The Turkish Journal of Pediatrics
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Thirty-Three-Year Experience on Childhood Poisoning
Ramazan Özdemir, Benan Bayrakcı, Özlem Tekşam, Bilgehan Yalçın, Gülsev Kale
Department of Pediatrics, İhsan Doğramacı Children’s Hospital, Hacettepe University Faculty of Medicine, Ankara, Turkey
|By comparing our data for the period 1985-2008 with findings from a previous
report covering the period 1975-1984, we aimed to share our experience with
poisoning cases in order to contribute toward its prevention, diagnosis and
treatment. The records of patients admitted to the Pediatric Intensive Care
Unit with acute poisoning between November 1985 and October 2008 were
evaluated retrospectively. The records of 2251 patients with acute poisoning
could be retrieved. Poisoning mostly occurred in the home (92%), via the oral
route (92.5%) and by a single intoxicant (81.3%). Two distinct peaks were
observed: in boys between 1-5 years of age and in girls between 13-16 years
of age. It was noted that 67.4% of poisoning cases were accidental, whereas
25.9% were suicidal and 6.7% were a result of a therapeutic error. Nearly
two-thirds (64%) of cases were drug-related, while 36% were non-drug-related.
Analgesics-antipyretics ranked first among the drug-related cases, whereas
ingestion of a corrosive substance was most common among cases with nondrug
poisoning. Colchicine was associated with the highest fatality, while
among the causes of non-drug poisoning, carbon monoxide was the deadliest.
The overall mortality rate in this study was 1.9%. Mortality from non-drug
poisoning was higher than from drug-related causes (3.9% vs. 1.3%). Almost
all cases of poisoning below the age of 6 years are potentially preventable.
The results of this study highlight the need for reforms in industrial and
health policies, with the aim of increasing awareness regarding potential
toxins, appropriate storage of potential toxins, and general precautions to
promote safety in the home.|
poisoning, intoxication, childhood.
|Poisoning is a common and potentially fatal
public health problem, which contributes to the
added costs of both emergency and in-patient
care. The cause of poisoning varies with age,
gender, education, and cultural background,
and also shows seasonal variations. Causative
agents also differ between countries, making
it important for every nation to establish its
own poisoning profile and to identify the
associated risk factors, while at the same time
implementing preventive measures.
Although poisoning may occur at any age,
children are at particular risk. According to
the most recent data from the National Poison
Center at the Refik Saydam National Public
Health Agency in Turkey, 56% of 78,679
reported poisoning cases were children. In a
2006 publication by the American Association
of Poison Control Centers (AAPCC), 64.5% of
poisoning cases in the United States were
children under the age of 19 years.
Epidemiological identification and
documentation of childhood poisonings are
very important for prevention and for the
development of industrial and health policies
and treatment plans. Hincal et al. previously
reported the epidemiologic portrait of childhood
poisoning cases who were admitted to the
Children’s Hospital of Hacettepe University
between 1975 and 1984.
In this study, we attempted to share the
experience of a single center on childhood
poisoning over a period of 33 years. Demographic
and clinical characteristics are presented, while
changes over time with regard to diagnosis
and treatment are also discussed. The main
purpose of the study was to determine the
factors associated with mortality to help in
the diagnosis, management and prevention of
|Material and Methods |
|In this retrospective study, the records of
children aged 0-19 years who were admitted to
the Pediatric Intensive Care Unit at Hacettepe
University İhsan Doğramacı Children’s Hospital,
in Ankara, Turkey, for acute poisoning between
November 1985 and October 2008 were
reviewed systematically. In addition, the results
of this study were compared with Hincal et al.’s
report, which demonstrated the epidemiologic
portrait of childhood poisoning cases who
were admitted to the same hospital between
1975 and 1984. The traditional policy of our
hospital for acute poisonings is admitting them
to the Pediatric Intensive Care Unit in order
to provide essential vital monitoring.
