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Children poisoning in Taiwan

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Poisoning is a well known cause of morbidity and mortality in children. In Taiwan, little information has been published regarding the status of pediatric poisoning exposures. To provide more information on pediatric poisoning exposures for the
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  Symposium : Toxicology & Poisoning-Part I Indian J Pediatr 1997; 64 : 469-483 hildren Poisoning in Taiwan Cheng Chang Yang 1 2, Jia-Fen Wu 2, Hsin-Chen Ong 1, Yih-Pyng Kuo, Jou-Fang Deng 1,2 and Jiin Ger 1,2 1Division of Clinical Toxicology Department of Medicine Veterans General Hospital-Taipei and 2National Yang-Ming University Taiwan R.O.C. Abstract. Poisoning is a well known cause of morbidity and mortality in children. In Taiwan, little in- formation has been published regarding the status of pediatric poisoning exposures. To provide more information on pediatric poisoning exposures for the purpose of poison prevention, a retro- spective study was designed and conducted to analyse the data of National Poison Centre (NPC), Taiwan. All telephone inquiries concerning poisoning exposures in those under 19 years of age, re- ceived by NPC-Taiwan from July 1985 through December 1993, were included in this study. The age, sex, reason for exposure, route of exposure, substances involved and clinical outcome of those telephone calls were then analyzed. A total of 5,812 inquiries concerning poisoning expo- sures in children were recorded. Male exposures were more prevalent than females (59 ) Vs 41 ) Accidental exposures accounted for 77.7 of the cases and most were exposed by the oral route. Substances most frequently ingested were household products, benzodiazepines and pesti- cides. The data revealed a mortality rate of 1.4 . Accidental poisoning exposures from household products and drugs remain a significant problem for those younger than 6 years of age. Further education of parents and care takers and the employment of child-resistant containers are needed to prevent cases of pediatric poisoning. Reduction of amphetamine abuse in adolescents is also of major concern and deserves more attention. Indian J Pediatr 1997; 64 : 469-483) Key words : Pediatric poisoning; Benzodiazepines; Amphetamine abuse Although the exact incidence of acute poi- soning is difficult to estimate, poisoning it- self represents a serious problem in most countries and the reported cases continue to increase annually worldwidelZ Among these pediatric poisoning is of particular concern since most children are poisoned accidentally and this should be prevented. In 1993, the number of acute poisoning ex- posures in children less than 6 years of age, Reprint requests : Chen-Chang Yang, M.D., Division of Clinical Toxicology, Department of Medicine, Veterans General Hospital-Taipei, Taiwan, R.O.C. Fax : 886-2-8739193. as reported to poison centers, was approxi- mately 9,80,000 in the United States, with the overwhelming majority (99.3 ) being accidentally exposedL In accidental pediatric exposures, the most frequently ingested poisons are those within easy reach of children and are not kept in child- resistant packaging* Common household substances and medications are the most commonly ingested by young children. In Taiwan, there is tremendous accessi- bility to over-the-counter drugs which are inadequately regulated and where use of child-resistant containers is rare. Little epi- demiological data concerning acute poi-  470 C-C YANG ET AL Vol. 64, No. 4, 1997 soning exposures in children are available in Taiwan to draw any conclusions 7. A thorough review of the data of the National Poison Centre-Taiwan (NPC-Taiwan) was conducted to develop a better understand- ing of the incidence of poisoning exposures in children and the demographic data, sub- stances involved and clinical severity: of poisoning in children. M TERI L ND METHODS This study consisted of retrospective analy- sis of NPC records for a period of 8.5-years (July 1985-December, 1993). All telephone inquiries concerning human exposures during this period, received by the NPC- Taiwan, were recorded and following in- formation gathered : name, age, sex, phone number of both caller and patient, patient s weight (if available), relationship of caller and patient, route and dose of exposure, reasons for exposure, initial symptoms and signs, substances involved in exposure, methods of management (including use of antidotes), clinical outcome, cause of death (if applicable), and days from exposure to death. Data was then entered into a dBase III computer file for subsequent analysis. Exposures in those aged less than 19 years, after exclusion of cases with symptoms un- related to their exposures, were included hi this study. The