European Journal of Cardiovascular Medicine

Poisoning is the exposure of a victim to an agent that cause symptoms and signs of organ dysfunction leading to injury or death even in low doses when swallowed,  injected, inhaled, or delivered through skin to human¹.A Poison may be defined as a substance which, when administered, inhaled or swallowed is capable of acting deleteriously on the body. Thus, there is no boundary between a medicine and a poison; a medicine in a toxic dose is a poison and a poison in small dose may be a medicine.

Poisoning in children is largely an accidental phenomenon and is common all over the world. It is an important health problem, which has significant costs, both financial and emotional. It is also a prime target for prevention and cost saving measures². Accidental poisoning is the twelfth leading cause of admission in the pediatric ward in India and accounts for about 1.0% of the hospitalized patients³

Recently, there is an increase in the number of poisoning cases due to suicidal motive in adolescents, especially females contributing to high morbidity and mortality. This has become a major challenging social problem. In various studies carried out in India mortality in childhood poisoning, rangedupto 11.6%⁴.Though there is a lot of data about childhood poisoning from developed countries, the subject is neglected in developing countries

It is the pattern of pesticide use and the toxicity of the products, not the quantity used, that influences the likelihood they will be used in acts of fatal self-harm⁵..Pattern of poisoning in a given area depends upon the availability of poisonous substance, occupation prevalence in the society, religious and cultural influences⁶

Accidental poisoning of a child is a complex interaction between the child, a hazardous substance and environmental situations⁷

Time of day, relationship to meals, accessibility of product, recent experience with the substance and family stress are some of the environmental factors involved⁸

Improper storage of poisoning agents, non-compliant behaviour, curiosity, misinterpretation of the substance, inadequate child monitoring, inability to read warning labels, desire to imitate adults, lack of public awareness about handling chemical materials, carelessness and lack of knowledge of parents are the important causes of accidental poisoning in children Family stress is an important risk factor in accidental ingestion of poisons in childhood⁹ Potential risk factors behind suicidal poisoning are low economic status, rural background, easy availability of the poisonous insecticides at home, school dropouts, gender inequality, family stress, poor vigilance,  adolescent problems and psychiatric disorders. These children have risk factors of quarrelling with parents and siblings, failure in love, failure at school and exams, conflicts with friends, etc. Most of these suicidal poisoning occur under impulsive act

“Assessment And Therapy Should Proceed In Parallel” to quickly assess the potential dangerand prompttherapy to reduce absorption, increase elimination and specific antidotesand observe the patient for an appropriate interval

The golden rule of treating the child with active ingestion;‘’treat the child not the poison’’

AIMS AND OBJECTIVES: To study the Clinical profile of children presenting with poisoning.

To analyze the socio demographic factors in relation to motive, mode, pattern and types of poisoning in children.

To determine the factors affecting outcome of poisoning in children.

The study was conducted with an overall objective to focus on the magnitude of poisoning in children

A prospective study of all the children between 1 to 18 yearsof age admitted at SVRR Govt Gen Hospital (tertiary care hospital), Tirupati with poisoning during the study period of one year from February 2016 to February 2017.Infants, Mentally subnormal children, No signs of life on presentation, Food poisoning and Envenomation were excluded from the study. A detailed history was obtained, complete physical examination done, pre referral treatment and treatment given in the hospital was noted; socioeconomic circumstances and other conditions leading to poisoning were evaluated and for children with suicidal intent, psychiatrist opinion was taken.

Statistical analysis was done by chi-square test and T Percentage methods

Socioeconomic status was taken based on modified kuppuswamy classification (upper class, upper middle class, lower middle class, upper lower class and lower class)

Age was divided into toddlers(1-3 yrs), preschool(3-5 yrs), school going(5-10 yrs) and adolescents (10-18 yrs).The basis for this categorization of age group was each group have specific behavioral phenomena, specific needs, specific problems and hence the specific pattern of poisoning.

