3/9/2017
There’s no place like
home…
for life-threatening pediatric
poisoning
Goal
• Become aware of substances and
items in your home which may be
potentially hazardous to children, and
what makes them so dangerous.
Dina Wallin, MD
UCSF Division of Pediatric Emergency
Medicine
March 8, 2017
Objectives
• After this talk, you’ll be able to:
1. Name several common medications
which are particularly dangerous to
children.
2. Describe the risks of laundry detergent
pods and edible marijuana in pediatric
patients.
3. Discuss other risky exposures in the home,
and how to prevent life-threatening
illness or injury for kids.
BACKGROUND
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Background
• Poisoning = leading cause of injuryrelated death in the US
• Kids are more vulnerable!
• 60,000 ED visits each year because kids
got into household meds
• In 2015:9
– Poison Control Center managed 2.8 million
cases
– 59% kids 0-19 years old, 47% younger than 6
years old
From Source 9
Background
• 80-85% unintentional
• Bimodal distribution: ages 1-5 and
adolescents
• Risk factors for ingestion:
– Age 1-4 years old
– Male
– Hyperactive temperament
– Increased finger-to-mouth activity
From Source 9
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PREVENTION
From Source 9
Prevention
• Store medicines, chemicals, and cleaning
products up and away out of child’s reach
and sight
• Put medicines away every time
• Do not store chemicals in food containers or
same cabinets as food
• Make sure safety cap is locked
• Teach kids about medication safety
• Tell guests about medication safety
• Be careful to understand dosing for small kids
TIME FOR A LITTLE GAME…
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Which is more dangerous?
• Calamine lotion or citronella candle?
– Cintronella!
• Tylenol or shoe polish?
Which is more dangerous?
• Oil of wintergreen or hydrogen
peroxide?
– Wintergreen!
– Tylenol!
• Latex paint or a hint of vodka?
• Aspirin or household bleach?
– Vodka!
– Aspirin!
• Dishwashing liquid or a detergent
pod?
• Visine eye drops or shaving cream?
– Visine!
– Detergent pod!
THE KILLERS
From Source 12
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3/9/2017
LET’S KICK IT OFF WITH A
CASE…
Salicylates
• Salicylates: Aspirin, other analgesics,
cold medicines, Pepto-bismol, topical
medications
• Symptoms: vomiting, rapid breathing,
ringing of the ears, lethargy
• Can have seizures, coma, brain
swelling, severe bleeding
Salicylates
• Toxic dose:
– Mild intoxication at 150-200 mg/kg, severe
300-500 mg/kg, and death at > 500
mg/kg
– Jake: symptoms after 4 standard aspirin
tablets, and severe symptoms or death
after 9-15 tablets
• Conclusion:
– Aspirin is dangerous!
– Lock it up, especially when grandparents
are around!
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3/9/2017
Oil of Wintergreen
• Contains 1.4 grams of aspirin per mL, or
7.5 grams per teaspoon
• Jake: sick after 2 mL (less than half a
teaspoon), could die after 3.6 mL (well
under a teaspoon)
• Conclusion:
– Just don’t.
Acetaminophen
• Acetaminophen = Tylenol, cold
medications (DayQuil, NyQuil),
Excedrin, Vicodin, Norco
• Early symptoms: nausea and vomiting,
no appetite, pallor, confusion
• Late symptoms: jaundice with severe
liver failure, progressing to liver
transplant or death
WHAT ABOUT THIS ONE…
Acetaminophen
• Toxic dose:
– 200 mg/kg
– Jake: 4 Vicodin or Tylenol tablets, or 60
mL Tylenol elixir
• Conclusion:
– Tylenol isn’t the benign medication we
think it is…
– Lock it up!
– Carefully measure out doses to kids
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The blockers
DIZZY MISS LIZZIE
The blockers
• Symptoms:
– Dizziness, confusion, nausea and vomiting
 all from low blood pressure and slow
heart rate
– Coma, seizures
– Can have hypoglycemia or
hyperglycemia
– Wheezing in kids with asthma
• Calcium channel blockers, beta
blockers
• Used to treat high blood pressure,
atrial fibrillation, even migraines
• Calcium channel blockers:
amlodipine, diltiazem, nifedipine,
verapamil
• Beta blockers: atenolol, carvedilol,
metoprolol, propanolol
The blockers
• Toxic dose:
– Varies by medication– as little as one pill
can kill a toddler or infant
• Conclusion:
– Lock ‘em up!
– Ask guests, especially older adults, about
their meds
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Sulfonylureas
• Medicine for diabetes– glipizide,
glimepiride, glyburide
• Cause insulin secretion 
hypoglycemia
• Symptoms: agitation, confusion, fast
heart rate, sweating, seizures, coma
• 2002-2009: 1943 cases reported to
California Poison Control
SWEET AS SUGAR
Sulfonylureas
• Toxic dose:
– One tablet!
• Conclusion:
– Lock ‘em up!
From Source 8
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The ‘lines
•
•
•
•
‘LINE IN…
Tetrahydrozoline, oxymetazoline
Visine, Afrin
2011 exposures in 2013 alone!
Symptoms: low blood pressure,
hypothermia, lethargy, stopping
breathing, coma
The ‘lines
• Toxic dose:
– Jake: 1.25-2.5 mL (about a quarter of a
bottle of Visine)
– Much higher dose if bottle isn’t upright10
• Conclusion:
– Don’t use these medicines in kids!
– Lock ‘em up!
ANOTHER CASE…
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Hydrocarbons
• Solvents, degreasers, fuels, lubricants
– Gasoline, lighter fluid, kerosene,
turpentine, furniture polish
• Poisoning via choking, ingestion,
inhalation, skin
• Still in the top 5…
From Source 9
Hydrocarbons
• 2010: 42,663 hydrocarbon exposures
reported4
• Majority in boys
• 1/3 younger than 5 years old
From Source 4
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Hydrocarbons
• Symptoms:
– Choking/coughing, trouble breathing,
vomiting
• Toxic dose:
– A few milliliters!
• Conclusion:
– Kids will try to drink gross things.
– Be especially careful in the summer, as kids
are playing.
– Lock ‘em up!
From Source 4
Opioids
• Opium, heroin, morphine,
hydromorphone (Dilaudid), fentanyl,
codeine, oxycodone (Percocet),
hydrocodone (Vicodin, Norco),
methadone
• Huge problem:
SWEET DREAMS!
– Death rate rose from 6.1/100,000 in 2009 to
13.8/100,000 in 201414
– More than 250,000 Americans have died from
opioids in the last 20 years3
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3/9/2017
Opioids
• Roughly 7,000 people are treated per
day in the ED for opioid misuse3
• In 2011, 19% of all opioid-related visits
were pediatric patients14
• From 2006-2012, 928 ED visits for poisoning
by prescription opioids in kids younger
than 18, 62% unintentional
• Kids whose moms were prescribed an
opioid were 2.4 times more likely to
overdose3
From Source 14
Opioids
• Symptoms:
– Decreased respiratory rate, confusion, coma
– Death because you stop breathing
• Toxic dose:
– As little as one pill
• Conclusion:
– Think twice about filling the prescription
– Dispose of unused medicines properly
– Lock ‘em up!
PARTY TIME!
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3/9/2017
Ethanol
• Alcoholic beverages, cologne,
aftershave, mouthwash, perfume,
hand sanitizers, medication elixirs
From Source 13
Ethanol
• Symptoms:
– Nausea and vomiting, confusion, bad
balance, coma, hypoglycemia
– Toddlers: hypothermia, hypoglycemia,
coma at low levels
• Toxic dose:
Ethanol
• Conclusion:
– Be careful with alcoholic beverages!
