AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

A wide variety of medications and substances can kill a toddler who ingests just a single dose. More than 1 million children ingest toxins in the United States every year, and more than 85% of the ingestions are accidental. Most of the children are younger than 6 years.

The intent of this article is not to guide treatment of poisoned children but rather to report toxic ingestions that proved fatal in small doses. The article addresses some types of toxic ingestions and those that may cause serious illness or injury, even in small quantities.

Many of the involved toxins are common in the home or in household products. Ingestion of relatively small amounts of commonly used perfumes, cosmetics, cleaning solutions, alcoholic beverages, and other products may cause serious injury or death. Medications also are a common source of toxic ingestions in small quantities. Without taking prior precautions, visits to the homes of friends or relatives (even grandparents) or visits from guests who bring medications into the home may result in tragedy.

Pathophysiology

Pathophysiology varies according to the ingested substance. Children are particularly susceptible to injury from ingestion of small doses for the following reasons:

• The low body mass of children means that a single ingested dose of a substance may easily be toxic.
• While exploring their surroundings, younger children, especially toddlers, may ingest substances with objectionable tastes or odors that would be rejected by older children and adults.
• The metabolic pathways of young children, particularly infants, are less developed and use sulfonation rather than glucuronidation to process some toxins.

Frequency

United States

Most ingestions by children involve nontoxic substances. More than 1 million ingestions are believed to occur annually, most involving children younger than 7 years.

Mortality/Morbidity

Mortality and morbidity depend on the substance or drug ingested and the quantity relative to body weight (ie, mg/kg/dose).

Race

Race and frequency of toxic ingestions appear to have no correlation.

Age

Toxic ingestions from a single dose occur most often as accidental ingestions by young children aged 1-6 years.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Most cases involve a history or suspicion of ingestion based on circumstances surrounding the child's illness. Some patients may present before developing significant symptoms. Patients may present in an obtunded state and without a clear history of ingestion. Elicit the following information:

• What substance was ingested? If the substance was a medication, obtain the name and dosage. Specific identification may require retrieving the pill bottle or product container.
• What are the ingredients of the ingested substance? Learning the product name or finding the container helps determine the specific ingredients and concentrations.
• When was the substance ingested?
• When did the patient last eat?
• What is the patient's medical history?
• Did anyone observe the ingestion? If so, ask to speak with the person who saw the incident because this may help determine the amount ingested.
• Is the ingestion consistent with the history provided? If the history is inconsistent, the suspicion of abuse or neglect is raised, and the incident must be reported.

Physical

Physical examination results may range from normal to patients who present in an obtunded state or even in cardiopulmonary arrest. Some examination results may offer subtle specific clues regarding the type of ingestion.

• Begin the examination by evaluating the patient's ABCs. Initiate appropriate interventions for any abnormalities.
• Perform a complete physical examination, and record all vital signs.
• Search for evidence of specific toxidromes.
• Pay particular attention to neurologic examination results and changes, since this is a primary means of monitoring patients with toxic ingestions.

Causes

Ingestion of a number of common substances and drugs may be fatal in small doses. Many of the case reports listed below specify quantities; however, a significant number of young children have died from ingesting unknown quantities of a substance.

The Gosselin system classifies agents as extremely toxic when the probable lethal oral dose is 5-50 mg/kg and as supertoxic when the probable lethal oral dose is less than 5 mg/kg. The following list includes drugs and chemical agents classified as either extremely toxic or supertoxic, the quantities of each that are potentially fatal to children, and selected case studies.