Table 1. Baseline variables

A total of 94 cases were enrolled in the study. There was equal sex distribution with 47 males and 47 females. 34% of the children in our study belonged to adolescent age group constituting most common age group affected, followed by 30% with toddlers, 28% preschool  and 8% school going age group

When male and female children were assessed with age group involved; Among males, highest incidence is seen in the toddler age group with 36%, whereas among the females, highest incidence is seen in the adolescent age group with 51%

In our study 53% of the children belonged to lower middle class, 39%  to the upper middle, 8% to the upper lower group

Agents involved in the poisoning was most commonly with kerosene(34 cases), organophosphorus compounds (16 cases),turpentineoil(11 cases), followed by rodenticides (zinc phosphide 3 cases, bromodiolone 3 cases), 2 cases each by (nail polish, camphor, calotropis, datura, phenytoin and acid); 1case each by (agents salicylate, valproate, lactocalamine, amlodidpine, cresol, lysol, organochlorine, imidacloprid, toddy, hair oil, paint thinner, laxmanrekha, antilice and harpic)

Among the types of poisons involved, household products like kerosene, pesticides, cosmetics and disinfectants contributed to 46% followed by agrochemicals like organophosphates and organochlorines to 29%, industrial chemicals like turpentine oil, cresol, Lysol (upto 12%), drugs upto 8%, plants to 5% and miscellaneous 2%

Household products contributed to 46% of the poisoning among the types of poisoning.Among the household products involved, hydrocarbon products of household usage (kerosene and turpentine oil) contributed to 83 % of the household products, where kerosene is the single most common cause of poisoning with household products contributing to 63% among the household products. Drugs contributed to 7.5 % of all the poisoning cases. Plants contributed to 4 % of the poisoning in children in our study with 2 case of datura and 2 cases presented with calotropis ingestion

AGENTS WITH SUICIDAL AND ACCIDENTAL MOTIVE

50% of the poisoning with suicidal motive was due to organophosphate insecticides followed by other household products(laxmanrekha, harpic toilet cleaner,etc).50% of the poisoning taken accidentally was kerosene, followed by turpentine oil, rodenticides, drugs and plants

Table 2.AGE AND MOTIVE OF POISONING

In pre-adolescent age group, all the children presented with accidental poisoning where as 87 % of the children in the adolescent age group took the poison with suicidal motive, which is statistically significant

Fig 1. AGE AND MOTIVE OF POISONING

Table 3.GENDER AND MOTIVE OF POISONING

Accidental poisoning is more in males(62%). SuicidalPoisoning is more in females with 79% with significant p value of 0.0003.

Table 4.URBAN/ RURAL DIFFERENCE AND MOTIVE

Motive of poisoning in urban and rural areas differ in relation to poisonous substances available, socioeconomic circumstances, family stress, parental care and supervision, etc.Accidental poisoning is more in both urban and rural areas, 83% in the urban area and 53 % in the rural area.In rural areas poisoning with suicidal motive is more with 47% when compared to urban areas which is 17% which is significant statistically

Table 5.AGENTS AND MOTIVE

Associating most common agents involved in poisononig with the motive of the poisoning i.e kerosene and organophosphorus compounds,the organophosphorus compounds are used mostly (81% of OP)  for commiting suicide which is easily available agrochemical in rural areas where as 97 % of the kerosene is taken accidentally, mostly seen in urban areas

Table 6.MOTIVE OF POISONING AND OUTCOME

There is 100% survival in accidental poisoning where as 6% mortality is associated with poisoning with suicidal motive, contributing to overall mortality of 2%. The 2 cases expired in the study are due to organophosphate insecticides with suicidal motive

Table 7.SENSORIUM AT ADMISSION AND OUTCOME

All the children with poisoning brought in conscious state to the hospital survived, where as among 4 cases  brought unconscious to the hospital , 2 cases survived showing 50% mortality associated when children with poisoning presents in a state of unconsciousness.

Table 8. TIME LAG AND OUTCOME

When outcome is assessed with time lag before admitting into the hospital after poison ingestion, in our study 2 cases expired are brought to the hospital with a time lag of more than 3 days

Table 9. VENTILATION AND OUTCOME

Fisher exact 2 tailed 0.03

Among 94 cases of poisoning enrolled in the study, 15 children required mechanical ventilation. Out of 15 cases who are put on mechanical ventilator 13 cases survived with ventilator survival of 87%. The two cases expired in the study who were also mechanically ventilated were associated with risk factors of more time lag in getting to the hospital, brought unconscious to the hospital and were poisoned with suicidal motive

Table 10.HOUSEHOLD PRODUCTS AND OUTCOME

Household products contributed to most of the cases of poisoning in our study, both accidental poisoning and with suicidal motive. When mortality was assessed with household products or non-household products, mortality is seen with poisoning due to ingestion of non- household products especially agrochemicals (organophosphate compounds)

Table 11.PRE REFERAL TREATMENT AND OUTCOME

Pre referral treatment is given in most of the cases of poisoning when referring to tertiary centres from rural areas. Among the two cases expired in the study population, only one child had received pre referral treatment

Psychiatrist opinion was taken for 22 cases ofpoisoning with suicidal motive. Most common problem was found out to be impulsive act with 54%. Children had deliberately ingested poison, more an act of defiance than a true suicidal attempt. The factors behind impulsive act were; parents not accepting demands, fear of exams, failure in exams, love failure, quarreling with siblings. The other psychiatric problems associated with suicidal poisoning in our study were bipolar disorders, depression, coversion disorder

SCHOOL DROPOUTS AND SUICIDAL MOTIVE:

Poisoning with suicidal motive is associated with many risk factors. One of the risk factors is school dropouts because of various reasons related mostly to low socio economic status. In this study 8 out of 28 children with suicidal motive (29%) were school dropouts

GENDER INEQUALITY

79 % of Poisoning with suicidal motive is seen in females, where gender inequality is also contributory.out of 22 females with poisoning due to  suicidal motive (32%), reported gender inequality

Poisoning in children is largely an accidental phenomenon and is common all over the world. It is an important health problem, which has significant costs, both financial and emotional. It is also a prime target for prevention and cost saving measures³³. Accidental poisoning of a child is a complex interaction between the child, the hazardous substance and the environmental situations³⁴. Recently, there is increase in number of poisoning cases with suicidal motive in adolescents, especially females contributing to high morbidity and mortality. This has become a major challenging social problem.

According to the World Health Organization, 1 million accidental and 2 million suicidal poisonings with insecticides occur worldwide every year, and of these approximately 200,000 die, mostly in developing countries³⁵.

A total of 94 cases were enrolled in this study. All cases presented with oral mode of poisoning. There was equal sex distribution with 47 males and 47 females when compared to other studies where Males were predominantly affected³⁶.Most common age group involved in poisoning in our study is toddlers and preschool children with 58% followed by adolescent age group with34% of the study populationas comparable to study by Kanchan et al, where toddlers and preschool group were commonly affected^{37, 38}

Among females 51% were in the adolescent age group whereasamong males, highest incidence is seen in the toddler age group with 36%, in accordance with the study by Dutta et al showingmales outnumbering the females in children below 5 years of age³⁹

Regarding etiological agents involved in the poisoning, it is most commonly by kerosene with 36% in our study, mostly with accidental intent followed by organophosphate compounds with 17%, mostly with suicidal motive. In developing countries like India and subcontinent countries, kerosene is still used for burning and other household usage and on the other hand, India being an agriculture based country, organophosphate compounds are widely used in farms and easily available in rural areas which is taken mostly with suicidal motive. Kerosene has been reported as important and leading house hold product taken accidentally by children in other studies⁴⁰. Easy availability of the compounds has resulted in a gradual increase in accidental and suicidal poisoning, mainly in developing countries⁴¹

Half of the children with poisoning with suicidal motive were due to organophosphate insecticide poisoning and half of the poisoning taken accidentally is kerosene. Household products contributed to most of the cases of poisoning in our study, both accidental poisoning and poisoning with suicidal motive. Kerosene remains the commonest household substance involved in accidental ingestion as observed by Sharma et al⁴²

Drugs contributed to 7.5 % of all the poisoning cases with agents which are commonly used for common diseases, like antiepileptics (phenytoin, valproate), amlodipine, lactocalamine, salicylate and multiple drugs. It is comparable to study done by Lukas et al⁴³. Plants contributed to 4 % of the poisoning in children in our study with 2 cases of datura and cases presented with calotropis ingestion. Buchetal reported plant poisoning in 13.4% of cases⁴⁴, which is higher in incidence when compared to our study.

