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13 Common Pediatric Ingestions to Know
Joseph U Becker, MD | March 4, 2022
| Contributor Information
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Severe pulmonary edema from amitriptyline poisoning in a teenager after a suicide attempt. Image from Abeyaratne et al. BMC Res Notes. 2016;9:167. PMID: 26980525; PMCID: PMC4791788. [Creative Commons Attribution License 4.0 International (CC by 4.0).]
13 Common Pediatric Ingestions to Know
Joseph U Becker, MD | March 4, 2022 | Contributor Information
Pediatric ingestions account for about 1.1-1.3 million annual calls to US poison control centers (PCCs),[1,2] but the scale of such occurrences is undoubtedly much larger than the data suggest due to incomplete reporting. Cases include nonintentional (accidental) ingestions in infancy and early childhood, and intentional and recreational ingestions in the preteen and adolescent years.
Many ingestions are relatively harmless, requiring only time and observation for symptomatic resolution, but some can be life threatening, even in very modest quantities. Toxic ingestion is often on the differential diagnosis for children who present with unexplained illness, depressed/altered mental status, renal or hepatic dysfunction/failure, cardiac dysrhythmia or electrocardiographic (ECG) interval abnormalities, seizure, physical examination findings, or laboratory results.
A systematic approach that emphasizes early stabilizing care is crucial to optimizing outcomes, including the ABCDEs (Airway, Breathing, Circulation, Disability, and Exposure) and ABC support when necessary. Clinicians should also be alert to common pediatric toxidromes and recognize constellations of symptoms when they present. Consultation with a toxicologist or a PCC may be helpful when an ingestion is suspected but unable to be confirmed.[3,4]
The national poison control center number is 1-800-222-1222, or visit the official site of the American Association of Poison Control Centers (AAPCC) (poisonhelp.org).
Left image from Wikipedia | James Heilman, MD. [CC Attribution-Share Alike 3.0 Unported License (CC by-SA 3.0.)]. Table courtesy of Joseph U Becker, MD.
13 Common Pediatric Ingestions to Know
Joseph U Becker, MD | March 4, 2022 | Contributor Information
Gastric Decontamination
Gastric decontamination is one of many methods used to reduce or functionally eliminate the amount of a toxin after ingestion. In general, candidates for this process should present soon after ingestion (broadly within 1-2 hours), before most of the absorption is likely to have occurred. In addition, the toxic agent should be amenable to decontamination, and the potential toxic effect(s) should warrant the risk of decontamination.[3,5]
Activated charcoal
Activated charcoal is the most often used decontamination modality. It is a liquid slurry of highly absorbent charcoal that functionally eliminates many ingested toxins and is most effective when administered rapidly (≤1 hour of an ingestion). It is not effective or contraindicated in some ingestants. (Use the mnemonic PHAILS: Pesticides, Hydrocarbons, Heavy metals, Acids, Alcohols, Iron, Lithium, Solvents.) Activated charcoal is also not as effective in cases of toxic liquid ingestions (due to rapid absorption).[3,5]
Activated charcoal may be dangerous when aspirated. It should only be used in settings in which a patient's mental status and airway are protected and unlikely to rapidly deteriorate.[3,5]
Image courtesy of Stella C Wong, DO.
13 Common Pediatric Ingestions to Know
Joseph U Becker, MD | March 4, 2022 | Contributor Information
Gastric lavage
Gastric lavage involves introducing fluid into the stomach via a nasogastric tube and using suction to evacuate a toxic ingestion before it is fully absorbed. (Only perform in patients with adequate mental status or protected airways to prevent aspiration.) Place patients in the left lateral decubitus position (lower the head by 20°). Although gastric lavage may be beneficial in cases of large, potentially lethal ingestions, it is rarely performed at present due not only to the inconsistent amount of toxin removal (particularly in ingestions >1 hour) but also the potential for complications.[3,5,6]
Whole bowel irrigation (WBI)
WBI incorporates the administration of a large volume (20 mg/kg/hr) of electrolyte balanced solution (eg, GoLYTELY) to decrease intestinal transit time and thus reduce absorption of a toxic ingestion. This process may be considered in potentially lethal ingestions of sustained-release (SR) medications as well as agents that are not well absorbed by activated charcoal (eg, lithium, iron). Contraindications to WBI include bowel perforation or obstruction, gastrointestinal (GI) bleeding, recalcitrant vomiting, or an unprotected airway.[3,5,7]
Table courtesy of Joseph U Becker, MD.
