Gulati Raj Rani, MBBS, DCH, MRCP - Sr. Specialist, Sayeda Akhter, MBBS, MD. Registrar, Fahed Al-Anezi, MD, Canadian Board - Specialist

Department of Pediatrics, Al-Jahra Hospital, Kuwait

Correspondence to:
Dr.Raj Rani Gulatti
Tel. : 009656074570
P.O.Box : 1853
Pin Code :13019
Safat, Kuwait
E-mail: rajrani151@yahoo.com
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Globally, poisoning in the pediatric age group still remains a common problem⁽¹⁾. Despite the reduction in number of deaths due to poisoning, there are still significant number of potential exposures⁽²⁾ More than one million exposures occurred in children less than six years of age during 1994 in the U.S., accounting for 54% of all exposures. In contrast, only 121,512 poison exposures were seen in children aged six to twelve years. In addition to morbidity and mortality associated with poisonings, these exposures involved significant use of health care resources. In America three percent of poisonings in children lead to admission to a critical care unit⁽³⁾ While households with small children are often the focus of poison prevention education, it is estimated that one fifth of all poisonings occurred outside the home^(1,2).

Previously introduced poison warning stickers in 1970 have failed to provide a deterrent effect in clinical trials⁽⁴⁾. Unit dose packing, such as strip or blister packs was introduced to decrease the risk of accidental poisoning in children less than six years. However, users do not always re-engage the closure in its protective position^(5,6,7).

Improper storage of hazardous household products remains one of the leading causes for pediatric exposures universally. It has been noted that hyperactive, inquisitive, impulsive children and those exposed to recent stress are at greater risk^{(8, 9, 10)}. It is estimated that nearly 30% of all children less than six years of age who experience an accidental ingestion will be involved in at least one or more episode before the age of six years⁽¹¹⁾. Recently Woolf and colleagues have reported a recurrence rate of 3.7% within three months surveillance period^(12,13). Daycare centers and play groups for pre-school children are equally potential places for poisoning in children of nuclear families with working parents. However, there is little if any evidence, to support this belief. Recent stresses in the family, unstable families and recent change of residence have been implicated as the predisposing factors^(14,15) for pediatric poisoning.

The nature of the causative agent implicated in poisoning varies with local beliefs, customs and current availability of drugs and chemicals^(16-26). Kerosene still remains a multipurpose household product commonly available in the majority of houses in the Gulf region. In Kuwait it is used more during outdoor picnics in spring.

The high risk age groups include ages between one and three years^(16-26). A fairly high incidence of passive poisoning was reported by Buffali et al in infants in their first year of life as a consequence of mistake by the mother or caretaker⁽²⁴⁾.

Our study shows a wide spectrum of agents, commonly ingested by the inappropriately supervised children of Kuwait.

We reviewed the medical records of 678 children admitted with acute poisoning during a fifteen year period from January 1992 till December 2006. Medical analysis included (1) historical information, age, sex, nationality (2) physical examination and⁽³⁾ chemical identification. The positive historical information confirmed witnessed exposure or observation of the child mouthing, playing and or spitting the toxic substance. Physical findings were considered significant whenever a child presented with signs and symptoms suggestive of toxic product ingestion e.g. coloring of the tongue, repetitive cough, drowsiness and smell etc. The causative chemical agent in the blood was identified by florescent polarization technique in our hospital laboratory. Each medical record was reviewed by one author. 20% of the medical records were re-reviewed to confirm the data. The high risk factor like age was divided into 4 subgroups (a) less than one year (b) 1-3 years (c) 3-6 years (d) 6-12 years.

The causative agent was categorized as (a) household product (b) medicinal product (c) plant product. The type of poisoning was divided into accidental or non accidental.

Of the total pediatric admissions during our study period, 678 admissions accounted for acute poisoning. 508 (74.7%) children were less than three years of age, while 627 ( 92.4% ) children were under six years of age. Overall male predominance was noted (Table 1). Acute poisoning affected local children twice more commonly as compared to expatriate children.