• Antidepressant drugs
• • Tricyclic antidepressants - Fifteen to 20 mg/kg (Linakis, 1988; Manoguerra, 1982; Frommer, 1987)
  • Desipramine - Two 75-mg tablets
  • • A 3-year-old boy on long-term therapy using desipramine 100-mg tablets died within 47 hours postingestion after obtaining 2 or 3 extra tablets either from his own or a 6-year-old sibling's prescription (Litovitz, 1996, case 406).
    • A 2-year-old boy ingested 1 desipramine 50-mg tablet and died a few hours postingestion (Litovitz, 1992, case 420).
  • Imipramine - One 150-mg tablet
  • Monoamine oxidase inhibitors - Fatal ingestions have occurred with 4- to 6-mg/kg doses (Linden, 1984).
  • Amitriptyline - A 9-month-old girl was administered half of a 100-mg tablet to induce sleep. She arrived unresponsive at the emergency department (ED) 2-3 hours postingestion and died a few hours after admission (Litovitz, 1993, case 309).
  • Amoxapine - The minimum fatal dose is 250 mg in children (Shepard, 1983; Ellenhorn, 1988).
• Antimalarial drugs
• • Chloroquine - One 500-mg tablet
  • • A 24-month-old boy was found with a single tablet in his hand. His respiratory system became compromised, and he required cardiopulmonary resuscitation (CPR) shortly thereafter. Life support was withdrawn 8 days postingestion (McCarthy, 1996).
    • A 12-month-old boy who ingested 1 g was unresponsive 30 minutes postingestion and died within 3 days (Litovitz, 1987, case 269).
  • Chloroquine phospate and primaquine (Aralen) - A 12-month-old child was pronounced brain dead approximately 24 hours after ingesting 1 Aralen tablet and sucking the coating of 12 tablets (Kelly, 1990).
• Antipsychotic drugs
• • Thioridazine - One 200-mg tablet
  • Chlorpromazine - A 1-year-old child went into coma and respiratory arrest after ingesting 200 mg (Cann, 1960).
  • Clozaril - A 2-year-old girl who weighed 10.5 kg was found chewing a single 100-mg clozapine tablet. She was brought to the ED an hour later after becoming ataxic. The girl died 16 days after ingestion from cardiac arrest secondary to respiratory failure (Litovitz, 1995, case 669).
• Cardiovascular drugs
• • Clonidine - Ingestion of 0.1 mg/kg may cause bradycardia, hypotension, respiratory depression, and apnea.
  • Lorcainide - Approximately 50 mg/kg (Evers, 1995)
  • Quinidine - Two 300-mg tablets
  • Verapamil - One or two 240-mg tablet(s)
  • • A 4-year-old boy who ingested 6-10 sustained-release tablets and 2-4 cold capsules (acetaminophen, chlorpheniramine, pseudoephedrine, dextromethorphan) went into cardiac arrest approximately 5 hours postingestion and died within 24 hours of admission (Litovitz, 1991, case 473).
    • A 7-day-old boy inadvertently ingested 25 mg and died 20 hours postingestion (Litovitz, 1988, case 300).
  • Disopyramide - A 2-year-old child ingested 600 mg and died 12 hours postingestion (Baselt, 2000).
  • Lidocaine - Ingestion of 1 oz of 2% viscous lidocaine solution was almost fatal in a 20-month-old girl (Garrettson, 1992).
  • Nifedipine
  • • A 14-month-old girl who ingested a single 10-mg capsule died 3 hours postingestion (Lee, 2000).
    • An 11-month-old boy ingested four 10-mg capsules and died 2 days postingestion (Litovitz, 1993, case 539).
    • A 14-month-old child ingested a single 10-mg capsule and died 4 hours postingestion (Pearigen, 1993).
• Drugs of abuse
• • Ibogaine - Approximately 29 mg/kg (Bogusz, 1999)
  • Lysergic acid diethylamide (more commonly known as LSD) - A dose of 0.2 mg/kg is potentially fatal (Ellenhorn, 1988).
  • p-Methoxyamphetamine - Ingestion of a single tablet is potentially fatal.
  • Nicotine - Ingestion of a single whole cigarette can be fatal. An 11-month-old girl was found dead at home. Autopsy revealed 5 undigested cigarettes and 1 tablet of diazepam (Litovitz, 1998, case 182).
• Miscellaneous drugs