13 Common Pediatric Ingestions to Know
Joseph U Becker, MD | March 4, 2022 | Contributor Information
One Pill Can Kill
Several medications can kill small children, even in very small quantities (shown).[3,4,8,9] A variety of over-the-counter (OTC) (non-prescription [non-Rx]) agents can also be fatal, such as the following:
Benzocaine (Orajel)
Diphenoxylate/atropine (Lomotil)
Salicylates
Other nonpharmacologic agents can be fatal to children (and adults).[3,4,8,9] Consider the following in the appropriate settings:
Image of an infant in the intensive care unit from the National Cancer Institute (NCI) | Bill Branson. [Public domain.]
13 Common Pediatric Ingestions to Know
Joseph U Becker, MD | March 4, 2022 | Contributor Information
Acetaminophen (APAP)
APAP (paracetamol) is a common household OTC medication that is also present in many cold/flu, antipyretic, and analgesic medications, which may lead some patients to accidentally ingest toxic amounts of APAP. When this drug is ingested in excess, it can cause significant hepatotoxicity. Generally, an APAP dose above 140 mg/kg within 24 hours is considered potentially hepatotoxic.[3,10]
Typically, within 1-24 hours after toxic ingestion, children begin to experience abdominal pain, nausea, and vomiting. Jaundice and elevated hepatic function tests usually occur within 24-72 hours, which can progress to fulminant hepatic failure within 72-96 hours.[3,10]
Left image of the Rumack-Matthew nomogram from Wikimedia Commons | Merlin Cyrstal. [CC by-SA 3.0).] Right image of a liver wedge prepared for perfusion with N-acetylcysteine (NAC, Mucomyst) and thermolysin medium (Liberase) via two cannulae from Bartlett DC, Hodson J, Bhogal RH, Youster J, Newsome PN. Cytotherapy. 2014;16(6):800-9. PMID: 24642019; PMCID: PMC4029080. [CC Attribution 3.0 Unported License (CC by 3.0).]
13 Common Pediatric Ingestions to Know
Joseph U Becker, MD | March 4, 2022 | Contributor Information
Treatment
NAC is an antidote to APAP overdose.[3,10] It restores hepatic glutathione stores, thereby increasing hepatic clearance of APAP. When evidence of a significant overdose is present, NAC should be given promptly via an intravenous [IV] loading dose of 150 mg/kg over 15-60 minutes, followed by 12.5 mg/kg/hr over 4 hours, and then 6.25 mg/kg/hr over 16 hours.
Evidence suggests a benefit of NAC even in delayed administration (>4 hr post ingestion.[3,10] In settings with unknown ingestions or those in which the quantity of APAP ingested is unknown, an at least 4-hour post-ingestion APAP level can be plotted on the Rumack-Matthew nomogram to determine the likelihood of toxicity. If the ingestion timing is known, subsequent APAP levels can be further plotted on the nomogram to not only assess the likelihood of toxicity but also the indication for NAC.
Some sources express concern about OTC SR formulations of APAP. They recommend an at-least 8-hour APAP level when an SR preparation is suspected.[11]
Image of liver tissue harvested from a child with a fatal case of Reye syndrome (acute noninflammatory encephalopathy with fatty liver failure) from the Centers for Disease Control and Prevention (CDC). [Public domain.]
13 Common Pediatric Ingestions to Know
Joseph U Becker, MD | March 4, 2022 | Contributor Information
Salicylates are frequent ingredients in multiple oral and topical analgesic preparations. The therapeutic range of salicylate is 15-30 mg/dL. Symptoms often occur at concentrations above 40-50 mg/dL, with severe symptoms and potentially significant toxicity when levels exceed 100 mg/dL. The potential toxic acute dose is above 150 mg/kg; expect serious toxicity at over 300 mg/kg. Wintergreen oil (methyl salicylate) is a very concentrated analgesic solution of salicylate that can be lethal to children even in minute quantities.[3,12]
Absorption of salicylates is often rapid, but symptoms can be delayed 6-12 hours or longer in different preparations (enteric coated) or if a bezoar forms. Symptoms of salicylate toxicity include tinnitus (may manifest as undifferentiated irritability in small children), and nausea, vomiting, and vertigo may be present. As toxicity progresses, altered mental status, seizures, and hyperthermia may develop. Death is typically via cerebral edema, although persistent and worsening acidosis is a poor prognostic indicator.[3,12]
Table courtesy of Joseph U Becker, MD.