Information recorded included: age, sex,
weight, date and time of presentation, time
from poisoning to arrival at the emergency
department, prior interventions either at home
or at a previously visited health center, nature/
purpose of the toxin(s) consumed, site/route
by which toxin was consumed, the person
responsible for the error (in case of accidental/
therapeutic poisoning), the number of previous
suicide attempts (in case of toxin consumption
with suicidal intent), means of acquisition of
the toxin, presence of poisoning symptoms on
presentation, treatments administered in the
pediatric emergency department or intensive
care unit, treatment-related complications, and
the overall survival rate of patients.
The computerized automation system of the
hospital was used for the records after 2000.
The older documents were obtained from
the classical archival system. A template
was designed regarding the previous studies
present in the literature. The same investigator
completed all the templates in the same manner
and double checked the accuracy of the data
with the electronic charts when possible.
Statistical analysis was performed using the
Statistical Package for the Social Sciences ver.
17.0 (SPSS Inc., Chicago, IL). Independent
samples t-test or Mann-Whitney U test was
used to compare continuous variables and chisquare
test or Fisher’s exact test for categorical
variables. Mortality-associated risk factors were
determined using multivariate (backward)
logistic regression analysis. A p value <0.05
was considered statistically significant.
| ||Fig. 1. The distribution of poisoning cases by years.|
The study was approved by the Medical
Research Local Ethics Committee of Hacettepe
|A total of 2251 cases of acute childhood
poisoning were admitted to the Pediatric
Intensive Care Unit in our hospital between
November 1985 and October 2008 (Fig. 1).
Drug-related poisonings were the cause of
poisoning in 64.4% of patients, while non-drug
poisoning was encountered in 35.6% of cases.
Overall, the mean age of patients presenting
with poisoning was 6.7 years (range: 0.1-19
years). The average age of cases of accidental
non-drug poisoning was higher than that of
drug-related cases (5.5 years vs. 3.2 years;
p<0.001). Patients presenting with suicidal
poisoning had a mean age of 14.2 years.
Children between 1-5 years of age accounted
for 56.1% of all cases of poisoning, most of
whom were male, whereas 25.5% of cases
were between 13-16 years of age, with a
female predominance (Fig. 2). Although drugs
were the most common cause of poisoning
in the 1-5 years age group, cases of non-drug
poisoning were not uncommon. Cases of
poisoning in the 13-16 years age group were
exclusively drug-related (Fig. 3). While cases
of poisoning in children less than 5 years of
age were mainly accidental, adolescent cases
were more commonly suicidal. Therapeutic drug poisoning occurred most frequently in
children younger than 1 year of age (Fig. 4).
| ||Fig. 2. Sex and age distribution of poisoning cases.|
| ||Fig. 3. Distribution of nature of toxin ingested
according to age.|
Although there was no significant difference in
overall gender distribution (50.6% girls, 49.4%
boys), drug-related poisoning occurred more
frequently in girls (53.4% vs. 46.6%; p=0.001),
whereas non-drug poisoning was more common
in boys (59% vs. 41%; p=0.001).
While only 18% of patients presented within
30 minutes of the initial poisoning incident,
36% presented within 60 minutes, 57% within
2 hours, and 83% after 6 hours. The mean
time to presentation to a health facility was
5.1 hours. For accidental cases of poisoning,
the mean time to presentation was 4.2 hours,
compared to 4.1 hours for suicidal cases.
Patients with therapeutic drug poisoning had a
mean time to presentation of 18.5 hours. While
the mean time to presentation for patients who
were discharged after making a full recovery
was 5 hours, this duration was 10.3 hours for
those who died (p=0.032).
Incidents of poisoning occurred more frequently
in the spring and summer months (p=0.001),
mostly consisting of non-drug related cases
(p=0.001). Carbon monoxide poisoning was
the only non-drug cause of poisoning to occur
year round. Similarly, drug-related cases did not
show any seasonal variations (Fig. 5).
The majority of poisoning incidents occurred
at home (92%), involving a single intoxicant
(81.3%), mainly administered via the oral
| ||Fig. 4. Distribution of cause of poisoning according to
| ||Fig. 5. Seasonal distribution of poisoning cases.|
While 67.4% of all poisoning incidents were
accidental, 25.9% were suicidal and 6.7%
occurred as a result of a therapeutic error.