• • Amantadine - Ingestion of more than approximately 30 mg/kg is potentially fatal (Sartori, 1984).
  • Colchicine - Ingestion of more than approximately 0.8 mg/kg is potentially fatal (Ellenhorn, 1988). An adult reportedly died after ingestion of a 0.31 mg/kg dose (Mullins, 2000).
  • Hypoglycemic agents
  • • Sulfonylureas - Two 5-mg tablets of glyburide
    • Theophylline - A dose of 40-50 mg/kg or a single 500-mg tablet may be fatal.
  • Albuterol - A 2-month-old child who received 6 times the recommended oral dose had a postmortem concentration of 31 mcg/L (Baselt, 2000).
  • Chloral hydrate
  • • A 3-year-old girl received 10 mL (250 mg/5 mL) chloral hydrate for sedation prior to CT scanning. She arrived in the ED 45 minutes postingestion in cardiorespiratory arrest and died 45 minutes later (Litovitz, 1993, case 595).
    • A 2-year-old child had a near fatal exposure after ingesting 250 mg (Granoff, 1971).
• Opioid analgesic agents
• • Codeine may be fatal to a toddler who ingests three 60-mg tablets.
  • Fentanyl patches have caused death in opioid-naive patients who have chewed or sucked on the patches or in those for whom the patches have been prescribed for acute pain.
  • Diphenoxylate 2.5 mg and atropine 0.025 mg (Lomotil) - Five or 6 tablets may cause coma or respiratory depression (Rumack, 1974).
  • Methadone
  • • A 2-year-old boy who ingested approximately 12 mL (ie, 10 mg/mL) of his mother's methadone died within 3 days of presentation (Litovitz, 1998, case 332).
    • A 5-year-old girl given a single 10-mg tablet to stop coughing died 6.5 hours postingestion (Litovitz, 1991, case 260).
    • A 12-month-old boy who drank 1.5 oz of a bottle containing 35 mg of methadone in 8 oz of formula died approximately 24 hours postingestion (Litovitz, 1988, case 170).
• • Oxycodone - A 6-year-old girl on long-term imipramine therapy for attention deficit disorder was found dead in her home after her mother had given the child 15-20 mg to induce sleep (Litovitz, 1998, case 359).
• Nonprescription medications
• • Iron - Ten adult tablets
  • Aspirin - A 3-year-old girl weighing 4.3 kg who ingested a total of 2400 mg died 12 days postingestion (Litovitz, 1989, case 176).
  • Pseudoephedrine - A 2-year-old child was found dead after ingesting approximately seven 60-mg tablets (Baselt, 2000).
• Topical preparations
• • Benzocaine - Two milliliters of 10% solution
  • Camphor - Five milliliters (ie, 1 tsp) of 20% camphor oil or more than 50 mg/kg is a potentially lethal dose (Ellenhorn, 1988). A 19-month-old child ingested 5 mL of camphorated oil and died 5 days postingestion (Smith, 1954).
  • Lindane - Two teaspoons (ie, 10 mL) or 6 mg/kg (Falk, 1957)
  • Dibucaine
  • • An 18-month-old girl who ingested approximately half of a 30-g tube (ie, 150 mg = 15 mg/kg) died 7 hours postingestion (Litovitz, 1995, case 364).
    • A 17-month-old girl ingested approximately 22.5 g of ointment, developed cardiorespiratory arrest, and died approximately 4 hours postingestion (Litovitz, 1989, case 226).
  • Methylsalicylates - Less than 5 mL (ie, 1 tsp) of oil of wintergreen is a potentially fatal dose. Case reports of fatal ingestions of oil of wintergreen include a 2-year-old boy who ingested 7.5 mL (MacCready, 1943), a 2-year-old girl who ingested 15 mL (Litovitz, 1992, case 758), and another 2-year-old girl who ingested 10 mL (Litovitz, 1991, case 609).
• Alcohols
• • Methanol - Fifteen milliliters of 40% solution (Ellenhorn, 1988)
  • Ethylene glycol - One to 1.5 mL/kg (Ellenhorn, 1988)
  • Isopropyl alcohol - Two to 4 mL/kg of 70% solution (Ellenhorn, 1988)
  • Ethanol - One to 2 oz of cologne (Ellenhorn, 1988)
• Other chemical agents
• • Aniline - A 4 ½-year-old child developed a blood methemoglobin (metHb) level of 77% at 13 hours after ingesting 5 mL of aniline. Although the child was treated successfully with an exchange transfusion, metHb levels exceeding 60% are considered life threatening (Mier, 1988).