13 Common Pediatric Ingestions to Know
Joseph U Becker, MD | March 4, 2022 | Contributor Information
Salicylates (Aspirins)
Treatment
Clinical condition and symptomatic severity guide therapy for salicylate overdose (toxicity often does not correlate with serum levels).[3,12] A reliable history suggesting a toxic ingestion (>150 mg/kg) should prompt early, aggressive treatment. Check initial and regular salicylate levels; obtain levels of electrolytes (serially, especially potassium), glucose, and arterial blood gases (ABGs), as well as renal and hepatic function tests.
Initial supportive measures include monitoring the ABCs, acid-base status, electrolyte levels, and neurologic status. Endotracheal intubation may be needed; maintain increased minute ventilation to compensate for worsening metabolic acidosis. If the ingestion is severe and mental status and airway protection allow, some clinicians advocate for gastric lavage up to 60 minutes after ingestion, and activated charcoal can also be used (1 g/kg). WBI may also be considered in severe cases.[3,12]
Urinary alkalinization improves the renal excretion of salicylates. A bolus of a 1 mEg/kg dose of sodium bicarbonate (NaHCO3) solution is given, followed by continuous administration of D5W at double the maintenance rate with three ampules of 44 mEq NaHCO3 added. For severe or life-threatening salicylate toxicity or when gastric decontamination and urinary alkalinization are ineffective, hemodialysis is an option.[3,12]
Sonogram depicting ibuprofen-induced acute liver injury from Shahnazarian V, Ramai D, Reddy M. Cureus. 2018;10(8):e3225. PMID: 30410832; PMCID: PMC6207489. [CC by 3.0.]
13 Common Pediatric Ingestions to Know
Joseph U Becker, MD | March 4, 2022 | Contributor Information
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Overdose from an NSAID (eg, ibuprofen) is usually not life threatening unless it is taken in large quantities. Infants and small children may be more susceptible (immature renal and hepatic metabolism). Reported dose toxicities are as follows[3,13]:
Less than 100 mg/kg: Asymptomatic
100-300 mg/kg: Mild GI and central nervous system (CNS) symptoms
Over 300 mg/kg: Risk of multisystem organ dysfunction (MODS)
Symptoms of NSAID toxicity include nausea, vomiting, abdominal pain, and GI hemorrhage. A gap metabolic acidosis is often seen with concomitant respiratory compensation. In larger, toxic doses (>300 mg/kg), coma, seizures and shock may be present.
Therapy
There is no specific antidote for NSAID overdose.[3,13] Although activated charcoal may be given if the patient is awake, their airway is protected, and if less than 1 hour has passed since ingestion, GI decontamination is not believed to play a significant role in reducing absorption. Most NSAIDS are largely protein bound; thus, hemodialysis is not likely to remove substantial amounts of the circulating drug. However, hemodialysis may provide supportive care to address other complications that may arise from NSAID toxicity (eg, renal failure, hyperkalemia).[3,13]
ECG revealing a complete or third-degree atrioventricular (AV) block with junctional escape rhythm in 2-year-old girl who initially presented with first-degree AV block courtesy of M Silvana Horenstein, MD.
13 Common Pediatric Ingestions to Know
Joseph U Becker, MD | March 4, 2022 | Contributor Information
Calcium Channel Blockers (CCBs)
CCBs belong to a class of "1 pill can kill" drug threats in infants and young children; verapamil and diltiazem are the most lethal in acute overdose.[3,14] Additionally, SR preparations of CCBs are common, further complicating overdose management by delaying and prolonging the course of toxicity. Toxic CCB effects can manifest as bradycardia with first-degree heart block and hypotension. With progression, worsening heart blocks (complete AV nodal blockade), ventricular or junctional escape, heart failure, and/or pulmonary edema with resultant respiratory distress may occur. Hyperglycemia may also result.