Almost all (93.2%) cases of poisoning in
children under 6 years of age were accidental,
with the remaining occurring as a result
of a therapeutic error. Accidental non-drug
poisoning occurred more commonly in males
than in females (57.7% vs. 42.8; p=0.02).
Throughout the 23-year study period, accidental
poisoning remained the most frequent cause
of childhood poisoning, although there has
been a decrease in accidental cases in recent
years. In contrast, the number of cases of
suicidal poisoning has increased from 1984-
2008 (Fig. 6).
Accidental poisoning occurred more frequently
in summer and less commonly during the
winter months. On the other hand, the
number of suicidal poisoning cases peaked in
winter, while occurring less frequently during
the summer (p=0.001). Seventy percent of
children presenting with accidental poisoning
acquired an intoxicant, most commonly a drug/
medication (82.7%), from a readily accessible
| ||Fig. 6. Chronological variations in cause of poisoning.|
| ||Fig. 7. The distribution of some drug poisonings over
Corrosive agents were the most frequently
encountered cause of non-drug poisoning in
our patients (44.3%; p=0.001). On the other
hand, analgesics/antipyretics were the most
common cause of drug-related poisoning,
aspirin being the number one culprit followed
closely by paracetamol. This group was followed by antidepressants and antiepileptics. Among
the cases of suicidal poisoning, antidepressants,
particularly amitriptyline (Laroxyl®), were the
most commonly ingested medication. Cases
of aspirin poisoning peaked between 1990
and 1992, while in the last three years of the
investigated study period (2005-2008), no cases
of aspirin poisoning were reported. The last
10 years, however, have witnessed a gradual
increase in amitriptyline poisoning (Fig. 7).
Vomiting was induced by a family member in
8.5% of cases before presentation to a healthcare
facility, whereas 7.6% of patients were given
either milk or yoghurt. Interventions performed
at our hospital and/or other healthcare facilities
visited prior to presentation are summarized in
Table I. It was observed that use of activated
coal has increased over the years (p=0.001).
| ||Table I. Interventions Employed at our Hospital and
other Health Facilities for the Management of Poisoning|
Overall, 39 patients (1.9%) who presented to
our hospital with acute poisoning eventually
died. For drug-related poisoning, the mortality
rate was 1.3% (19 patients) compared to 3.9% (17 patients) for non-drug poisoning. Most
of the patients who died were boys (71.8%;
p=0.014). Mortality rates for accidental,
suicidal and therapeutic poisoning were 2.2%,
1.4% and 3.2%, respectively. Of all the deaths,
76.9% were a result of accidental poisoning,
while 12.8% occurred as a result of suicide. The
most fatal intoxicant among the drug-related
cases was colchicine, while carbon monoxide
was the most common cause of non-drug
Of all the interventions employed in the
management of poisoning (induced vomiting,
milk/yoghurt consumption, gastric lavage,
activated coal, forced diuresis, alkalization,
cathartics, hemodialysis, and peritoneal
dialysis), only activated coal was shown to
have significant benefit (Odds ratio: 2.5 [95%
confidence interval: 1.6–10.9]; p=0.04).
|Identification and documentation of
epidemiological aspects and other variables in
childhood poisonings are of great importance
for planning treatment and determining
proper preventive measures. The results of
our study may reflect the epidemiology of
childhood poisonings and alterations over time
because our hospital is the largest children’s
hospital in Turkey. The most striking findings
in our study were the increasing cases of
amitriptyline poisoning, decreasing cases of
salicylate poisoning and rising number of
suicide attempts in children over the 33 years.
The most deadly poison was colchicine.
Poisoning occurs more commonly in boys, and
is mainly due to accidental use of a single
agent during the first five years of life. In
adolescents, poisoning is more common in girls,
usually involving multiple intoxicants with the
intent of suicide. We observed that 61.2% of
our cases were younger than 6 years of age,
a result consistent with findings of previous
studies from our institutes and the literature.
