieku dzieci w 2004 (dane z Oœrodka Informacji
Toksykologicznej CM UJ w Krakowie).
Discussion
A number of factors, including increased
industrialisation, and trade of chemicals and
poverty have an impact on children's health.
The effects suffered during special developmental periods – "windows of vulnerability" – can be permanent and irreversible [79]. Acute toxic exposures lead to poisoning, and chronic low-level exposures may
cause functional and organ damage during
periods of special vulnerability.
Infants and children are not little adults.
In contrast to adolescent or adult ingestions,
pediatric ingestions are unintentional events
secondary to development of exploration
behaviours and the tendency of place objects in the mouth [2]. All the exposures reported to our PIC in 2004 concerning children up to 9 years were accidental.
During the early years, the child concentrates on sensimotor stimuli. All infant
toxic exposure resulted from inappropriate
care or/and parents or care providers mistakes (medication overdosing, pills given by
mistake, non-prescribed medications).
Children exposure is magnified by their
hand – to mouth behaviour and their play
close to ground. Realising that the young
infant will try to place almost anything into
the mouth should be a remainder to keep
small items, diaper pins, deadly plants, and
other toxic materials from the infant's action space.
In later years, the child concentrates on
cognitive stimulation. Baby becomes more
mobile, opportunities to explore (and get into
danger) increase. Insatiable curiosity, and
a lack of self-discipline together with inappropriate care resulted in highest number
of enquiries about the children up to 4 yrs,
of them 2 yrs were most numerous. The
curiosity of the toddlers and preschooler
may prompt the opening of many containers that should remain safely closed and
untouched by little hands. Pharmaceuticals
were the most common cause of enquires
about the children in 2004 reflecting the tendency observed in Poland [5] and in the
566
United States [3,13]. With the increase of
more potent pharmaceuticals on the market, even small amounts of medications can
cause adverse reactions in children [3,6]. A
specifics commonly believed to be safe (vitamins formulation, anti-emetics, antacids,
iron specimens, nasal drops, homeopathic
and herbal specifics) were the reasons for
70 poisoning enquiries concerned youngest
children (up to 4 years). Enquiries about
children up to 4 yrs concerned also household corrosives (toilet cleaners, bleaching
agents, disinfectants), pesticides, hydrocarbons (solvents and grill lighter) and plants.
A few enquires about mushroom in the
youngest group resulted from improper nutritional habits of their parents.
An increasing repertoire of motor skills,
and insatiable curiosity, and a lack of selfdiscipline make it imperative that poisons,
electrical sockets, and other potentially
harmful items are made inaccessible by
parents and care providers.
As the healthy preschooler develops a
sense of self, he or she becomes more independent when faced with realities of everyday life. The toddler and the preschooler
need multiple sensory experiences to help
them to integrate perceptual information [10].
The most common cause of enquiries to
Kraków PIC in 2004 about the 5-9 age children concerned besides medication drugs
also pesticides, mushrooms, hydrocarbons,
corrosives, plants, and detergents. Imitation
of adult behaviours is very common during
these years. Parents should set limits as to
haw much the child can help at home and
the garden and what the child can use and
do alone to avoid toxic exposures to pesticides, household products, plants and mushrooms.
The pattern of agent ingested varied with
age reflecting mobility and psychosocial
development of the children. Although medication drugs were the most common cause
of enquires to PIC irrespective of age,
neuroleptics, antiepileptics, non-opioid analgesic drugs and opioid analgesics and
Przegl¹d Lekarski 2005 / 62 / 6
benzodiazepines co-ingested were taken for
suicidal attempt only by the oldest children.
Also drug abuse (mostly amphetamine, THC
and ethanol) was a reason for poisoning
enquires about the oldest children. Adolescence is a time when new life tasks (orientation toward peers of the other sex, romantic and sexual involvement) need to be mastered. Parent-child conflict increases and
becomes more intense as the adolescent
struggles for more independence while still
requiring support. These normal changes
can become problematic if biological and
social expectations diverge e.g. entering
puberty very early or very late. Early pubertal timing, especially in girls, have negative
impact affect emotional well-being [12]. Intentional overdosing of medication drugs as
well as illicit drug or ethanol abuse was reported already in 10 and 11 years children.
In the younger age groups analysed an intentional overdosing was not reported at all.
