Toxic ingestions in children

Last reviewed: 2 Jan 2023

Last updated: 16 Mar 2021

Children may ingest a toxic substance accidentally while exploring their environment, or deliberately in response to stress or underlying mental problems, or in an attempt to get 'high'.

A regional poison-control centre or medical toxicologist should be contacted with any suspected overdose in a child.

The range of possible ingestions is broad; diagnosis is based on a combination of thorough clinical assessment and comprehensive laboratory investigation to identify all ingested substances.

Some asymptomatic patients require observation for 6 hours, or 24 hours for high-risk ingestions.

The mainstay of management of symptomatic patients is management of airway, breathing, and circulation, with appropriate supportive care. Specific antidotes may also be required.

If patients present within 1 hour of ingestion, activated charcoal can be considered provided that it is not contraindicated. The decision to administer oral activated charcoal should be carefully considered and discussed with a medical toxicologist or poison control centre.

With prompt diagnosis and appropriate treatment, patients have a good outcome. Fatalities are rare.

Definition

Toxic ingestions refer to the accidental or deliberate ingestion of a substance with resultant toxicity or risk of toxicity. Agents consumed may be pharmaceutical substances; drugs of abuse (including alcohol); toxic plants, berries, or mushrooms; or chemicals.

History and exam

Key diagnostic factors

medication error in infants
witnessed ingestion or child found with empty bottle or pill
history of deliberate ingestion
history of substance abuse
sympathomimetic toxidrome
antimuscarinic toxidrome
opioid toxidrome
sedative-hypnotic toxidrome
cholinergic toxidrome

More key diagnostic factors

Other diagnostic factors

nausea, vomiting, or diarrhoea
altered mental status
fever or hyperthermia
staining or burns of the mouth and oropharynx
hypertension or hypotension
hyperventilation or hypoventilation
seizures
blindness or reduced vision
reduced hearing or tinnitus
reddened skin coloration
symptoms and signs of hypoglycaemia
jaundice
hyperreflexia and myoclonus
muscle rigidity
nystagmus
ataxia
stridor

Other diagnostic factors

Risk factors

presence of medications in the household
easy access to medications or household chemicals
young age
pica
emotional stress
history of depression or other mental illness
female sex
family history of alcohol use disorder

More risk factors

Diagnostic investigations

1st investigations to order

serum electrolytes
serum urea
serum creatinine
fingerprick or serum glucose
capillary blood gas or ABG
anion gap
serum lactate
serum ketones or acetone
INR
LFTs
serum paracetamol levels
serum salicylate levels
urine drug screen
urinalysis
ECG
pregnancy test
serum creatine kinase
abdominal x-ray
chest x-ray

More 1st investigations to order

Investigations to consider

ethanol level
serum methanol or ethylene glycol
serum digoxin level
serum anticonvulsant levels
serum iron levels
serum lithium, theophylline, or whole blood heavy metal levels
comprehensive urine drug screen
therapeutic trial of naloxone
therapeutic trial of sodium bicarbonate
therapeutic trial of atropine and pralidoxime
therapeutic trial of flumazenil
therapeutic trial of octreotide
therapeutic trial of physostigmine

More investigations to consider

Treatment algorithm

ACUTE

asymptomatic

symptomatic and/or high-risk ingestion and/or elevated drug levels

Contributors

Authors

David L. Eldridge, MD

Associate Professor

Clerkship Director

Department of Pediatrics

Brody School of Medicine at East Carolina University

Greenville

Disclosures

DLE has received research grants and been a site investigator for an ongoing clinical trial from GlaxoSmithKline and a closed clinical trial from Cempra Pharmaceuticals. DLE is an author of one reference cited in this topic.

Matthew R. Ledoux, MD

Associate Professor of Pediatrics

Vice Chair of Pediatrics

Co-Medical Director, Maynard Children’s Hospital, Vidant Medical Center

Division Chief, Division of Pediatric Critical Care and Hospital Medicine

Department of Pediatrics

Brody School of Medicine at East Carolina University

Greenville

Disclosures

MRL declares that he has no competing interests.

Acknowledgements

Dr David Eldridge and Dr Matthew Ledoux would like to gratefully acknowledge Dr Cynthia K. Aaron and Dr Keenan M. Bora, previous contributors to this topic.

Disclosures

CKA and KMB declare that they have no competing interests.

Peer reviewers

Laurie Prescott, MD, FRCP

Emeritus Professor of Clinical Pharmacology

Faculty of Medicine

University of Edinburgh

Edinburgh

Disclosures

LP declares that he has no competing interests.

Mark Mannenbach, MD

Consultant in Pediatric Emergency Medicine

Assistant Professor of Pediatric and Adolescent Medicine

Mayo Clinic College of Medicine

Rochester

Disclosures

MM declares that he has no competing interests.

Colin A. Graham, MBChB, MPH, MD, FRCSEd, FRCSGlasg, FIMCRCSEd, FCCP, FCEM, FHKCEM, FHKAM

Editor

European Journal of Emergency Medicine

Professor of Emergency Medicine

Chinese University of Hong Kong

Hong Kong

People's Republic of China

Disclosures

CAG is the editor of the European Journal of Emergency Medicine and receives an annual honorarium from Wolters Kluwer Health, the journal's publishers.

Differentials
- Non-toxic causes of wide complex tachycardia
- Non-toxic causes of status epilepticus
- Non-toxic causes of anion gap metabolic acidosis
More Differentials
Guidelines
- Expert consensus guidelines for stocking of antidotes in hospitals that provide emergency care
- Royal College of Emergency Medicine and National Poisons Information Service guideline on antidote availability for emergency departments
More Guidelines
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Toxic ingestions in children

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

asymptomatic

symptomatic and/or high-risk ingestion and/or elevated drug levels

Contributors

Authors

David L. Eldridge, MD

Disclosures

Matthew R. Ledoux, MD

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Laurie Prescott, MD, FRCP

Disclosures

Mark Mannenbach, MD

Disclosures

Colin A. Graham, MBChB, MPH, MD, FRCSEd, FRCSGlasg, FIMCRCSEd, FCCP, FCEM, FHKCEM, FHKAM

Disclosures

Differentials

Guidelines

Log in or subscribe to access all of BMJ Best Practice

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