While most of the patients in the 1-5 years
age group were male, those in the 13-16 years
age group were mostly female-.
Another expected finding of our study was
that non-drug poisoning was more common
in boys than in girls (59% vs. 41%; p=0.001).
This may be because during the spring and
summer months, boys tend to play unattended outdoors more often than girls. On the contrary,
drug-related poisoning was encountered more
commonly in females than in males (53.4%
vs. 46.6%; p=0.001), which may be explained
by the predominance of girls among cases of
suicidal poisoning (93%).
| ||Table II. Clinical Characteristics and Substances Involved in Poisoning by Time Period|
In our study, nearly two-thirds of poisoning
cases were drug-related, while the remaining
one-third were cases of non-drug poisoning.
A similar result was reported from a previous
study from our center covering the period
1975-1984 (Table II). According to published
data from the National Poison Center at Refik
Saydam National Public Health Agency, 43,939
cases of childhood poisoning (0-19 years)
were reported nationwide between 2000 and
2004, 71.4% of which were drug-related. The
results from our center are also consistent with
findings from other hospitals in Turkey-.
The introduction of child safety caps in 1970
led to a 40% decrease in the number of drugrelated
cases of poisoning, with a similar
decrease in poisoning-associated mortality-.
This supports the idea that by taking the
necessary precautions, it could be possible to
decrease drug-related poisoning rates to the
levels of developed countries. Although the
use of child safety caps has unequivocally
been demonstrated to prevent accidental drugrelated
poisoning and to decrease morbidity
and mortality associated with poisoning, only
a limited number of medications are sold with
such caps in Turkey, and there is a dire need
for a government policy that makes use of such
a precautionary measure mandatory.
According to our study results, 83.2% of
patients were brought to medical attention
within 6 hours of the initial poisoning incident,
compared to 51.2% of patients in the previous
study covering 1975-1984. This may be
attributed to a higher level of awareness among
parents with regards to the importance of early
intervention in cases of poisoning.
In our study, we also observed that patients
with poisoning due to a therapeutic error
tended to be brought in later than patients
with accidental or suicidal poisoning. This
may be because symptoms of poisoning are
often mistakenly attributed to the disorder that
required treatment initially. Other contributory
factors may be parental exhaustion brought on
by the demanding nature of the underlying
chronic condition, or delay in seeking medical
attention for fear of legal or social retribution.
As reported in numerous studies, most of the
cases of poisoning in our study occurred during
the spring and summer months,,. With
the exception of carbon monoxide poisoning,
cases of non-drug poisoning occurred most
commonly in summer. Drug-related poisoning
did not show any seasonal variation. The
higher frequency of non-drug poisoning in
summer may be attributed to an increased
use of farming chemicals as well as increased
consumption of unwashed, toxin-contaminated
fruits. Unsupervised outdoor play may also
increase the likelihood of encountering toxic
materials, plants and mushrooms. Renovation
and remodeling work is usually undertaken
during the summer months, which may also
make potentially toxic drugs more accessible to children. During winter months, on the
other hand, children spend most of their time
indoors, making their supervision easier.
The cause of poisoning in children shows
geographical variations, also influenced
by economical status. In developed and
industrialized countries, poisoning is most
frequently from drugs, cosmetics and beauty
products, household cleaning products, and
alcohol, while for developing countries, where
the economy is based on agriculture, common
causes of poisoning are hydrocarbons, pesticides,
traditional medicines, and mushrooms,-. In
our study, 44.3% of cases of non-drug poisoning
were due to corrosive agents, followed by
pesticides and farming agents, at 37.4%.
Interestingly, during the period 1975-1984,
almost all cases of non-drug poisoning were
due to pesticides, followed by toxic plants and
mushrooms as well as petroleum products, with
corrosive agents in fourth place. This finding
suggests a drift from agriculture to industry
over the years. The increased incidence of
poisoning with corrosive agents in Turkey could
be attributed to a higher number of industrial
areas, with lesser dependence on agriculture.
Furthermore, corrosive agents have found their
way into the household for daily consumption,
making them readily accessible to children.
Additionally, the sale of smaller amounts of
such products in unconventional containers,
such as water or beverage bottles, may also
contribute to accidental poisoning in children.
In our study, analgesics/antipyretics, antidepressants
and antiepileptics were the three groups
of drugs responsible for almost all cases
of single drug-related poisoning. For the
period 1975-1984, analgesics were followed by
barbiturates as the most common cause of drug
poisoning (Table III). The number of cases of
antidepressant poisoning has increased with
time, perhaps representative of sociocultural
Many studies from developed and developing
countries list analgesics as the most commonly
encountered drugs in cases with childhood
poisoning,,-. In Turkey, analgesicsantipyretics,
most of which are packaged in
bottles with child safety caps, are available over
the counter, without the need for a doctor’s
prescription, making them readily available in
the home within children’s reach.
After Reye’s syndrome was described in 1986,
many pediatric formulations of acetylsalicylic
acid were removed from the market. This,
combined with the change in habits of doctors
in prescribing aspirin as an antipyretic, may
have contributed to the decrease observed in
poisoning cases due to aspirin. While aspirin
poisoning comprised 91.2% of all cases of
poisoning from analgesics in patients presenting
from 1975-1984, its frequency has decreased
with time, and no cases were observed in the
last three years of our study period.
| ||Table III. Substances Involved in Poisoning in the Two Time Periods|
Antidepressants were the most frequently
used drug group among cases of suicidal poisoning by a single agent, particularly
amitriptyline (Laroxyl®). In contrast, cases
of suicidal poisoning from 1975-1984 were
mostly with analgesics (44.1%), while tricyclic
antidepressants were responsible for only 3.4%
of cases. In a different study from Turkey, on
adult patients presenting with poisoning from
1997-2002, it was observed that the number
of cases of poisoning with psychoactive drugs,
including antidepressants, had increased with
time, while cases due to analgesics showed
a gradual decrease. Amitriptyline is one
of the most commonly prescribed tricyclic
antidepressants, and the last 10 years have
witnessed a dramatic increase in amitriptylinerelated
cases of poisoning in Turkey-. This
drug is preferred by local doctors mainly
because of its efficacy and low cost, and a
combination of prescription habits along with
the wide availability of the drug nationwide
may have contributed to the sharp increase in
the number of cases of amitriptyline poisoning.
In our study, accidental, suicidal and therapeutic
poisoning was determined in 67.4%, 25.9% and
6.7% of patients, respectively. The corresponding
frequencies for 1975-1984 were 69.9%, 12.8%
and 15.1%, respectively,. Although the
rate of accidental poisoning has remained
unchanged through the years, the number of
suicidal cases of poisoning has nearly doubled,
while poisoning due to therapeutic error has
decreased by half. Similar trends have been
reported from Northern Ireland and the United
States,,. These changes are suggestive of a
negative impact of social westernization that
renders some children more likely to attempt
In 70% of children in our study, the responsible
intoxicant was stored within their easy reach,
particularly with respect to drug-related
poisoning (82.7%). Precautionary measures
that may be implemented to prevent access
include storing potential intoxicants in high
places beyond the reach of children, preferably
in locked cupboards.
Vomiting was induced by parents in 8.5% of
children before they were brought for medical
attention, whereas 7.6% were given yoghurt
or milk. A comparison with the period 1975-
1984 revealed a two-fold increase in the
parental practice of induced vomiting (4.5%
vs. 8.5%), while consumption of yoghurt and/
or milk remained generally the same (8.7%
vs. 7.6%). Our study, along with another
study from Israel, failed to demonstrate any
added benefit of these practices on mortality.
Since 63.2% of our patients presented to a
healthcare facility more than an hour after the
initial poisoning incident, it would seem that
some patients underwent unnecessary gastric
lavage. In two prospective studies on childhood
poisoning from Norway, use of gastric lavage
in patients with acute poisoning decreased
from 36% in 1980 to 9% for the period
2003-2005. Gastric lavage is associated with
a 3% complication rate, which highlights the
need for diligence when making a decision to
go through with the procedure.