Sociodemographic factors play prime and most important role in causation of poisoning.High number of children (53%) in our study population belonged to lower middle class group. Most incidence of poisoning in the lower socioeconomic group is related to poisoning with suicidal motive in relation to use of organophosphates in agriculture usage in rural background, and also related to accidental poisoning with kerosene, which is the most common culprit, is still used for burning and cooking purpose in urban as well as rural areas among lower middle class group. And poor understanding of the storage of these substances, parental unawareness and non vigilance are contributory.

Accidental poisoning is more in males with 62% where as suicidal poisoning is more in females with 79%. And accidental poisoning is more in both urban and rural areas, 83% in the urban area and 53 % in the rural area but in rural areas poisoning with suicidal motive is more with 47% when compared to urban areas which is 17%. The accidental poisoning was the commonest (79.7%), intentional as noticed byNational Poisons Information Centre, All India Institute of Medical Sciences, New Delhi by Suresh Kumar GUPTA et al⁴⁶.Although accidental poisoning is more common in our study, the increase in the incidence of self-poisonings was remarkable in females and in the rural areas, as in the other parts of the world⁴⁵as shown by Lifshitzetal.

In pre-adolescent age group, all the children presented with accidental poisoning as in other studies showing accidental poisoning as common in children below 5 years of age and males outnumbering the females⁴⁷where as in adolescent age group 87 %  of the children took the poison with suicidal motive, a pattern similar to that of adults, which has also been observed by other studies⁴⁸.After 10 years of age, self-poisonings were the leading cause, with females predominant⁴⁹. A male predominance has been reported in younger children but gender distribution reverses in teenage years

Thus the present study brings out two distinct patterns of poisoning: accidental poisoning in pre adolescent age group and adult pattern of suicidal poisoning in children over 10 years age.

Poisoning with suicidal motive is associated with potential risk factors like rural background, low socioeconomic status, school dropouts, gender inequality. Psychiatrist opinion was taken for 22 cases of poisoning with suicidal motive. Most common problem was found out to be impulsive act, observed among 54% of the children with suicidal poisoning. Children had deliberately ingested poison, more as an act of defiance than a true suicidal attempt.The factors behind impulsive act were parents not accepting their demands, fear of exams, failure in exams, love failure, quarreling with siblings. The other psychiatric problems associated with suicidal poisoning in our study were bipolar disorders, depression, conversion disorder.

The possible impulsive events leading to suicidal poisoning are stress of school work, failure at school, failure in love and conflicts with parents. In our study,out of 22 females with poisoning due to suicidal motive, 32% of them reported gender inequality.

Comprehensive programmes that improve school connectedness, parent-child relationships and coping skills to avoid violent peer conflicts may help decrease suicide ideation among youths⁵⁰

Two cases expired in the study are due to organophosphate insecticides with suicidal motive, contributing to overall mortality of 2% in the study group. There is 100% survival in accidental poisoning. All the children with poisoning brought in conscious state to the hospital survived, where as among 4 cases  brought unconscious to the hospital , 2 cases survived showing 50% mortality associated when children with poisoning presents to the hospital in unconscious state. Children with suicidal poisoning requires prolonged hospital stay; 75 % of the children with suicidal poisoning in our study required prolonged hospital stay, for more than 3 days. When outcome is assessed with time lag before admitting into the hospital after poison ingestion, in our study 2 case expired are brought to the hospital with a time lag of more than 3 hours. There is good survival with mechanical ventilation in our study. Among 15 children who required mechanical ventilation, 13 cases survived (87%). Pre referral treatment plays an important role when referring from rural areas. Among the two cases expired in the study population, only one child had received pre referral treatment

