Acute toxic exposures in children: analysis of a three year registry managed by a Pediatric poison control Center in Italy

Poisoning is a common and potentially life-threatening public health problem, which contributes to the added costs of both emergency and in-patient care. Although poisoning may occur at any age, children are at particular risk. According to the American Association of Poison Control Centres (AAPCC), about 59% of poisoning cases in the United States involved patients under the age of 20 [1]. As far as we know, this is one of the few dedicated reports describing a large cohort of children exposed to xenobiotics in Europe and stratified by age groups. Improving our understanding of the current problem of paediatric poisoning may provide valuable informations for future education efforts, prevention strategies, public policies and treatment decisions. The aim of this study was to analyze the characteristics of a paediatric population exposed to xenobiotics, recorded over a three-year period by the Paediatric Poison Control Centre (PPCc) of the National referenced Children Hospital in Italy. The PPCc provides support to families of poisoned paediatric patients requiring counselling through an active phone line, which is accessible by parents and primary care/hospital physicians, or by providing direct access to the Emergency Department.

In Europe, under ECHA (European Chemical Agency) supervision, European Union Countries have their own National Poison Centres for giving information and collecting data on hazardous substances [2‐5]. Our centre is one of Italian Poison Control Centres and the one dedicated exclusively tochildren and managed, in the three years of activity here reported, 2566 children, aged 0–18, divided in two groups: P (children whose parents or caregivers contacted by phone the PPCc) and ED (children directly acceding to our Hospital). A total of 1611 phone calls were registered, of which 1313 were managed by phone counselling alone, without need to ED referral. This unique telemedicine service has a pivotal role, since it provides specialized support, avoiding unnecessary accesses to the hospital, with flux reduction in ED, decreasing both individual and collective risk of infectious disease spread. This last risk has been particularly relevant in the current Covid-19 pandemic reducing also health care costs for the population [6, 7]. The description of services provided by PPCcP and PPCcED accesses is also useful to public health authorities in order to describe the risk of xenobiotic exposure in children and adolescents and to identify prevention measures and policies to be implemented.

Pre-school was the age group most frequently managed by PPCc, reflecting the unintentional exposure due to environment exploring attitudes typical of this age. Accidental exposure to pharmaceuticals appeared an important cause of exposure in all ages among P and ED groups. The most frequent drugs exposure in infants, pre-school and school age children involved analgesics, a category of drugs often available at home, while for the adolescent group is represented by neuroactive drugs, often taken intentionally by this age group.

Data for the age group 14–18 years could be underestimated as these patients can also be referred to an adult ED. Nevertheless, our PPCcP plays an important role within local health reality and especially for this age group, it represents a guide for other hospitals. This aspect underlines the importance of a specific pediatric poison control center able to carry out a correct management of xenobiotic intoxication in all pediatric ages.

Among the younger age groups, the leading categories of exposure were drugs, industrial and domestic products, followed by cosmetics, caustics, plants and pesticides. Interestingly, plantexposure is a frequent reason of PPCcP consultation among youngsters probably due to the overestimation of the danger and also because plants and their toxicity represent an unknown world [8]. This huge variety of xenobiotics reflects the heterogenous types of products available around children’s world. Being surrounded by such a large amount of products represents a potential hazard for children. This is a reason why exposure to xenobiotics happened most frequently via the oral route, because of the acquired competence of this age group.

Medication errors represented an uncommon exposure and our experience shows that most of them were managed at home (90.1%) and no referral to hospital was necessary. However, this phenomenon deserves particular attention because it is not determined directly by the child. Data collected suggested that exposures are due to difficult management and to limited experience in drug administration. Even drug labelling and packaging complexity may increase difficulties in finding and understanding information. Similarly, socioeconomic status and poor awareness of side effects can play an important role. Although linguistic difficulties in the medical prescription interpretation could be considered as the main reason for an erroneous drug administration, however, in our case series most of these errors were made by Italian and non-foreign parents. Moreover, some parents may also intentionally give children additional doses, if the prescribed doses do not achieve the desired outcome (e.g. antipyretics and cold medicines) increasing the risk of side effects [9]. Around 36–67% of the drugs used in paediatrics age are drugs administered off-label [10], and this aspect leads more frequently to medication errors [11, 12]. Off label drug use in children requires special attention and detailed instruction that are not always reported in the leaflets and need adjunctive instructions provided by the prescribing physician. Furthermore, safety data relating to the use of medicines in children are limited and not always possible to extrapolate them from the information available on adult studies [11, 12]. In our experience, adverse drug reactions represent a rare occurrence and the small number of cases mirrors the trend reported in literature [13]. However, to our knowledge, adverse drug reactions are hardly described by the PPCcP also because this event is directly referred to ED. Since PPCcP physicians are competent also to manage ADR, an educational action should be directed to the population, in order to refer more frequently to PPCcP and consequently to reduce inappropriate access to ED.