  • Arsenic - Two hundred milligrams (Trestrail, 2000)
  • Boric acid - Two to 3 g (Locatelli, 1987; Wong, 1964)
  • Chloroform - Ten milliliters (Baselt, 2000)
  • Hydrogen cyanide - Fifty milligrams (Trestrail, 2000)
  • Dimethylnitrosamine - Thirty milligrams per kilogram (Cooper, 1980)
  • Diquat - Ingestion of 20 mL of a 20% solution was fatal in a 2-year-old child (Pond, 1983).
  • Methylene iodide - A 20-month-old girl who ingested 10-15 mL developed acute hepatic failure within 2 days and died 9 days postingestion (Litovitz, 1989, case 119).
  • Elemental yellow phosphorus - One milligram per kilogram (Ellenhorn, 1988)
  • Sodium monofluoroacetate (Compound 1080) - Three to 7 mg/kg is a potentially fatal dose. Thirteen to 14 mg/kg of Compound 1081 is a potentially fatal dose (Ellenhorn, 1988).
  • Sodium fluoroacetate - Two to 10 mg/kg (Trestrail, 2000)
  • Paraldehyde - A single fatality has been reported with a 25-mL dose (Ellenhorn, 1988).
  • Paraquat - Twenty-five to 50 mg/kg (Ellenhorn, 1988)
  • Pentachlorophenol - A 2-g dose is potentially fatal in adults (Ellenhorn, 1988; Baselt, 2000).
  • Selenious acid (a component of gun bluing with copper sulfate and nitric acid) - A single swallow may be fatal.
  • • A 22-month-old boy ingested 15 mL of gun-bluing solution. He was unresponsive upon arrival at an ED 3 hours after ingestion and died after lengthy unsuccessful CPR (Litovitz, 1997, case 179).
    • A 30-month-old boy who ingested less than 1 oz of gun-bluing solution was unconscious when the ambulance arrived 10 minutes postingestion. He died less than 90 minutes after arrival at an ED (Litovitz, 1991 case 182).
• • Strychnine - Five to 8 mg/kg (Trestrail, 2000; Ellenhorn, 1988)
  • Tetrachlorodibenzo-p-dioxin - A dose of 0.1 mcg/kg is potentially fatal (Ellenhorn, 1988).
  • Thallium - Twelve to 15 mg/kg (Trestrail, 2000; Ellenhorn, 1988)
  • Pyriminyl (Vacor) - Five milligrams per kilogram (Ellenhorn, 1988)
  • Xylene - Fifteen milliliters (Baselt, 2000)
  • Zinc phosphide - Forty milligrams per kilogram (Ellenhorn, 1988)
• Hydrocarbons
• • Kerosene and gasoline - A single mouthful may be fatal if aspirated.
  • Aliphatic hydrocarbon - An 18-month-old boy who ingested/aspirated a mouthful of saddle dressing died 20 days postingestion (Litovitz, 1989, case 136).
  • Lighter fluid - A 14-month-old boy ingested/aspirated a mouthful of lamp oil and died (Litovitz, 1999, case 170).
  • Motor oil - A 15-month-old boy who ingested/aspirated one swallow of motor oil died 51 days postingestion (Litovitz, 1999, case 174).
  • Mineral oil and mineral spirits - A 2-year-old girl ingested/aspirated 15-30 mL of hair weaving remover (ie, 20% mineral oil, 30% mineral spirits) and died 2 days postingestion (Litovitz, 1993, case 78). A 3-year-old boy who ingested/aspirated "a couple of swallows" of fabric protector containing mineral spirits died 19 days postingestion (Litovitz, 1992, case 168).
• Plants and natural toxins
• • Amatoxin (ie, mushroom) - A dose of 0.1 mg/kg is potentially fatal (Ellenhorn, 1988).
  • Amygdalin is a cyanogenic glycoside (toxicity or death occurs secondary to cyanide ingestion) - In separate case reports, 2 of 9 (Sayre, 1964) and 1 of 8 (Lasch, 1981) intoxicated children died after eating apricot seeds.
  • Botulism toxin - Fifty nanograms or 0.1 mL of contaminated food (Trestrail, 2000)
  • Castor beans (ie, ricin) - One milligram per kilogram or approximately 8 seeds (Ellenhorn, 1988)
  • Pennyroyal - A 12-week-old boy with a history of rhinorrhea and mild cough was administered 4 oz of tea made from 3-4 pennyroyal leaves. The child developed fulminant hepatotoxicity and died within 2.5 days postingestion (Litovitz, 1996, case 168).