– Also be careful with other household
products…
– Lock ‘em up!
– 10-15 mL/kg beer, 4-6 mL/kg wine, 1-2
mL/kg hard liquor
– Jake: 40-60 mL wine or 10-20 mL hard
liquor
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3/9/2017
GUESS WHAT– ANOTHER CASE.
LAUNDRY DETERGENT PODS
From http://www.goodhousekeeping.com/homeproducts/laundry-detergents/a36470/best-laundry-packets2016/
Pods
• Available in Europe since 2001, US
since ~2012
• 2012-2013: 17,230 calls (6267 in 2012,
10,963 in 2013) for exposure in kids
younger than 615
• Highest among 1 and 2-year-olds
• Two deaths, 4.4% admitted to hospital
From Source 15
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3/9/2017
Pods
• Poisoning by ingestion, eye, skin
• Easily dissolves when exposed to saliva
• Most commonly ingested household
product
• Symptoms:
– Vomiting, coughing, rash, drowsiness, hole
in esophagus
Pods
• Toxic dose:
– 1 pod!
• Packaging has been changed…
• Conclusion:
– Lock ‘em up…
– But just don’t use them if you have kids
younger than 5.
EDIBLE MARIJUANA
From http://gizmodo.com/weed-candy-wreaks-havoc-on-sanfrancisco-quinceanera-1785041304
From https://commons.wikimedia.org/wiki/File:Amsterdam420-cannabis-products-window.jpg
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Edible marijuana
• Incidence increasing!
• Colorado:
– 2000: medical marijuana legalized
– 2009: DOJ stopped prosecuting
merchants
– 2014: legal for recreational use
From Source 16
Edible marijuana
• Median age 2.4 yr
• 48% of known marijuana exposures
were edibles
• 36% admitted to hospital
– 21% to general pediatric ward
– 15% to ICU
• AAP opposes legalization of marijuana
From Source 14
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3/9/2017
Edible marijuana
• THC: stimulant, sedative, or
hallucinogenic effects
• Symptoms: pallor, bloodshot eyes, fine
tremor, imbalance, confusion (lethargy
or agitation)
• Onset 30 min to 1 hour, with peak at 23 hours
• Toxic dose:
Edible marijuana
• Child-resistant packaging is an
option…
• Conclusion:
– Lock it up!
– If you have kids around, reconsider buying
edibles that look at all appealing.
– Depends!
YEP, ANOTHER CASE
From Source 2
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3/9/2017
Magnets
• Single magnet? No problem.
• Multiple magnets that travel together?
No problem.
• Multiple magnets flying solo? Big
problem.
• 2003-2006: 20 cases resulting in serious
complications12
MAGNETS
– 19 kids needed surgery and 1 died
Magnets
• Survey of pediatric surgeons17
– 99 reported cases
– 32% of kids got endoscopy, 65% of which
were successful
– 72% ultimately needed surgery
– 9% needed long term care and 1 child died
• Conclusion:
– Don’t buy magnets for kids, even tweens.
– More dangerous than they seem!
BUTTON BATTERIES
From
https://commons.wikimedia.org/wiki/File
:Coin-cells.jpg
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3/9/2017
Button batteries
Button batteries
• More frequent in ages 4-8
• Kids with hearing aids at increased risk
• Number of cases has remained
constant, but injury and death have
increased sevenfold!
• Toxic when in contact with a mucosal
surface– mouth, esophagus, ear, nose
• Mucosa bridges positive and negative
ends of the battery 
• Current generates free radicals, which
kill the tissue
Button batteries
• If swallowed, most will pass within 72 hours
without issue
• If stuck in esophagus, need emergent
removal
• National Battery Ingestion Hotline: 202625-3333
• Conclusion:
– Button batteries are dangerous!
– A button battery stuck anywhere needs
immediate removal.
From Source 6
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3/9/2017
A BRIEF PSA…
UpAndAway.org
Safety first
• Call the Poison Control Center
– 1-800-222-1222
• Helmets!