We reported a high percentage of asymptomatic cases (90%), higher in infant, pre-school and school groups, probably due to parental anxiety that inversely correlates with aging. Hospital referral was recommended for 18.5% of cases calling the PPCcP, with higher prevalence for pre-school and adolescent age group. A limitation of this study is that it was not possible to follow up patients who were referred to other hospitals after having a contact with the PPCcP.

Suicide attempts referred to ED are infrequent but remain a cause of concern, in fact suicide is the second leading cause of death in adolescents [14]. Generally, suicide attempts are numerically higher than actual suicides, but the real number is underestimated because it is difficult to obtain reliable information. We found a low number of consultations to the PPCcP all performed by the parents of asymptomatic older teenagers, with a tendency of downplaying what happened, while those directly referred to ED were symptomatic with mild/severe presentation and in a greater number. We believe that these types of exposures rarely makes little use of PPCcP. A significant association was not detected between age and severity of intoxication. Suicide attempts can be a risk factor for suicidal behaviour. Although in Italy suicide rates are the lowest in Europe, the presence of the risk factors listed in literature must be strictly evaluated and actively treated to avoid suicides [15, 16]. In our study, ingestion results the principal route of exposure. Enteric decontamination (DE) prevents the absorption of xenobiotics from the gastrointestinal system and includes the use of activated charcoal, gastric lavage, cathartics, whole bowel irrigation and ipecac or other emetics. To our knowledge, in the paediatric age group, activated charcoal and gastric lavage remain the most frequently treatments. In our study, 18,1% of our patients received a DE treatment. In children the use of activated charcoal or gastric lavage depends on the type of xenobiotic, modality exposure and time of latency. However, it is necessary to consider that invasive procedures are more difficult to perform and present major challenges, which may worsen the outcome. Consensus of clinical toxicologists showed that activated charcoal in the case of drug poisoning may prevent absorption if given within an hour [17, 18].

In about 8% of cases, admission to the PICU was required. Approximately 70% of hospitalizations in the PICU required only advanced vital signs monitoring, and this is similar to what has been reported in literature [19, 20]. The reason is that in most cases, after an exposure, they may not show symptoms when arriving to the ED. In these cases, if the exposure is confirmed by the clinical history and the xenobiotic is dangerous, it is reasonable to think that the maximum absorption of the xenobiotic has not been achieved yet and PICU admission may be therefore advised. In our study, fatality is an event that did not occur, in accordance with current literature [21‐23]. Differently from adults, the fatality rate of paediatric poisoning is much lower because most of them are unintentional and the ingested xenobiotic dose is too low to induce severe intoxication.

The results of this study describe in detail the types of xenobiotics most frequently involved in paediatric exposures, requiring hospitalization and, they show the role of PPCc, both by Phone and directaccess to the ED, as the figure that can manage all of the cases. As a consequence of PPCcP, a larger number of cases can be initially screened and remotely managed, avoiding unnecessary hospital referral, Our experience confirms that mortality is low in paediatric age and most cases of toxic exposures are either asymptomatic or develop mild symptoms. This information represents the foundation for avoiding unnecessary medicalization and hospitalization. The data collected also indicate that intentional exposure is significant in the adolescent group, where there is an autonomous use of the substances. Furthermore, as underlined by World Health Organization, suicide attempts or self-harm in adolescents are an emerging health problem worldwide and poisoning with drugs represents the most used method. In our opinion an exclusively pediatric Poison Control Center can represent the opportunity for not only a better care, but also for an improved understanding of pediatric and providing useful information and implementing successful preventive strategies.