Treatment
Management of acute CCB toxicity involves aggressively addressing threats to life (eg, ABCs; early intubation if mental status or respiratory distress indicate), such as shock. Support blood pressure and perfusion; consider cardiac pacing in extreme bradycardia or high-degree AV block; and consider extracorporeal membrane oxygenation (ECMO) or cardiopulmonary bypass in last-ditch situations.[3,14]
Calcium is the direct antidote to CCB toxicity. It may be given as 10% calcium gluconate (children: 0.6-1.0 mL/kg) or 10% calcium chloride (children: 0.2 mL/kg, central venous access).[3,14]
ECG from the same child with third-degree AV block discussed in the previous slide after placement of a dual chamber (DDD-R) pacemaker. Image courtesy of M Silvana Horenstein, MD.
13 Common Pediatric Ingestions to Know
Joseph U Becker, MD | March 4, 2022 | Contributor Information
Given the potential lethality of CCBs even in small doses, gastric decontamination with activated charcoal may be attempted. WBI is also advocated in severe overdose, but this entails risk; avoid WBI in the presence of severe cardiovascular symptoms of overdose. As with other toxic ingestions, only consider these interventions in patients who are awake and alert, or who have protected airways.[3,14]
Although insulin and glucagon have many contradictory effects, both are thought to have some benefit in CCB overdose. Increasingly, high-dose insulin euglycemia therapy (HIET) has been promoted. Compensatory dextrose is provided to support the administration of significant insulin doses; this has been associated with improvements not only in outcome but also metabolic and cardiovascular toxic effects. Closely monitor glucose and potassium levels. Glucagon stimulates cellular calcium uptake. The recommended pediatric glucagon dose in CCB overdose is 50 mcg/kg IV over 5 minutes, followed by an infusion of 0.07 mg/kg/hr.[3,14]
Most CCBs are lipid soluble. There has been some success with the use of infusions of lipid emulsifying solutions.[15]
Rhythm strips from different patients depicting polymorphic ventricular tachycardia (PVT) due to sotalol toxicity. Top image courtesy of Steven J Compton, MD, FACC, FACP, FHRS. Bottom image courtesy of Medscape.
13 Common Pediatric Ingestions to Know
Joseph U Becker, MD | March 4, 2022 | Contributor Information
Beta Blockers (BBs)
Many cases of BB toxicity are benign; however, large doses can produce serious cardiac and cardiovascular effects.[3,16] As with CCBs, BB toxicity can result in bradycardia, heart block, heart failure, shock, and respiratory distress. Metabolic effects include hyperkalemia and hypoglycemia.
Sotalol and propranolol specifically present unique toxicologic challenges. Sotalol overdose can lead to PVT; toxic doses of propranolol can lead to ventricular dysrhythmia and cardiac arrest.[3,16]
Treatment
As always, early identification of life-threatening conditions and attention to ABC support (particularly circulation) is critical.[3,16] Glucagon is the main antidote to BB toxicity (50 mcg/kg, up to 10 mg); multiple doses and/or a continuous infusion (2-10 mg/hr) may be necessary.[3,16,17]
HIET and lipid emulsifying solutions, as well as gastric decontamination with activated charcoal in ingestions that are less than 1 hour old, may be considered. Gastric lavage or WBI are not generally indicated except in BB ingestions of grave and potentially lethal amounts, and before the onset of severe symptoms.[3,16]
Joseph U Becker, MD | March 4, 2022 | Contributor Information
Sulfonylureas
Sulfonylureas exist in multiple formulations (eg, glimepiride, glipizide, glyburide/glibenclamide, gliclazide) and are commonly used in the treatment of type 2 diabetes. They can produce a potent and long-lasting hypoglycemia in children, who can present with signs/symptoms that include lethargy, altered mental state, weakness, excessive sleepiness, diaphoresis, dizziness, and/or nausea and vomiting. Prompt recognition of hypoglycemia is crucial; perform a rapid blood glucose test in all patients presenting with any of these symptoms.[3,18]
Treatment
Early treatment involves administering oral carbohydrate-containing substances if possible; however, IV dextrose may be preferable in the setting of declining mental status or in the presence of nausea/emesis.[3,18] Glucagon may be given IV or, in cases when an IV or intraosseous (IO) access is not yet available, intramuscularly (IM).