Children's exposure to environmental
contaminants in the context of activity pattern was already reported by many authors
[1,4,7,8]. Contact with toxic agents can occur in uterus through trans-placental transfer of chemicals from mother to foetus; it
can occur via breast milk in nursing infants;
and it can occur in early childhood via hand
– to mouth transfer of toxic chemicals [7,9].
It is more important that the environment
keep pace with the child than to force the
child to keep pace with the environment. The
child's interests and motivations should always be kept in mind. The concept of safety
is important type of learning necessary to
the individual child's well-being. More than
one-half of all childhood deaths are caused
by accidents [11]. Three out of four nonfatal
accidents to young children occur in the
home or in areas nearby. Of these accidents,
90% have been estimated to be preventable. All potential poisons (including cosmetics) should be kept out of the reach of ingenious youngsters who have learned how to
pull drawers out, use them as steps and
climb. Poisonous plants that look "good
enough to eat" should be removed. Of the
509 exposures reported to Kraków Poison
Information Centre in 2004, 444 were accidental thus potentially preventable.
Children have more years of future life
and thus more time to develop diseases initiated by early acute and chronic toxic exposure. The protection of small children
against toxic agents in their homes and
nearby areas is a challenge mostly to parents or/and care providers. The protection
against toxic chemicals in the environment
is a major challenge to modern society.
Conclusions
Most children exposures reported to
Kraków PIC in 2004 were accidental thus
estimated to be preventable.
A publicity about poisoning in children
resulting in advice for parents and the introduction of child – resisting containers are
necessary.
A warning labels with emergency telephone number for PIC should be obligatory
placed on each household product.
B. Szkolnicka et al.
References
1. Armstrong T.W., Zaleski R.T., Konkel W.J.,
Parkerton T.J.: A tiered approach to assessing children's exposure: a review of methods and data.
Toxicol. Lett. 2002, 127, 111.
2. Ashburn S.S., Schuster S.C.: Cognitive Development During Infancy. [In:] Schuster Show C. (Ed):
The Process of Human Development. 1986, Little,
Brown Company, USA.
3. Bond G.R.: The poisoned child: evolving concepts
in care. Emerg. Med. Clin. North Am. 1995, 13, 343.
4. Cohen Hubal E.A., Sheldon L.S., Burke J.M. et
al.: Children's exposure assessment: a review of factors influencing children's exposure, and the data
available to characterize and assess that exposure.
Environ. Health Perspect. 2000, 108, 475.
5. Kotwica M., Rogaczewska A.: Causes of Poisoning in Children During the Period 1990-1993. Przegl.
Przegl¹d Lekarski 2005 / 62 / 6
Lek. 1996, 53, 329.
6. Kyle P.B., Spencer J.L., Purser C.M. et al.: Suspected pediatric ingestions: effectiveness of immunoassay screens vs. gas chromatography/mass
spectroscopy in the detection of drugs and chemicals. J. Toxicol. Clin Toxicol. 2003, 41, 919.
7. Landrigan P.J., Kimmel C.A., Correa A., Eskenazi
B.: Children's health and the environment: public
health issues and challenges for risk assessment.
Environ. Health Perspect. 2004, 112, 257.
8. Needham L.L., Sexton K.: Assessing children's exposure to hazardous environmental chemicals: an
overview of selected research challenges and complexities. J. Expo. Anal. Environ. Epidemiol. 2000,
10, 611.
9. Pronczuk de Garbino J.: The Sentinel Role of Poisons Centers in the Protection of Children's Envi-
ronmental Health. J. Toxicol. Clin. Toxicol. 2002, 40,
493.
10. Schuster S.C., Ashburn S.S.: Cognitive Development of the Toddler and the Preschooler. [In:]
Schuster Show C. (Ed): The Process of Human Development. 1986, Little, Brown Company, USA.
11. UNICEF: A league table of child deaths by injury in
rich nations. Innocenti Report Card No.2, February
2001. UNICEF Innocenti Research Centre, Florence,
Italy.
12. Waylen A., Wolke D.: Sex 'n' drugs 'n' rock 'n' roll:
the meaning and social consequences of pubertal
timing. Eur. J. Endocrin. 2004, 151, (Suppl. 3), U 151.
13. Wiseman H.M., Guest K., Murray V.S., Volans G.N.:
Accidental Poisoning in Childhood: Multicenter Survey. 1. General Epidemiology. Hum. Toxicol. 1987,
6, 293.
567