• Close the windows.
SUMMARY
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3/9/2017
Summary
Summary
• Now that you’ve endured this talk, you
can:
• Hopefully, now you’ve become aware
of substances and items in your home
which may be potentially hazardous to
children, and what makes them so
dangerous.
1. Name several common medications which
are particularly dangerous to children.
•
Aspirin, acetaminophen, the blockers, the ‘lines,
sulfonylureas, hydrocarbons, opioids, ethanol
2. Describe the risks of laundry detergent pods
and edible marijuana in pediatric patients.
3. Discuss other risky exposures in the home,
and how to prevent life-threatening illness
or injury for kids.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
[email protected]
QUESTIONS?
11.
12.
13.
14.
15.
16.
17.
Bonney AG, Mazor S, Goldman RD. Laundry detergent capsules and pediatric poisoning. Can. Fam. Phys. 2013;59:1295-1296.
Chandra S et al. Magnet Ingestion in Children and Teenagers: An Emerging Health Concern for Pediatricians and Pediatric
Subspecialists. Jour. Pediatr. Gastro. Nutr. 2012;54(6):828.
Finkelstein Y et al. Overdose Risk in Young Children of Women Prescribed Opioids. Pediatr. 2017;139(3):e20162887.
Jolliff HA et al. Pediatric Hydrocarbon-Related Injuries in the United States: 2000-2009. Pediatr. 2013;131(6):1139-1147.
Karel LI, Handzel MC, Rosini JM. Laundry Detergent Pod Ingestion in 2 Pediatric Patients. Jour. Emerg. Nurs. 2015;41:80-82.
Leinwand K, Brumbagh DE, Kramer RE. Button Battery Ingestion in Children: A Paradigm for Management of Severe Pediatric Foreign
Body Ingestions. Gastrointest. Endosc. Clin N Am 2016;26:99-118.
Love JN et al. Lack of toxicity from pediatric beta-blocker exposures. Hum. Exper. Toxicol. 2006;25:341-346.
Lung DD and Olson KR. Hypoglycemia in Pediatric Sulfonylurea Poisoning: An 8-Year Poison Center Retrospective Study. Pediatr.
2011;127(6):e1558-e1584.
Mowry JB et al. 2015 Annual Report of the American Association for Poison Control Centers’ National Poison Data System (NPDS): 33rd
Annual Report. Clin. Toxicol. 2016;54(10):924-1109.
Nordt SP, Vivero LE, Cantrell FL. Not Just a Drop in the Bucket– Inversion of Oxymetazoline Nasal Decongestant Container Increases
Potential for Severe Pediatric Poisoning. J Pediatr 2016;168:240-241.
Olson KR, ed. Poisoning & Drug Overdose, 6th ed. New York, NY; McGraw-Hill Companies Inc., 2012.
Osterhoudt KC et al. Toxicologic Emergencies. In GR Fleisher & S Ludwig (Eds.), Textbook of Pediatric Emergency Medicine, 6th ed (p.
1171-1221). Philadelphia, PA: Lippincott Williams & Wilkins.
Rayar P and Ratnapalan S. Pediatric Ingestions of Household Products Containing Ethanol: A Review. Clin. Pediatr. 2012;52(3):203209.
Tadros A et al. Emergency department visits by pediatric patients for poisoning by prescription opioids. Amer. Jour. Drug Alc. Abuse.
2016;42(5): 550-555.
Valdez AL et al. Pediatric Exposure to Laundry Detergent Pods. Pediatr. 2014;134(6):1127-1135.
Wang GS et al. Unintentional Pediatric Exposures to Marijuana in Colorado, 2009-2015. JAMA Pediatr. 2016;170(9):e160971.
Waters AM et al. Surgical management and morbidity of pediatric magnet ingestions. Jour. Surg. Res. 2015;199:137-140.
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