Activated charcoal may be used. Delayed or repetitive administrations may be considered, as sulfonylureas may persist in the gut lumen even hours after the ingestion.[3,18]
Image of the abdomen (left) and lower leg (right) of a severely sunburned patient who suffered a life-threatening coma from opioid toxicity while using a fentanyl transdermal patch from Sindali K, Sherry K, Sen S, Dheansa B. J Med Case Rep. 2012;6:220. PMID: 22835002; PMCID: PMC3427044. [CC 2.0 Generic (CC by 2.0).]
13 Common Pediatric Ingestions to Know
Joseph U Becker, MD | March 4, 2022 | Contributor Information
Opioids
Overdose of opioids (including synthetic forms such as fentanyl), either alone or in conjunction with other analgesic or sedative medications or illicit substances, is a significant US public health problem. Suspect opioid toxicity when the clinical triad of CNS depression, respiratory depression, and pupillary miosis are present.[3,19] Somnolence or coma may be noted. The onset and duration of action of these agents vary; some are rapidly absorbed and exert effects within minutes (eg, fentanyl, carfentanyl), whereas others have a duration of action of 24 hours or more (eg, methadone or fentanyl patches). Note any co-ingestants, as several opioid preparations (eg, Vicodin, Percocet) contain APAP, and illicit opioids often contain cocaine or amphetamines.
Treatment
Initial therapy for opioid toxicity is supportive, with administration of oxygen and provision of positive pressure ventilation via endotracheal intubation if mental or respiratory status indicates.[3,19] A trial of naloxone (along with a rapid blood glucose test) is an important initial intervention in anyone with an unexplained coma and/or respiratory depression; in children, 0.1 mg/kg may be administered IV, IO, IM, or intranasally.
In longer duration opioids, repetitive doses of or a continuous naloxone infusion may be required. Activated charcoal may be used to reduce the impact of ingested opioids in the absence of mental status or respiratory contraindications.[3,19]
Brain magnetic resonance images (MRIs) depicting acute fatal posthypoxic leukoencephalopathy after benzodiazepine overdose in a 19-year-old male from Aljarallah S, Al-Hussain F. BMC Neurol. 2015;15:69. PMID: 25925073; PMCID: PMC4418099. [CC by 4.0.]
13 Common Pediatric Ingestions to Know
Joseph U Becker, MD | March 4, 2022 | Contributor Information
Benzodiazepines
Benzodiazepines are often co-ingestants in toxic overdoses as they potentiate the effect of other agents (eg, opioids, alcohol).[3,20] In small children, benzodiazepines alone may cause significant and life-threatening symptoms. Symptoms of benzodiazepine toxicity include somnolence, coma, dizziness, weakness, and/or confusion. Small children may initially be excessively drowsy, hypotonic, and/or ataxic; progression may result in coma and respiratory depression. The toxidrome may resemble that of opioid toxicity; however, the miosis noted with opioid poisoning is usually absent with lone benzodiazepine ingestions.
Therapy
Management is usually supportive, as benzodiazepine toxicity is rarely fatal. Airway protection and supplemental oxygen are critical. Activated charcoal is not typically useful: Many patients with benzodiazepine toxicity have reduced consciousness and may be at risk for aspiration. Flumazenil (Romazicon) is an antidote, but it is not routinely recommended due to its potential for precipitating a dangerous withdrawal syndrome (eg, vital sign instability, seizures) in cases of chronic benzodiazepine use.[3,20]
Table courtesy of Joseph U Becker, MD.