Multivariate logistic regression analysis of
the potential benefit of specific interventions
employed, such as induced vomiting, milk/
yoghurt consumption, gastric lavage, activated
coal, forced diuresis, alkalization, cathartics,
hemodialysis, and peritoneal dialysis, revealed
that only activated coal was associated with a
2.5-fold decrease in mortality (Odds ratio: 2.5
[95% confidence interval: 1.6–10.9]; p=0.04).
Being gleaned from retrospectively gathered
data makes this statistically impressive result
a scientifically weak conclusion. Activated
charcoal administration in acute overdose
remains a controversial problem. Use of
activated coal for acute poisoning was first
introduced in 1989, and by 1994, more than
70% of cases of poisoning were subject to
such treatment, which has been reported to
be most effective when administered within
one hour of the initial poisoning incident.
While 52.5% of our patients had received at
least a single dose of activated coal, overall,
only 36.8% of the cases of acute poisoning
were brought to medical attention within one
hour of being poisoned. Measures to ensure
timely administration of such a life-saving
procedure, such as making activated coal readily
available in primary healthcare centers as well
as in ambulances, should be implemented to
help improve the outcome of acute poisoning.
Although deaths from poisoning are far more
common in adults than in children,, children
remain at greater risk. According to data
published by the AAPCC in 2006, children
under 19 years of age comprise 64.5% of all
cases of poisoning, whereas poisoning-related deaths occurred in only 8.1% of patients in
this age group. In another publication by the
AAPCC, of the 15,447 deaths reported since
1983, 540 (3.5%) were children under 6 years
of age, 402 (2.6%) of whom were younger
than 2 years of age.
In our study, we established a mortality rate of
1.9% among patients admitted to the Pediatric
Intensive Care Unit at our hospital with acute
poisoning. This is a 65.3% decrease from the
mortality rate of 4.9% reported in a previous
study covering the period 1975-1984. A
similar trend has also been reported in western
countries,,. This decrease in mortality may
be attributed to greater parental awareness
regarding poisoning in general, resulting in
them seeking medical attention earlier. This
is supported by the observed increase in the
number of cases that presented to a healthcare
facility within six hours of an initial poisoning
incident (51.2% between 1975-1984 vs. 83%
between 1985-2008). Other factors include
the accumulation worldwide of knowledge
regarding poisoning, emergency department
staff who are better educated and trained in
the management of poisoning, technological
advances in intensive care, recall of commonly
known intoxicants from the market, production
of less toxic corrosive agents, and the increased
use of containers with child safety caps,
especially for drugs with higher fatality rates.
Many studies on childhood poisoning
have reported higher mortality rates for
suicidal poisoning compared to accidental
poisoning,,. In our study, on the other
hand, we observed increasing mortality rates
of 1.4%, 2.2% and 3.2% in patients with
suicidal, accidental and therapeutic poisoning,
respectively. Mortality rates for 1975-1984
were 1.3%, 3.4%, and 13.3%, respectively.
In contrast to other reports from western
countries, our findings show that the mortality
rate of accidental poisoning is higher than that
for suicidal poisoning. This may be explained
in terms of intent behind the suicide attempts.
In most cases in Turkey, the main purpose is
to draw attention and/or scare one’s parents,
rather than to inflict real harm or cause death.
This is of course achieved by taking less toxic
drugs in smaller amounts.
Nearly 85% of all cases of poisoning in children
under the age of 6 years, including all fatalities,
could have been avoided if necessary preventive
precautions had been implemented, particularly
since in 70% of cases the intoxicating agent
was kept in an easily accessible location. The
result of this study highlights the need for
reforms in industrial and health policies, with
the aim of increasing awareness regarding
potential toxins, their appropriate storage,
and general precautions to promote safety in
the home. Of course, every country needs to
establish its own poisoning profile, while at
the same time identifying specific risks, which
may help in developing preventive measures.
Establishing an epidemiological profile of
poisoning that correctly represents the whole
country would require centers nationwide to
share and combine their experiences through
prospective and retrospective studies.
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