Journal
Bond GR, Woodward RW, Ho M. The Growing
Impact of Pediatric Pharmaceutical Poisoning. J Pediatr. 2012 May;160(5):888-9.
Article Background
Objective: To investigate the medications and situations
that are responsible for an increase in pediatric medication poisonings,
resource use, and morbidity.
Source: The Journal of Pediatrics, 5-year Impact
Factor = 4.281, Ranked 6 out of 118 in pediatric journals.
Authors: Authors were affiliated with Cincinnati
Children’s Hospital Medical Center Division of Emergency Medicine and the Drug
and Poison Information Center. Authors
declared no conflicts of interest.
Funding: There were no external funding
sources for the study. The American
Association of Poison Control Centers costs about $136 million and the federal
government provides $17 million in support with additional support from state
governments, hospitals, and additional nonfederal sources.
Current Knowledge & Relevance: 82% of adults and 56% of children
take at least one medication every week1. There has been a decline in
non-pharmaceutical (cleaning, pesticides, and personal care products) poisoning
exposures in children aged ≤ 5 years, but poisoning exposures related to
medications have been increasing2.
Pediatric exposure to medication is a type of preventable injury with
over 50% of toxic exposure occurring in children less than 6 years of age with
the most common age being 2 year olds3. Robin et al 2006 conducted retrospective
research of 200 phone calls made to a regional poison control center that showed
that access to medication regardless of type of container (CRC vs non-CRC) was
the only statistically significant outcome (P<0.001) in pharmaceutical
poisoning. In the research sample, the
most common easy access locations were tabletop or counter, low shelf,
pocketbook with secure locations being cabinet or high shelf. Approximately 50% of the poisonings were child
resistant containers (CRC) with the most common non-CRC exposures being
multiple day medication containers, bottles, box, and plastic bag. Medications that are lethal to children in
unintentional pediatric exposures are analgesics, anesthetics, antidepressants,
antihistamines, antimicrobials, asthma, cardiovascular, hormonal, psychotropic,
stimulants, and topicals4. The
three E’s of injury prevention include educational
initiatives, engineering
modifications such as CRCs, and enforcement
of the 1970 Poison Prevention Packaging Act5. Recently, a new Healthy People 2020 objective
aims to reduce morbidity by decreasing the number of emergency visits for
medication overdose in children aged <5 years by at least ten percent6.
Rationale: Poisoning remains a common childhood
injury with each year > 500,000 children aged ≤ 5 years exposed to
pharmaceuticals in a potential poisoning event and more than 50,000 emergency
department visits yearly with injury and poisoning being the most common reason
for pediatric emergency room visit7.
This is especially relevant to community pharmacy as community pharmacists
can play a key role in educating patients about correct medication use and
storage. This study will address the
medications and circumstances related to increased medication poisonings.
Methods & Design
Design: Retrospective data analyzed
utilizing the National Poison Data System (NPDS) electronic database of all
calls to the 61 member poison control centers of the American Association of
Poison Controls Centers (AAPCC).
Randomization: Observational study design with no
randomization reported.
Inclusion Criteria: Patient electronic database records of
calls made to poison control centers from 2001-2008 of 453,559 children ≤ 5
years were evaluated in a health care facility following exposure to a
potential toxic dose of a single pharmaceutical agent. Combo products such as
antihistamine/decongestant cough and cold products were considered single
products and included in the analysis.
Acetaminophen containing combination cough and cold products were
included as cough and cold products.
Exclusion Criteria: Cases were excluded if additional
information suggested the drug exposure was not related to patient’s death or
exposure route was not ingestion. 67,080 patients were excluded from analysis
with 64,017 excluded because patient ingested >1 medication.
Intervention: Pharmaceutical agents were
classified by type as over-the-counter or prescription and by functional
category. Exposures were also classified by reason type as unintentional self-exposure
or unintentional therapeutic error, and those exposed to a single product. The impact of each class of agent for agent
type and reason was calculated using percent admitted and morbidity calculated
as percent meeting NPDS standardized symptom-based outcome criteria for
moderate effect, major effect, or death.
Further review of information was conducted to validate the nature of
exposure, the reason, and the primary agent.
Main Outcomes: Child self-exposure was responsible
for 95% of health care visits with the greatest resource use and morbidity
following self-ingestion of prescription products especially opioids,
sedative-hypnotics, and cardiovascular agents.
Statistical Analysis:
All statistical analysis were conducted with SAS version 9.2 and comparisons
were considered significant if P<0.05.
Advantages: Large sample size used and
classifying agent and exposure type was appropriate.
Disadvantages: Case-records in the database are
from self-reported calls and may not accurately represent a poisoning or
overdose nationally.
Main Results
Primary Outcome: Prescription products had the most
health care impact with 248,023 of visits (55%), 41,847 admissions (76%), and
18,191 significant injuries (71%) with the greatest resource use and morbidity
following self-ingestion of opioids, sedative-hypnotics, and cardiovascular
agents. Oral hypoglycemic agents had the
highest admission rate and the highest injury rate.
Additional Outcomes: The increases reported for injury
(43%), admission (36%), and emergency department use (30%), and exposures (22%)
were all statistically significant greater than the increase in the population
of US children aged ≤ 5 years. Child
self-exposure was responsible for 95% of health care visits. Therapeutic error victims were younger,
disproportionately boys, and more likely to be identified at hospital than
children who self-ingested medications. 48% of the calls to the poison control
center originated from the emergency department and 45% originated from the
patient’s own residence before travel to the emergency department. Admission to an intensive care unit was 43%,
34%, 41%, 35% following self-exposure to prescription medications, OTC
medications, therapeutic errors with prescription medications, and therapeutic
errors with OTC medications, respectively.
Evaluation: Based on this
study results, we can conclude that pediatric pharmaceutical prescription
poisonings have been rising.
Conclusion
Summary: The rising availability of
prescription medications has potentially contributed to an increase in
pediatric pharmaceutical poisonings and has shown that prevention efforts have
been inadequate in limiting pediatric poisonings especially opioids,
sedative-hypnotics, and cardiovascular agents. This may be due to increased
societal emphasis on pain management and an increased in prevalence of obesity
and other metabolic syndromes.
Evaluation: The results of the study are
appropriate based on the large sample size used.
Strengths: Study highlights the rise in
prescription medication self-ingestion poisonings. NPDS data matches the Consumer Product Safety
Commission’s National Electronic Injury Surveillance System in volume and
substance distribution thus corroborating the NPDS data by an entirely
different mechanism of ED sampling.
Limitations: Study did not make available data on
medication poisonings in children older than age 5 years. Study only includes
cases that caused a call to be made to the poison control centers and not cases
that were managed independently at home or at the emergency departments. A large number of patients (64,017) were excluded
because the patient ingested >1 medication is a limitation as this data could
provide for additional analysis on the combinations of drugs ingested.
Bottom Line: Self-ingestion of prescription
poisonings is increasing and this should be addressed by improving education,
storage, and packaging design that limits child access without impairing
appropriate use at other times. Community
pharmacists should encourage patients to properly store their medications away
from children’s reach especially when the medications are stored in easy to
access containers such as pill boxes.
Study Analysis and
Critique
Future Research: Investigate the
primary source of medications poisonings such as grandparents, parents, and
siblings medications and also investigate the relationship between
socioeconomic status and medication poisoning.
Useful References/Practice
Guidelines:
1.
Patterns of medication use in
the United States, 2004: a report from the Slone Survey, Slone Epidemiology
Center.
2.
Bronstein AC et al. 2006
Annual Report of the American Association of Poison Control Centers’ National
Poison Data System (NPDS). Clin Toxicol (Phila) 2007;45:815–917.
3.
Watson WA et al. 2003 annual
report of the American Association of Poison Control Centers Toxic Exposure
Surveillance System. Am J Emerg Med. 2004;22:335–404. Available at:
http://www.aapcc.org/2003.htm. Accessed June 9, 2006.
4.
Robin et. “Hang Up Your
Pocketbook” – An Easy Intervention for the Granny Syndrome: Grandparents as a
Risk Factor in Unintentional Pediatric Exposures to Pharmaceuticals. JAOA. 2006;106(7):405-411.
5.
Bond GR, Woodward RW, Ho M.
The Growing Impact of Pediatric Pharmaceutical Poisoning. J Pediatr. 2012
May;160(5):888-9.
6.
Healthy People 2020. Medical
Product Safety Objective 5-4: reduce emergency department (ED) visits for
medication overdoses among children less than 5 years of age. Available from:
http://www.healthypeople.gov/2020/topics-objectives/topic/medical-product-safety/objectives.
Accessed June 1, 2015.
7.
Overview of Children in the Emergency
Department, 2010. Available at:
http://www.hcup-us.ahrq.gov/reports/statbriefs/sb157.pdf
·
Tamara et al. Evaluation and Management of
Common Childhood Poisonings. American Family Physician. 2009 Mar 1;79(5):397-403.
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