Management

After undertaking a thorough history and examination of a poisoned child the Emergency physician will need to make a risk assessment of the likely exposure and the probable course of toxicity.

As a rule, as in adults, management is largely supportive in nature. The vast majority of ingestions in children will be of low or non-toxic substances. Details of these can be found on the Toxbase website (see poster). Reassurance can be given to parents if their child has ingested a substance on this list with advice to observe their child at home and to return if symptoms such as vomiting, rash or altered conscious level were to develop.

For other agents that Toxbase specifies as requiring further management this will fall under two headings, general and specific. Where you are unsure as to the most appropriate management of a child who has been poisoned, expert advice is available 24 hours a day, 7 days a week through the National Poisons Information Service and should be consulted.

Unknown ingestion

Where parents have provided a description of a particular tablet, leaf, berry etc or have a sample of that ingested there are various resources available to identify said substance. By contacting the Poisons Information Service (NPIS) they have access to TICTAC a comprehensive drug identification database. Links with the Royal Botanic Gardens at Kew similarly exist to help identify unknown plants.

General management

The cornerstone of effective management in paediatric poisoning cases is good supportive care and appropriate observation. Supportive care will aim to normalise abnormal clinical observations to ensure normothermia, euglycaemia, euvolaemia (with normalisation of acid-base balance and electrolyte abnormalities) and prompt management of seizures. First line treatment for drug-induced seizures will be benzodiazepines. Phenytoin, with its sodium channel blocking properties, should be avoided as it may exacerbate the problem. Be aware of potential secondary complications such as rhabdomyolysis, aspiration pneumonitis and persistent delirium.

Gut decontamination is covered fully in another session but includes activated charcoal in a small number of cases where a potentially toxic amount of a well charcoal-adsorbed poison has been ingested within the last one hour, in a child in whom there are no concerns regarding their ability to protect their own airway.

Induced emesis (ie syrup of ipecacuanha) is no longer recommended in any circumstance [9]. Gastric lavage is still mentioned however the appropriate expertise most be sought and the patients airway secured; this is unlikely to be achieved in the first hour post ingestion. Whole bowel irrigation remains a possibility for some slow release preparations but is reliant on patient compliance.

Activated charcoal can be mixed with a cola-type drink to make it more palatable without reducing its effectiveness [8].

Specific therapies

Antidotes

These are used in poisonings by a limited number of toxins but are rarely required in paediatric poisonings. Obtaining an antidote and its use should not distract from appropriate supportive care. Be aware of the changes to paracetamol overdose management implemented in 2012 following a review by the Commission on Human Medicines. Weight based tables are now available to guide dosage and administration of intravenous acetylcysteine [10].

Elimination for aspirin toxicity

This may include alkalinisation of the urine in severe salicylate poisoning as well as more invasive elimination methods including haemodialysis. Refer to Toxbase advice for specific poisonings.

Disposition

As mentioned above, most children will be able to be discharged home once fully assessed and the causative agent deemed low or non-toxic. Other ingestions may determine a longer period of observation in a healthcare facility with the ability to manage the child if they were to deteriorate. All however should be assessed for social, mental health and safeguarding risks.

Child protection and safeguarding concerns

Whether the child concerned is at risk of further harm on discharge from the ED must be considered in any poisoning case. Deliberate poisonings (including fabricated/induced illness by carers) are thankfully rare but your index of suspicion should be higher in children under the age of 1 or where the story relating to the ingestion of said substance does not fit with the developmental milestones that child has reached. Often deliberate poisonings may not present as this and may include failure to thrive, chronic problems or a non-specific acute presentation.

A much more common situation is that of accidental ingestion as a result of inappropriate supervision at home. Of children under the age of 6 who present to the ED with an ingestion of a toxin, 30% will represent to the ED with a further episode [11]. It is not just the child themselves that is at potential harm but also their siblings or other children in the household. This may be a symptom of a family network requiring extra support. Provide poison prevention advice and education to these parents and arrange further follow-up in the form of a health visitor or school nurse referral.

Where children have been placed at more significant risk or there are concerns about deliberate poisoning then the case will need to be discussed with the Lead for Child Protection before the child leaves the ED. Follow local safeguarding policies and ensure good documentation in the notes. To safeguard children it is important that health services share information.