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Order laboratory studies directed to the specific ingestion.
• Consider specific symptoms related to the ingestion or to the patient's preexisting medical conditions, if any.

Imaging Studies

• Radiography may help in specific ingestion cases. For example, in iron ingestion, radiopaque tablets may be visible in the GI tract. Other radiopaque substances include heavy metals, iodine, phenothiazines, enteric-coated tablets, and chloral hydrate.

Other Tests

• Perform an electrocardiogram in patients with known or suspected tricyclic antidepressant ingestion to look for a prolongation of the QRS interval of greater than 100 milliseconds.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

Immediate care should include the ABCs, plus 2 D's: disability (ie, neurologic examination) and decontamination (ie, gastric decontamination). ABC procedures should follow standard Pediatric Advanced Life Support (PALS) and Advanced Pediatric Life Support (APLS) recommendations.

Perform gastric decontamination for all serious ingestions.

• Perform gastric lavage in patients with life-threatening ingestions who present early (ie, generally, <1 h following ingestion). Beyond 1 hour, much of the toxin has already passed into the small intestine. Take special care to protect the patient's airway during gastric lavage. Protective measures may include intubation, particularly in comatose patients and patients with a decreased or absent gag reflex.
• Gastric decontamination with activated charcoal is highly recommended. The dosage is 1 g/kg of body weight. Charcoal may be administered mixed with juice or soda if the child can drink from a cup. Administration often requires placing a nasogastric tube because the charcoal's gritty texture is not palatable to most children.
• Whole bowel irrigation is effective in patients with certain ingestions who present too late for effective gastric lavage.

Consultations

• Always consult the regional poison control center.
• • Locate the nearest US poison control center by contacting the American Association of Poison Control Centers at 1-800-222-1222.
  • In addition to providing advice on management and specific treatment or antidotes, poison control centers have on-call toxicologists available for physician consultations.
  • Data on toxic ingestions are compiled through reports to the poison control centers; these data improve treatment of future patients with similar ingestions.
• The need for additional medical consultation depends on the nature of the ingestion and the toxicity of the substance.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical therapy is directed to the specific ingestion. Certain antidotes are well described for ingestion of a number of toxic substances. Provide supportive therapy for patients with other ingestions, based on symptoms. (Specific antidotes for each of the previously mentioned toxic substances are beyond the scope of this article.)

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Tailor inpatient treatment to the patient's condition.

Transfer

• Transfer may be required for patients whose needs exceed the capability of the hospital providing initial treatment (eg, a patient who needs hemodialysis).

Deterrence/Prevention

• Public education about the potentially fatal hazards posed by chemicals, medications, and common cleaning compounds is the key to prevention. Basic steps include the following:
• • Keep hazardous and toxic substances in their original containers. Containers should be appropriately marked.
  • Never store food near toxic substances.
  • Keep hazardous and toxic compounds in a secure place out of the reach of children.
• Parents and the public should know how to contact the regional poison control center for suspected toxic ingestions.

Complications

• Complications depend on the substance ingested and may include death or permanent neurologic disability.

Prognosis

• Prognosis depends on the ingested substance and the amount of time between ingestion and initiation of medical care.

Patient Education

• See Deterrence/Prevention.
• For excellent patient education resources, visit eMedicine's Substance Abuse Center and Poisoning - First Aid and Emergency Center. Also, see eMedicine's patient education articles Poisoning, Drug Overdose, Activated Charcoal, and Poison Proofing Your Home.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Be aware that even small ingestions may be deadly.
• Report all suspected cases of nonaccidental toxic ingestions.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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Article Last Updated: Apr 19, 2006