13 Common Pediatric Ingestions to Know
Joseph U Becker, MD | March 4, 2022 | Contributor Information
Iron Toxicity
Iron-containing supplements are widely available, making acute iron overdose a serious pediatric emergency. Iron toxicity may also be a chronic condition (eg, from chronic blood transfusions). Acute poisoning is directly related to the quantity of ingested elemental iron (% iron per tablet × amount ingested) and may occur with ingestions of 10-20 mg/kg; life-threatening toxicity may occur with doses over 50 mg/kg. Iron pills may be visible on radiography; thus, abdominal films may aid in estimating the ingested dosage.[3,21]
Iron is acutely toxic to the GI tract, resulting in GI irritation and hemorrhage. Early symptoms (phase 1) include nausea, vomiting, and abdominal pain. Severe acidosis follows intestinal iron absorption. In phases 2 and 3, worsening acidosis may lead to cardiogenic or hypovolemic shock. Survivors of the early phase who have damaged hepatocytes may suffer hepatic failure and coagulopathy within 2-3 days of the ingestion. Post recovery, local iron effects on the GI tract may cause scarring and stricture.[3,21]
Image of iron crystals in the gastric lamina propria and epithelium from Flickr | Atlas of Medical Foreign Bodies, Adam L Booth, MD. [CC by-SA 2.0).]
13 Common Pediatric Ingestions to Know
Joseph U Becker, MD | March 4, 2022 | Contributor Information
Treatment
Treatment for acute iron toxicity is multifactorial. Supportive care is critical. Focus on the ABCs as well as fluid balance; prompt recognition of vital sign and acid base abnormalities is important.
WBI and even endoscopy have been utilized to speed the transit of iron tablets through the GI tract. The iron-chelating agent deferoxamine binds iron and is excreted in the urine. Consider administering IV deferoxamine for iron levels above 500 mcg/dL or in the presence of significant acidosis or ongoing symptoms.[3,21]
Activated charcoal is ineffective at absorbing ingested iron. Similarly, gastric lavage has not been proven effective in functionally reducing iron absorption.[3,21]
Endoscopic image showing residual drugs adhering to the gastric wall (circle) of a patient with tricyclic antidepressant (TCA) overdose from Miyauchi M, Hayashida M, Yokota H. Int J Emerg Med. 2013;6(1):39. PMID: 24148152; PMCID: PMC3853774. [CC by 2.0.] Black arrow = nasogastric tube.
13 Common Pediatric Ingestions to Know
Joseph U Becker, MD | March 4, 2022 | Contributor Information
Tricyclic Antidepressants (TCAs)
Newer, less toxic antidepressant medications are replacing TCAs, but TCAs remain widely prescribed for various mental health diagnoses, chronic pain, and insomnia. Their toxicity is mediated by antimuscarinic effects, direct alpha-adrenergic blockade, inhibition of norepinephrine and serotonin reuptake, and blockade of myocardial sodium channels.[3,22] These effects lead to CNS depression and seizure activity, as well as prolongation of the QRS and QT intervals, resulting in ventricular dysrhythmias. Significant hypotension may also be noted.
Treatment
Emergency supportive care is essential. Intubate patients with inadequate respiration and place them on positive pressure ventilation. Treat seizures with IV benzodiazepines. Gastric decontamination with gastric lavage and activated charcoal may be helpful—if they can be performed before the onset of significant symptoms or absorption. TCAs are lipophilic; there is interest in using lipid emulsifying solutions to remove circulatory TCAs (20% lipid emulsion at 1.5 ml/kg bolus over 2-3 minutes, followed by an infusion at 0.25 mL/kg/min).[3,22]
For cardiotoxicity associated with TCA overdose, NaHCO3 (1-3 mEq/kg boluses) is the mainstay of therapy. In children and adolescents, administer NaHCO3 when the QRS duration is about 100 msec or the R wave in lead aVR is over 3 mm, as these are markers of severe cardiotoxicity. Closely and continuously monitor the ECG, serum pH level (not to exceed 7.55), and serum potassium level (avoid hypokalemia).[3,22]
ECG of long QT syndrome in a 15-year-old male courtesy of Medscape.
13 Common Pediatric Ingestions to Know
Joseph U Becker, MD | March 4, 2022 | Contributor Information
Diphenhydramine
Diphenhydramine, one of the most purchased and abused OTC medications, is regularly used as an allergy therapy, decongestant, sleep aid, and an antiemetic. An ingested dose exceeding 7.5 mg/kg may lead to toxicity; its sedative and anticholinergic properties are the main toxic effects, including disorientation, blurred vision, dry mouth, urinary retention, tachycardia, nausea, and constipation.[3,23] CNS depression and seizure may occur, and significant cardiovascular effects and overdose may lead to widening of the QRS and the QT intervals, raising the risk for the development of ventricular dysrhythmias.
