Introduction:

Childhood poisoning is one of the most common causes of emergency department visits and also one of the notable causes of morbidity and mortality in this age group. Because most cases of poisoning in children are accidental, it can be prevented.  (1, 2).

According to various studies, the causes of poisoning and related issues vary in different geographical areas based on cultural and social differences (3-6). Even the causes of poisoning in an area may change over time. Therefore, physicians should always improve their knowledge in this regard (7). Some substances can cause poisoning through ingestion, skin contact, and inhalation. Children aged less than five years are more likely to taste and eat different substances because of their great curiosity about exploring their environment, so accidental poisoning, especially from eating, is more common in this age group. Children are at home most of the time, so they are often poisoned by drugs or substances available at home (7-9).

 Although the number of poisonings in children is high, the resulting mortality is low. Severe poisoning is not common, but in some cases, emergency care and even hospitalization are required. Unfortunately, there is little information about the number of hospitalizations and the factors contributing to these poisonings (10). Preventing accidental poisoning is an essential step in significant health problems (11). Since etiological and epidemiological information of poisoning effectively makes appropriate decisions regarding its prevention and treatment, this study was conducted to investigate the epidemiology of poisoning in people under 18 years referred to Shahid Sadoughi Hospital in Yazd.

Methods:

This retrospective study was conducted based on the information recorded in the files of 105 patients younger than 18 years old who were admitted to Shahid Sadoughi Hospital in Yazd during 2018 due to accidental poisoning. Before running the study, the ethics committee approved its conduction. (IR.SSU.MEDICINE.REC.1399.209)

Data were extracted from patients’ files and transferred to standard forms, and sent for statistical analysis. Age, sex, type of toxin, main complaint, nationality, and outcome were assessed. Stata 16 Statistical Software (StataCorp. 2019. Stata Statistical Software: Release 16. College Station, TX: StataCorp LLC) was used for all statistical analyses.

Results:

In the present study, 105 patient files were reviewed, of whom 61.9% were male, and 38.1% were female. The highest rate of accidental poisoning was in children under four years old (77.1%), and the lowest rate of poisoning was in children over 12 years old (2.9%). (Table 1)

Furthermore, in 50% of the subjects, the family size was five or more, and only 9% of all cases had non-Iranian citizenship.

According to the results, the most common chief complaint of patients at the time of hospitalization was loss of consciousness (33%), while 23% of subjects were asymptomatic. Gastrointestinal symptoms (20%), respiratory symptoms (10%), restlessness (8%), and seizure (6%) were in the next ranks, respectively.

The most common causes of poisoning were drugs (51.4%), caustic substances (29.5%), and opiates (5.7%), respectively. Opioid analgesics, especially methadone, were the most common drugs that caused accidental poisoning in children. (Table 2)

The mean length of the hospital stay in the current study, was two days and 8 hours, and all the poisoned children were discharged from the hospital after recovery.

Discussion:

Since accidental poisoning in children is preventable and avoidable, this study was conducted in a tertiary center to investigate the common causes of poisoning in children of Yazd and the factors affecting it. In this study, the frequency of poisoning was higher in boys (61.9%). This result is consistent with many studies conducted in Iran and other parts of the world on children’s accidental poisoning (3, 7, 12-17). Males are probably more active and curious than females, and in most societies are less under parental supervision, which may justify the high rate of accidents, including poisoning in males (18-20). About 77% of participants were under four years old, and the highest frequency was seen in one to four-year-old (55%). Several studies in Iran have achieved similar results (1, 17, 21). In two separate studies in India and Pakistan, poisoning was usually observed between 1 and 5 years (3, 14). Numerous studies have reported similar results in the accidental poisoning of children (7, 16, 22, 23).  Children in this age group have a great desire to explore the environment, are very active, and have a great tendency to put everything in their mouths (14, 19).The frequency distribution of family size in participants was five and higher (50%), four (27%), and three (23%), respectively. Based on these results, it seems that in families with more than two children, parents probably have less supervision on children and the risk of accidental poisoning increases.