Drugs accounted for 356 (52.5%) poisonings in this study (Table 2). Analgesics were the commonest drugs implicated followed by methylsalicylates. Miscellaneous drugs like oral contraceptives, eltroxin, mosegor antibiotics and antihypertensives were ingested by 140 (22.1%) children in this series. Eight children ingested iron accidently. We could not identify the drug in eight cases.

The majority of these drugs were prescribed to the victim or other family members at home. They were dispensed from the ministry of health pharmacy or private pharmacies. Mostly these drugs were not stored in their original containers, and were kept at easily reachable levels in bed rooms/handbags. At times, drugs were kept at high levels, but the child would climb up and eat the drugs. The child resistant containers were left half open in 50% of cases. The parents, grandparents or caretakers were responsible for this improper storage at home. Most of the poisonings occurred accidently at homes or in the gardens.

• Four school going children self medicated themselves with analgesics during examination.
  
• Two nine year old girls were prescribed Buscopan by their colleague in the class.
  
• One eight year old boy with paracetamol and another nine year old girl with Tegretol ingestion were considered parasuicidal poisoning.
  
• Two boys with kerosene ingestion and two girls with methyl salicylate ingestion did this after a minor argument at home.
  

Ingestion of harmful household products was seen in 322 (47.5%) children (Table 3). Petroleum distillates stored in large soft drink bottles accounted for 157 (23.1%) cases. Detergents were accidently ingested by 45 (6.6%) children in this study. None of the children developed chemical burns. No child was endoscoped.

Miscellaneous hazardous household products like acetone, shampoos, glue, oil and henna were implicated in 51 (7.5%) cases. We were unable to identify the causative household agent in five cases. All these hazardous products were said to be kept at low easily reachable levels in the kitchen or bathrooms in loose containers. Mainly children from migrant families were the victims of household poisonings.

Most of our cases left the hospital after 24 hours. Eight cases had significant morbidity needing close monitoring in the Pediatric Intensive Care Unit (a) for ingesting an extra dose of digoxin with bradycardia. He improved after digiband therapy; (b) the 2nd casewas a two year old girl who developed severe hypotension after ingesting an antihypertensive. She responded to normal saline infusion followed by ionotopes for 2 days (c) the 3rd case, a six year old known asthmatic boy ingested accidently about 120 ml of kerosene oil kept in a large Pepsi bottle. He developed marked respiratory distress within six hours of admission. His chest X-ray showed bilateral basal and parahilar infiltrates. He required 72 hours of intensive care with ventilatory support, bronchodilatation, methyl predinisolone, antibiotics and oxygen supplementation in PICU. Complete recovery occurred after seven days. (d) Four children from different families were affected with organophosphorus poisoning. The youngest was 5 days old, a breast fed neonate. He developed apnoeic attack with bradycardia. He was ventilated and given pralidoxime with atropine. The other four required close observation and monitoring. One of them, a three year boy was brought again after six months with the same organophosphorus poisoning. He responded to prolidoxime and atropine. (e) One child after psychotropic ingestion developed respiratory failure. He was given ventilatory support for 24 hours and discharged home after five days in good condition.

22 (3.6%) cases showed some evidence of non-accidental poisoning. They were school going children between ages of six and twelve years. Their history was suggestive of peer pressure, examination stress, minor arguments at home/school. Four cases were poisoned iatrogenically (a nine year old by his peer in the school, a six year old boy who took belladonna mixture himself, and a mother who used methyl salicylate in two cases).

21 (3.1%) patients left for home against medical advice within the first four hours of hospitalization. All other patients were discharged home in good condition after receiving relevant information. A local hospital investigator was informed in all the cases.

Globally, exposure to drugs and hazardous household products remains a common health problem. To our knowledge, this is the first long retrospective study, that, still shows a significant morbidity due to acute accidental poisoning in children in the same health region of Kuwait over a period of 15 years. A previous study in 1986 and 1996 showed an incidence of 3.7% and 1.5% respectively^{(25, 26)}. There is some decline, but this is not a significant decline in the incidence of acute poisoning. However, the real incidence may be higher than reported here, for many, minor ingestions at home may not warrant a visit to the hospital.