age, sex, mode (uninten- tional or intentional) and route of expo- sure, substances involved and clinical out- come were then analyzed. Special attention was paid to the fatal cases and those cases which were suicide attempts. Reasons for exposure in this study were classified as : (1) unintentional (including unintentional general, occupational, thera- peutic error, environmental, malicious and unknown); (2) intentional (including sui- cidal, misuse, abuse, other and unknown); (3) adverse reaction (including prescribed drugs, Chinese herbs, food, other and un- known); and (4) totally unknown reason for exposure. Definitions for these reasons are as follows : Unintentional general : All unintentional exposures not specifically defined below. Occupational : Exposure occurring as a di- rect result of the person being on the job or in the working place. Environmental : Any passive, nonoccupational exposure result- ing from contamination of air, water, or soil. Malicious : Patients who are victims of another person s intent to harm them. Therapeutic error : An unintentional devia- tion from a proper therapeutic regimen that results in the wrong dose, incorrect route of administration, administration to the wrong person, or administration of the incorrect substance. Only exposures to medications or products substituted from medications were included. Unintentional unknozon : An exposure deemed to be unin- tentional but the exact reason is unknown. Suicidal : Exposure resulting from the inap- propriate use of a substance for reasons that were suspected to be self-destructive or manipulative. International misuse : An exposure resulting from the intentional, improper or incorrect use of a substance for reasons other than the pursuit of a psychotropic effect. Intentional abuse : An exposure resulting from the intentional im- proper or incorrect use of a substance in which the victim was attempting to achieve a euphoric or psychotropic effect. Intentional other : All intentional exposures not specifically listed above. Intentional un- known : An exposure that is known to be in- tentional but the specific motive is un- known. Adverse reaction prescribed drugs : An adverse reaction occurring with nor-  Vol. 64, No. 4, 1997 CHILDREN POISONING IN TAIWAN 471 mal, labelled or recommended use of pre- scribed drugs, excluding Chinese herbs. Adverse reaction, Chinese herbs : An adverse reaction occurring with normal, or recom- mended use of prescribed Chinese herbs. Adverse reaction, food : An adverse reaction occurring with normal use of prepared foods. Included are cases with an un- wanted effect caused by an allergic, hyper- sensitive, or idiosyncratic response. Adverse reaction, other : An adverse reaction occur- ring with normal use of the product not listed above. Adverse reaction, unknozon : An adverse reaction occurring with use of un- determined product. Totally Unknown : All cases with undetermined reason for expo- sure are included. Ingested toxins were classified in one of 14 categories : pesticides, drugs, animal bites and stings, rodenticides, insect repel- lents, food-borne toxins, plants, cosmetics, cleansing substances, solvents, hydrocar- bons, carbon monoxide and other toxic gases, Chinese herbs and miscellaneous toxins (desiccants, elemental mercury, oth- er heavy metals, etc. . Drugs were further subcategorized into 12 groups : cardiovas- cular drugs, benzodiazepines, tricycle anti- depressants and phenothiazines, ampheta- mine and related drugs, antihistamines, an- algesics, other drugs acting on central nervous system (barbiturates, anticholiner- gic drugs, anticonvulsants, etc. , topicals, gastrointestinal drugs, bronchodilators, others (including hormones, vitamins, diu- retics, etc. and unknown. Pesticides were also subcategorized into 7 groups : paraquat, glyphosate, organophosphates, carbamates, pyrethrin and pyrethroids, miscellaneous (fungicide, moltuscide, etc. and unknown. In most cases, follow-up calls were made several times to determine the pa- tient's outcome. Nonetheless, in those with a non-toxic ingestion, or insignificant amount implicated in the poisoning expo- sure or the route of exposure being un- likely to result in a clinical effect or those leaving no telephone numbers, no follow- up calls or only one follow-up call were made. The clinical outcomes were classified as no effect, minor effect, moderate effect, ma- jor effect, death, possible causal effect (ex- posure confirmed yet with inadequate clinical information to determine its out- come) and an unknown outcome. Defini- tions for these outcome are as follows : No effect : The patient developed no signs or symptoms as a result of the expo- sure. Minor effect : The patient developed some signs or symptoms following the poi- son exposure which were minimally both- ersome and resolved rapidly