Our study revealed that loss of consciousness was the most common complaint of children with poisoning when brought to the emergency room. In a similar study in a referral teaching hospital in Qazvin, Iran, it was identified that loss of consciousness was the most common symptom in 77.7% of patients (13). The results of various studies are consistent with our study (11, 20, 21, 24).

A notable result in this study was that 23% of children were asymptomatic on arrival at the emergency room. A study in southern Iran reported that most patients were asymptomatic at the time of referral, but the most common clinical presentation was decreased level of consciousness (8). In two different studies, Lee et al. and Dayasiri et al. reported that most patients were initially asymptomatic, whereas neurological symptoms were predominantly observed in symptomatic subjects (7, 15).

In our study, gastrointestinal symptoms were observed in 20% of children with poisoning. Numerous studies have cited gastrointestinal manifestations as one of the most common manifestations of acute poisoning in children (7, 13, 14, 21, 24).

Moreover, our study showed that drugs were the predominant cause of poisoning (51.4%), followed by caustic substances (29.5%), and opiates (5.7%). Abundant studies have reported drugs as the most common cause of poisoning, in line with our study (1, 4, 20-25). Based on the results, opioid analgesics, especially methadone, were the most common drugs that caused accidental poisoning in children. In a study conducted in Arak, Iran, The most common causes of poisoning were drugs (65.2%); methadone, metoclopramide, and clonazepam were at the top of the list (21). In other studies in Iran, methadone was reported as the most frequent cause of poisoning (20, 26). Methadone is a long-acting opioid prescribed in addiction treatment centers as a methadone maintenance treatment for addicts. Unfortunately, unlabeled factory packaging and parental storage of methadone syrup in medicine bottles such as acetaminophen or diphenhydramine may cause the mother or caregiver to make a mistake while giving the medicine (27, 28).

Moreover, caustic substances were the second leading cause of poisoning in our study. Caustic agents are the most dangerous substances at home, as swallowing small amounts can cause severe esophageal burning and complications (7).

In terms of patients outcome, the mean hospital stay in our study population was 2.34 days, and fortunately, no deaths were reported. Pirzadeh et al. reported that the mean hospital stay in patients was 25±22 hours and, death occurred in %0.06 of cases (20). Compared to our study, the mean duration of hospital stay in Tiwari et al. study was 4.2 days, and death occurred in 2.97% of patients(2) . The average hospital stay in a study in India was 4.8 ± 3.0 days, while death occurred in 7.4% of patients (29). The mean length of hospital stay in the study by Lee et al. was 1.02 days, and all cases survived (7). Higher survival in some of these studies may result from parental awareness of poisoning, early detection of toxin exposure in children, shorter time to arrival medical centers, and improved medical management.

Limitations:

The notable limitation of this study is its retrospective design, and therefore it has limited data. Furthermore, only one year has been considered; thus, it is difficult to know the main causes of poisoning and related factors.

 It is hoped that future studies will evaluate the risk factors and various treatments.

Conclusion:

The results of the present cross-sectional study showed that drug poisoning, mainly due to opioid analgesics, is the most common type of poisoning. To prevent poisoning, it is crucial to increase the awareness of families about how to use, side effects, and how to store drugs, especially in parents who use opioid analgesics. Also, educating people about detergents’ proper storage can prevent poisoning by caustic substances. Additionally, proper packaging of medicines and cleansing agents in the factory can help in reducing this danger in a way  that children are no longer able to open them easily. Parents should be advised to take their child to a medical center as soon as they are suspected of poisoning so that treatment can begin without delay.

Acknowledgment:

The authors would like to thank the staff of Shahid Sadoughi Hospital for their cooperation in the information gathering process. This study was derived from Nasrin Saboohi's MD thesis in the Department of Pediatrics, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.

Conflict of interest:

 None to be declared

Funding: