Over 2 million poisoning exposures are reported to the American Association of Poison Control Centers’ National Poison Data System each year.¹ Nearly half of all reported exposures involve children aged 5 years or younger, and two-thirds can be considered “pediatric” exposures. Seventy percent of poisoning exposures reported to poison centers are managed at home, with less than 10% of exposures leading to hospitalization. In 2004, the federally commissioned Institute of Medicine determined that poisoning was the second leading cause of injury-related death in the United States, with costs exceeding $12.6 billion each year.² Recently, poisoning has surpassed motor vehicle collisions as the leading cause of death due to injury in the United States.

The epidemiology of pediatric poisoning is bimodal: young, curiosity-driven children encounter toxicants through normal exploration of their environment, whereas adolescents become poisoned through substance abuse, experimentation, and intentional self-harm. Hospitalization rates, morbidity, and mortality are higher among the older group. Both groups are appropriate targets for preventive education in the hospital setting.

Poisoned children are frequently encountered by pediatric hospitalists. Typically, the poisoning scenario has been identified before inpatient hospitalization; however, pediatric poisoning may occasionally present as a diagnostic dilemma. The families of all children admitted to the hospital should be queried with regard to medication use; use of vitamins, herbs, or ethnic remedies; recreational drug abuse; occupational drug and chemical exposure; and environmental drug and chemical exposure. Several features of childhood illnesses that should raise the suspicion for poisoning are detailed in Table 165-1.

Respiratory arrest, shock, cardiac arrhythmia, and neurological injury are the most acute threats to life from poisoning. A standardized approach to initial life support is recommended (Table 165-2). Central nervous system depression due to poisoning may be most effectively assessed and communicated using the “AVPU” system (A, alert; V, opens eyes to verbal stimuli; P, opens eyes to painful stimuli; U, unresponsive). The Glasgow Coma Scale (GCS) was developed for trauma evaluation, and its prognostic properties do not apply to acute poisoning. It is important to identify hypoglycemia or hypoxia as a cause of altered mentation early in the resuscitative process.

With critical life functions stabilized, attention should be given to decontamination of the patient from offending poisons. Topical contamination of the eyes can be flushed with warmed normal saline, and skin can be washed with soap and copious water. Based on the recommendations of the American Academy of Pediatrics (AAP), inducing emesis with syrup of ipecac has largely been abandoned as a means of decontaminating ingested poisons.³ Gastric lavage, once a mainstay of gastric decontamination, has also fallen out of favor and should be considered only in rare circumstances (Table 165-3). Activated charcoal administration is the decontamination strategy of choice for most potentially toxic pediatric ingestions (Tables 165-4 and 165-5).⁴ Activated charcoal is typically administered as a slurry at a dose of 1 g/kg, up to a maximum of 75 g. Charcoal should be regarded as a drug, and vomiting, constipation, pulmonary aspiration, and death have complicated its clinical use.⁵ Naso- or orogastric tube administration of charcoal appears to be more commonly associated with severe adverse events. Whole-bowel irrigation with a polyethylene glycol-balanced electrolyte solution can be used to prevent the absorption of ingested toxic substances (Table 165-6). It is typically administered via nasogastric tube at rates titrated to 500 mL/hour in young children and 2 L/hour in adolescents. It is continued until the rectal effluent is clear but should be discontinued for refractory vomiting, abdominal pain, or abdominal distention.