without resid- ual disability. Signs and symptoms regard- ed as minor effect are usually nonspecific and are often limited to the skin or mucous membranes (e.g., self-limited gastrointesti- nal symptoms, skin irritation or first degree dermal burn, sinus tachycardia without hy- potension, transient cough or tachypnea). Moderate effect : The patient exhibited signs or symptoms that were more pronounced, more prolonged, or more systemic in na- ture than minor effects. Usually some form of treatment is indicated. Symptoms were not life-threatening, and there is usually no residual disability or disfigurement (e. , secondary degree burn, transient hypoten- sion, hypoxia that is rapidly reversed by appropriate treatment, isolated brief sei- zures that respond readily to treatment). Major effect : The patient exhibited signs or symptoms following the poison exposure that were life-threatening or resulted in sig- nificant disability or disfigurement (e.g.,  472 C-C YANG ET AL Vol. 64, No. 4, 1997 status epilepticus, respiratory insufficiency requiring intubation, ventricular tachycar- dia with hypotension, cardiac or respirato- ry arrest, disseminated intravascular coag- ulation, massive hematemesis or melena). Death : The patient died as a result of the exposure. Possible causal effect : The patient exhibited signs or symptoms as a result of the exposure, however, the effect is not clearly linked with the exposure e.g., un- consciousness associated with mild gas- trointestinal and respiratory symptoms in a patient with pyrethrin poisoning, delirium in a patient with benzodiazepine poison- ing). Exposure confirmed yet with inadequate clinical information to determine its outcome : There was reliable and objective evidence that an exposure really occurred, however, available information on clinical signs or symptoms were inadequate to draw any conclusion. Unknown outcome : The patient was lost for follow-up, or refused for fol- low-up. R SULTS During the 8.5-year period, 5,812 expo- sures in those aged less than 19 years were recorded. This represented 24.8 of all ex- posures during that time period. As shown in Fig. 1, the number of pediatric poisoning exposures reported to the NPC-Taiwan in- creased annually until 1993 when for the first time there was a significant decline in children exposure. The male to female ratio Number of cases 1200 1000 00 600 400 200 0 I t m I I I I I I [] Unknown sex [] emale [] Male 85 86 87 88 89 90 91 92 93 ear Fig. 1. Annual Incidence of Pediatric Poisoning Exposures Reported to NPC-Taiwan, from July 1985 through December 1993  Vol. 64., No. 4, 1997 CHILDREN POISONING IN TAIWAN 473 was 1.45 (3,412 Vs 2,346) with the sex be- ing unidentified in only 54 cases. Most of the patients were less than 6 years of age (3,914 cases, accounting for 67.3 of all cases). Table 1 presents the distribution of age and sex of the poison exposure victims. Of the 5,812 telephone inquiries, most were from health care professionals and only 30.9 of the calls came directly from the general public. The peak call volumes of NPC were noted from 8 A.M. to 6 P.M., with 59.3 of calls lo, gged during this 10- hour period. Unintentional exposure in Table 1. Age and Gender distribution of Pediatric 1985-1993 4,516 cases (77.7 ), was the most common reason for exposures in children. In those less than 6 years of age, the proportion of unintentional exposures was even higher, reaching a peak in the 2 year old (96.4 ). Table 2 shows the distribution of the rea- sons for exposure in children, whereas Fig. 2 delineates the relative proportion of rea- sons for exposure in different ages. Drugs were the most common sub- stances involved in pediatric exposures fol- lowed by caustics and other household cleaners, and pesticides, which constituted Poisoning Exposures Reported to NPC-Taiwan, Age Male Female (years) Unknown No. No: No. Total Cumulative total No. No. < 1 218 59.1 139 37.7 12 2.3 369 6.3 369 6.3 1 687 60.0 445 38.8 13 1.1 1,145 19.7 1,514 26.1 2 639 59.3 434 40.3 5 4.6 1,078 18.5 2,592 ~4~6 3 438 61.3 270 37.8 6 0.8 714 12.3 3,306 56.9 4 228 60.3 141 37.3 9 2.4 378 6.5 3,684 63.4 5 145 63.0 84 36.5 1 0.4 230 4.0 3,914 67.3 6 77 57.9 55 41.4 1 0.8 133 2.3 4,047 69.6 7 63 53.8 53 45.3 1 0.9 117 2.0 4,164 71.7 8 71 69.6 31 30.4 0 0.0 102 1.8 4,266 73.4 9 48 57.1 35 41.7 1 1.2 84 1.4 3,350 74.0 10 57 60.6 36 38.3 1 1.1 94 1.6 4,444 76.5 11 41 61.2 26 38.8 0 0.0 67 1.2 4,511 77.6 12 50 54.3 41 44.6 1 1.1 92 1.6 4,603 79.2 13 63 54.3 55 46.6 0 0.0 118 2.0 4,721 81.2 14 70 44.9 86 55.1 0 0.0 156 2.7 4,877 83.9 15 80 52.3 73 47.7 0 0.0 153 2.6 5,030 86.5 16 92 52.9 81 46.6 1 0.6 174 3.0 5,204 89.5 17 149 52.9 132 47.1 0 0.0 281 4.8 5,485 94.4 18 195 59.6 132 40.4 0 0.0 327 5.6 5,812 100.0 Total 3,411 58.7 2,349 40.4 52 0.9 5,812 100.0
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