Poisoning is one of the most common pediatric medical emergencies. In 2006, the American Association of Poison Control Centers (AAPCC) National Poison Data System reported 1,223,815 toxic exposures in children younger than 6 years. This report included 29 fatalities and 11,062 moderate or severe complications (1). For this same age group, greater numbers were previously reported by both the National Center for Health Statistics (53 fatalities and 20,000 hospitalizations during one 12-month period) (2) and the Consumer Product Safety Commission (85,000 emergency department visits by young children annually for poisoning) (3). In 2004, the Institute of Medicine conservatively estimated the annual incidence of poisoning episodes in the United States to be 4 million cases. That year, the AAPCC captured 56% of these cases. Extrapolating the 2004 rate of reporting to AAPCC poison centers to their 2006 total volume suggests that 4,292,034 US exposures occurred (1). Although there were an estimated 30,800 fatalities in 2004, US poison centers captured only about 3.5% of these reports. These discrepant data highlight the significant underreporting of toxic exposures to poison control centers.

Overall, poisoning episodes are largely exposures and only 7.5% lead to hospitalization. Poison centers are staffed by skilled professionals whom contacted early, can treat 72.9% of children at home (1). Beyond their ability to provide immediate first aid advice and reassurance to caregivers of poisoned children, poison centers have added value. They positively affect the utilization of health care resources and they uniformly compile data that provide real-time disease surveillance and drive safety initiatives (4). They actively carry out poison prevention activities for the public and for health care professionals. Finally, recent poison center enhancements provide anxious caregivers and health care providers in all 50 United States, Puerto Rico, and the District of Columbia universal access to specially trained pharmacists, nurses, and physicians via a toll-free number. This uniform nationwide number, 1-800-222-1222, is the result of collaboration among the AAPCC, the Centers for Disease Control and Prevention, and the Health Resources and Services Administration.

The peak age for poisoning is age 1 to 3 years. The age and gender distribution of human poison exposure victims is outlined in Table 61.1. Children younger than 3 years were involved in 38.0% of exposures and 50.9% occurred in children younger than 6 years. A male predominance is found among recorded cases involving children younger than 13 years, but this gender distribution is reversed in teenagers.

The most common agents involved in toxic exposures in children younger than 6 years are listed in Table 61.2. These tend to be substances that are found in and around the home. A few studies have attempted to establish which substances are most hazardous to children younger than 6 years. The first was a large analysis of 3.8 million exposures carried out between 1985 and 1989 (5). Findings included 2,117 cases of major life-threatening toxicity and 111 fatalities. The substances with the highest hazard factors were iron, which accounted for 30% of fatalities; tricyclic antidepressants; cardiovascular agents; aspirin; hydrocarbons; and pesticides. In a summary of serious pediatric toxic exposures between 1991 and 1995 (6) (Table 61.3), the substances most commonly associated with major effects in children younger than 6 years were cleaning substances, cardiovascular agents, hydrocarbons, sedative–hypnotic agents, antidepressants, pesticides, and analgesics. The most common fatal exposures in this group were to carbon monoxide, iron, and analgesics. Adolescent fatalities were most commonly associated with exposure to hydrocarbons, antidepressants, analgesics, and cardiovascular agents.

In 2006, there were 29 fatalities reported in children younger than 6 years, similar to numbers reported over the last decade (1). The reasons for these fatal exposures are outlined in Table 61.4. Of the reported deaths in children younger than 6 years, 21 were reported as unintentional. Four deaths in children younger than 6 years were from malicious intent. Of the 21 pharmaceutical-associated fatalities, 6 involved opioids, 3 involved heparin, and 3 involved antihistamines. Of the 8 nonpharmaceutical-associated fatalities, 2 involved carbon monoxide, 2 involved hydrocarbons, and 1 each involved lead, mineral spirits, disc battery, and other foreign body. In the age range of 6 to 12 years, there were 6 reported fatalities involving 6 substances: acebutolol, antihistamine, carbon monoxide, fentanyl, mushrooms
cyclopeptides, and pine oil. Although children younger than 6 years were involved in the majority of exposures, they comprised just 2.4% of the verified fatalities.

Differences between pediatric and adult poisoning exist. Most toxic exposures in children younger than 6 years are accidental or unintentional. Young children often ingest or are exposed to a single substance. Furthermore, the time to discovery is brief. Most (73%) of exposures in young children are reported within 10 minutes, and children arrive to the emergency department sooner than adults. Because the child is often found with the substance, exact ingredient identification is more feasible and reliable. Generally, a smaller amount of substance is ingested by children as compared with adults. Even so, one may be seriously misguided by the universal assumption that children “only ingest small amounts of pills” or “won’t ingest things that are malodorous or bad tasting.”

Why does pediatric poisoning continue to occur? As just noted, most exposures in young children are accidental and unintentional. These occur as toddlers explore their environment and exhibit normal hand-to-mouth activity.
Other factors include caregivers’ underestimation of the developmental skills of their child, imitative behavior (watching parents take medication), “look-alike” substances or containers (similarities between the intoxicant and familiar candy or beverages), and poor packaging. Concerning packaging, the use of child-resistant containers has dramatically decreased pediatric poisoning morbidity and mortality. Nonetheless, carelessness or distraction on the part the caregiver while the product is in use limits the effectiveness of this safety feature. Illustrative of this fact is that pediatric poisoning from exposure to cleaning products in the home occurs while the product is in use in 70% of cases (7). Lack of grandparent awareness about the safe storage of their own medication is another cause for pediatric poisoning. Often, these exposures are serious because they involve highly toxic pharmaceuticals such as cardiovascular agents or antidiabetics. Grandparent’s handbags, bedside stands, kitchen tables, and day-of-the-week pill dispensers are all potentially hazardous. Another important cause of poisoning, therapeutic error, constitutes 7.4% of toxic exposures and accounts for 31% of poisoning deaths in children younger than 6 years (1). Across age groups, 36% of therapeutic errors result from double dosing. This phenomenon is especially prevalent among children prescribed medication to treat attention deficit hyperactivity disorder, defining an emerging at-risk group for poisoning (8). Other therapeutic errors in children commonly result from dispensing-cup errors, 10-fold dosing errors, and drug interactions (1). Intentional poisoning may result from suicidal intent, home stressors, or substance abuse, and, unfortunately, should be considered as early as age 6 years. The most common reasons for poisoning fatality in 13- to 19-year-olds, a group with a steadily increasing fatality rate, are suicide followed by abuse.

Risk factors for pediatric poisoning have been analyzed. These include behavioral, environmental, and parental factors. Recurrent poisoning may occur in up to 30% of children with a history of previous ingestion (9). Behavioral traits in the child that predispose to accidental repeat poisoning are hyperactivity, rebelliousness, impulsivity, and pica. Environmental change or chaos, as occurs in the setting of a new home, new sibling, holiday event, or dinner preparation, presents a risk for poisoning. Parental factors include medical illness, depression, and social isolation (10,11).