Pediatric Single-Dose Fatal Ingestions

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A wide variety of medications and substances can kill a toddler who ingests just a single dose. More than 1 million children ingest toxins in the United States every year, and more than 85% of the ingestions are unintentional. Most of the children are younger than 6 years. [1]

The intent of this article is not to guide treatment of poisoned children but rather to report toxic ingestions that proved fatal in small doses. The article addresses some types of toxic ingestions and those that may cause serious illness or injury, even in small quantities. [2]

Many of the involved toxins are common in the home or in household products. Ingestion of relatively small amounts of commonly used perfumes, cosmetics, cleaning solutions, alcoholic beverages, and other products may cause serious injury or death. Medications also are a common source of toxic ingestions in small quantities. If prior precautions are not taken, visits to the homes of friends or relatives (even grandparents) or visits from guests who bring medications into the home may result in tragedy.

Ingestion of a small number of common substances and drugs may be fatal in small doses. Most pediatric ingestions are benign. A formal risk assessment is required to allow clinical decision making on the need for resuscitation, treatment, decontamination, enhanced elimination, antidote requirement, and period of observation

The American Association of Poison Control Centers reported that in 2014, children younger than 6 years accounted for 1,029,741 of the 2,165,142 total exposures, but only 16 of the 1173 total  fatalities. Thus, less than 0.002% of total exposures in that age group proved fatal. [3]

Pathophysiology varies according to the ingested substance. Children are particularly susceptible to injury from ingestion of small doses for the following reasons:

The low body mass of children means that a single ingested dose of a substance may easily be toxic.

While exploring their surroundings, younger children, especially toddlers, may ingest substances with objectionable tastes or odors that would be rejected by older children and adults.

The metabolic pathways of young children, particularly infants, are less developed and use sulfonation rather than glucuronidation to process some toxins.

Most ingestions by children involve nontoxic substances. More than 1 million ingestions are believed to occur annually, most involving children younger than 7 years.

Mortality and morbidity depend on the substance or drug ingested and the quantity relative to body weight (ie, mg/kg/dose).

Race and frequency of toxic ingestions appear to have no correlation. Toxic ingestions from a single dose occur most often as unintentional ingestions by young children aged 1-6 years.

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Chip Gresham, MD, FACEM Emergency Medicine Physician, Medical Toxicologist, and Intensive Care Consultant, Department of Emergency Medicine, Clinical Director of Medication Safety, Middlemore Hospital; Consultant Toxicologist, National Poisons Centre; Director, Auckland Regional Toxicology Service; Senior Lecturer, Auckland University Medical School, New Zealand

Chip Gresham, MD, FACEM is a member of the following medical societies: American College of Emergency Physicians, American College of Medical Toxicology, Australasian College for Emergency Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Sarah J Buller, MBChB, FACEM Consulting Physician, Department of Emergency Medicine, Auckland City Hospital, New Zealand

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Kirsten A Bechtel, MD Associate Professor of Pediatrics, Section of Pediatric Emergency Medicine, Yale University School of Medicine; Co-Director, Injury Free Coalition for Kids, Yale-New Haven Children’s Hospital

Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Timothy E Corden, MD Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children’s Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, Wisconsin Medical Society

Disclosure: Nothing to disclose.

Jeffrey R Tucker, MD Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut School of Medicine, Connecticut Children’s Medical Center

Disclosure: Received salary from Merck for employment.

William T Zempsky, MD Associate Director, Assistant Professor, Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Connecticut and Connecticut Children’s Medical Center

William T Zempsky, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Ann G Egland, MD Consulting Staff, Department of Operational and Emergency Medicine, Walter Reed Army Medical Center

Ann G Egland, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Association of Military Surgeons of the US, Medical Society of Virginia, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Cynthia L Morris-Kukoski, PharmD

Clinical Assistant Professor, Department of Pharmacy and Occupational Medicine, Medical College of Virginia

Cynthia L Morris-Kukoski, PharmD is a member of the following medical societies: American Academy of Clinical Toxicology

Disclosure: Nothing to disclose.

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