Poisoning with Suicidal motive is exclusively seen in adolescent group with Female to Male ratio is 4 : 1.Poisoning due to suicidal motive is mostly due to an impulsive act. Gender discrimination (32%) and other social issues like school dropouts and rural background are contributory. Organophosphate compounds are the commonest substance in this group of children. Mortality is high in this group. Accidental poisoning is predominantly seen in Pre adolescent children. Incidence is highest among Toddlers, followed by Pre school and School going children in that order. It is mostly due to household products. Most common agent is kerosene. Increased Morbidity and mortality are associated with poisoning due to suicidal motive, and patients brought in unconscious state. Outcome is better  with mechanical ventilation (even with sub optimal facilities for mechanical ventilation)

Conflict of Interest: None

Funding Support: Nil

1. Osterhoudt KC, Shannon M, Henretig FM. Toxicological emergences. In: Fleisher GR, Ludwig S. Textbook of Pediatric Emergency Medicine 4^th Philadelphia: Lippincott William & Wilkins, 2000;887-97
2. Woolf AD. Poisoning in children and adolescents.Pediatr Rev 1993; 14: 411-22.
3. Subedi BK. A retrospective study of poisoning cases at Bir Hospital, Nepal. J Inst Med 1990; 12: 296-302.
4. Indian J Pediatr.1998 May-Jun;65(3):365-70. Poisoning in children: Indian scenario.Dutta AK, Seth A, Goyal PK, Aggarwal V, Mittal SK, Sharma R, Bahl L  et al.
5. BMC Public Health.2007 Dec 21;7:357.The global distribution of fatal pesticide self-poisoning: systematic review.Gunnell D, Eddleston M, Phillips MR, Konradsen F
6. Opawoye AD, Haque T. Insecticide/ organophosphorus compound poisoning in Children. Ann Saudi Med 1998, 18: 171-72.
7. Scherz R G. Prevention of childhood poisoning: Acommunity project. Paediatric Clinics of North America 1970; 17(3): 713-27.
8. Scherz R G. Prevention of childhood poisoning: Acommunity project. Paediatric Clinics of North America 1970; 17(3): 713-27.
9. Sibert J R. Stress in families of children who have ingested poisons. British Medical Journal 1975; 3:87-9.
10. BMC Public Health.2007 Dec 21;7:357.The global distribution of fatal pesticide self-poisoning: systematic review.Gunnell D, Eddleston M, Phillips MR, Konradsen F
11. Safdar A, Mohammad N R, Saeed A. Organophosphorous poisoning; Emergencymanagement in intensive care unit. Professional Med J Dec 2003;10(4):30814.
12. Singh S, Singhi S, Sood NK, Kumar L, Walia BNS. Changing pattern of childhood poisoning (1970-1989): experience of a large north Indian hospital. Indian Pediatr1995; 32: 331-6.
13. Annals of Saudi Medicine, Vol 18, No 2, 1998INSECTICIDE/ORGANOPHOSPHORUS COMPOUND POISONING IN CHILDREN Adebayo D. Opawoye, MD; TanwirulHaque, MD
14. Namba T, Nolte CY, Jackirel J, Grob D. Poisoning due to organophosphorus insecticides: acute and chronic manifestations. Am J Med. 1971; 50: 475.
15. Adlakha A, Philip PJ, Dhar KL. Organophosphorous and carbamate poisoning in Punjab. J AssocPhys India 1988:36:210-12.
16. Bardin PG, Van Eden SF: Organophosphate poisoning: grading the severity and comparing treatment between atropine and glycopyrolate. Crit Care Med 1990, 18:956-960.
17. Professional Med J Dec 2008; 15(4): 518-523. / PROF-1373 organophosphorus compound poisoning; epidemiology and management atropinisationvspralidoxime a descriptive analysis, in allied hospital khurramsohail raja dr.uhammadowaisfazal prof. drahmadbilal
18. Journal of Surgery Pakistan (International) 13 (2) April - June 2008 ACUTE ORGANOPHOSPHATE INSECTICIDE POISONING NADIA A ATHER, JAMAL ARA, EJAZ A KHAN, RUKHSANA A SATTAR, RASHID DURRANI
19. Kiss Z, Fazekas T: Organophosphates and torsade de pointes ventricular tachycardia. J Roy Soc Med 1983, 76:983-984.
20. Petroianu G, Ruefer R: Beta-blockade or magnesium in organophosphorus insecticide poisoning. Anaesth IntensiveCare 1992, 20:538-539.