Treatment
There is no specific antidote for diphenhydramine toxicity.[3,23] Supportive care including the ABCDs is critical. Benzodiazepines may be used for seizures. Acetylcholinesterase inhibitors (eg, physostigmine) may be considered to counteract anticholinergic effects, and activated charcoal may be beneficial as the anticholinergic effects of diphenhydramine may lead to delayed gastric emptying. Dialysis plays no role.
Image of oral caustic burns in a child courtesy of Medscape.
13 Common Pediatric Ingestions to Know
Joseph U Becker, MD | March 4, 2022 | Contributor Information
Irritant and Caustic Ingestions
Incidents of irritant and caustic ingestions mainly occur in young children, who usually only ingest small amounts of household cleaning solutions and typically experience mild oropharyngeal irritation. However, acid or alkali substances may cause significant tissue damage to the oropharynx, esophagus, stomach, and deeper into the GI tract.[3,24] The injury severity is mediated by the strength of the substance, its duration of contact, and the depth of penetration needed to neutralize the substance (titratable reserve). Serious pulmonary or tracheal injury can result in respiratory or airway compromise. Liquid ingestions are generally more dangerous than that of solids.
Acidic substances cause liquefactive necrosis, and basic compounds produce coagulative necrosis.[3,24] Esophageal or intestinal perforation may occur, which may lead to peritonitis or mediastinitis, with significant morbidity (eg, scarring, occlusion of the intestinal lumen) and mortality.
Image of multiple button batteries in the stomach of a child from Wikimedia Commons | James Heilman, MD. [CC by-SA 4.0.]
13 Common Pediatric Ingestions to Know
Joseph U Becker, MD | March 4, 2022 | Contributor Information
Treatment
No direct antidote exists for caustic ingestions: Attempting to balance an alkali solution with an acidic one—or vice versa—can lead to an exothermic reaction and produce significant amounts of heat.[3,24] Care is generally supportive, and there is no role for activated charcoal. Nasogastric suction may be indicated in larger volume ingestions of acidic solutions, if it can be performed rapidly after the ingestion.
Ingestion of button batteries is a special situation as these can lead to significant intestinal damage and perforation, secondary to prolonged contact with the mucosa.[3,24]
Axial computed tomography (CT) scan depicts acute pancreatitis from Lactarius volemus (lower right inset) poisoning. Images from Karahan S, Erden A, Cetinkaya A, et al. J Investig Med High Impact Case Rep. 2016;4(1):2324709615627474. PMID: 26835473; PMCID: PMC4724762. [CC by 3.0.]
13 Common Pediatric Ingestions to Know
Joseph U Becker, MD | March 4, 2022 | Contributor Information
Plants and Mushrooms
Concerned parents may bring children to the emergency department (ED) because they either witnessed or believe their child ingested wild plants or poisonous mushrooms. The vast majority of such suspected or confirmed ingestions are innocuous.[3,25] However, clinicians must be diligent and cautious when assessing the risk of a possibly serious ingestion given the fact that several plant and mushroom species may cause significant toxicity, even in low doses.
It is beyond the scope of this slideshow to provide an in-depth discussion of the numerous toxicities and management of potentially ingestible plants. Note that multiple mushroom species and some varieties of plants may cause significant and delayed toxicity. Knowledge of local dangerous species, a low threshold for clinical observation, and consultation with a PCC is often reasonable when physical examination or laboratory abnormalities are present.[3,25]
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Author
Joseph U Becker, MD
Associate Professor
Department of Emergency Medicine
Stanford University School of Medicine
Palo Alto, CA
Disclosure: Joseph U Becker, MD, has disclosed no relevant financial relationships.
Editor
Olivia Wong, DO
Section Editor
Medscape Drugs & Diseases
New York, NY
Disclosure: Olivia Wong, DO, has disclosed no relevant financial relationships.
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