The high risk factors identified in this study include a target age group. Typically the high risk age group remains between one and six years, the majority being under three years of age (74.7%). Highly energetic and inquisitive males are twice more commonly affected than females^(1-9). Children at these ages are reported to have a higher propensity to explore and gain self experience. However, they are unable to discriminate between the safe and unsafe products. These high risk age group children need strict supervision by the caring adults. Acute poisoning seen in 4.2% infants in our study shows not only sheer neglect but poor packaging of drugs like methyl salicylate which was commonly mistaken for the oral analgesics.

The nature of the causative agent has changed over years^(1-16). Easy availability of certain drugs has resulted in the majority of acute poisoning in this study. Analgesics and methylsalicylate ingestion has replaced psychotropic ingestion. These agents are freely dispensed by the pharmacies in Kuwait. Our previous study shows a drug poisoning profile starting with antidepressants, antihistaminics, antiepileptics and oral contraceptives^{(25, 26)}. The present profile has reflected poor control on prescriptions, availability and packaging of analgesics, and antihistaminics. Cocktails of colourful attractive drugs were brought to the hospital by the parents not in their original containers.

The child resistant containers were left half open by the parents/caretakers as reported earlier by Mc Intire MS et al⁽⁷⁾. We observed an increasing number of asthma cases in the families with an increase in accidental salbutamol poisoning. However, there is no documented proof for the same.

Potentially toxic miscellaneous drugs, were ingested by a significantly large number (21.4%) in our study. Easy availability of a variety of oral contraceptives found in lady's handbags resulted in a large number of poisonings in this study. However, none of the children had developed any morbidity, thus raising the issue for questionable hospitalization. Potentially toxic iron ingestion was seen in eight cases from 1992 till 2000. Later no acute iron poisoning was seen in the last six years of our study. Many drug poisonings can lead to significant mortality & morbidity^{(21, 24)}. We had no mortality and none of our children were scoped. This is not intended to relax our current state of poison prevention vigilance.

Among the causative household agents, kerosene oil still remains an easily available multipurpose household product. In this community, it is commonly stored in large soft drink bottles at homes. Its accidental ingestion, though declining, still remains high, 157 cases (23.1%). Different authors have reported various kerosene related morbidities in their studies^(16-25) in the past . Our previous study showed a very large number (90) of cases (43.4%) of kerosene poisoning⁽²⁶⁾. With an increasing rate of asthma in children, kerosene ingestion may result in significant morbidity and mortality.

Detergent exposures have increased to 6.6% due to easy availability in the market. Rodenticide exposure can affect families and can be lethal⁽²⁰⁾ . Despite pesticide related significant morbidity in four children, they were discharged in good condition from our hospital. It is said that the most available rodenticides contain less anti coagulants. In Kuwait, with its construction boom, green revolution, improving fashion industry and modernisation, there is increased exposure to, rodenticides, insecticides, pesticides, shampoos, dyes, sprays, acetone, oils, henna and many different consumer items. The present study has shown a three fold increase in their exposure^{(25, 26)}. As reported earlier mainly children from the migrant families are the victims of the exposures^{(14, 15, 25, 26)}.

Our study has indentified several high risk factors. It has shown us some decline in incidence. It also shows a wide spectrum of agents implicated in acute poisoning in Jahra Health Region of Kuwait.
There are some limitations to our study. Since this study involved a long period, spread over fifteen years, and there is constant movement of bedouins and migrant families in this health region, hence recurrence rate could not be identified. Secondly, we were unable to educate certain families as they left against medical advice soon after admission

Our study shows some decline in the incidence of acute poisoning among children. Further studies are needed from different health regions, to compare results and to raise our awareness to this significant health problem.

It is recommended that

1. All the physicians working in the well-being clinics should regularly discuss poison prevention with parents and the caretakers.
   
2. A national community health education programme for child safety and poison prevention should be conducted regularly through mass media.
   
3. Exclusively the drugs, chemicals and hazardous household products with appropriate warning labels and safety precautions should only be sold in the markets.