Preventing Childhood Poisoning
by Audrey T. Hingley
Department of Health and Human Services
Food and Drug Administration
February 1996
Most people regard their home as a safe haven, a calming oasis in an
often stormy world.
But home can be a dangerous place when it comes to accidental poisoning,
especially accidental poisoning of children. One tablet of some
medicines can wreak havoc in or kill a child.
Childhood poisonings caused by accidental overdoses of iron-containing
supplements are the biggest concern of poison control experts, consumer
protection groups, and health-care providers. Iron-containing
supplements are the leading cause of pediatric poisoning deaths for
children under 6 in the United States. According to the American
Association of Poison Control Centers, from 1986 to 1994, 38 children
between the ages of 9 months and 3 years died from accidentally
swallowing iron-containing products. The number of pills consumed by
these children varied from as few as five to as many as 98.
FDA is taking steps to protect children from iron poisoning by proposing
regulations that will make it harder for small children to gain access
to high-potency iron products (30 milligrams of iron or more per
tablet). FDA is also taking steps to ensure that health-care providers
and consumers are alerted to the dangers associated with accidental
overdoses of iron-containing products, including pediatric multivitamin
supplements that contain iron.
Although iron poisoning is the biggest concern when it comes to
childhood poisoning, there is also concern about other drugs.
"Over-the-counter diet pills have the potential to be lethal to
children, as do OTC stimulants used to keep you awake and decongestant
tablets," says George C. Rodgers, M.D., Ph.D., medical director of the
Kentucky Regional Poisoning Center. "Tofranil [imipramine], an
antidepressant drug also used for childhood bedwetting, and Catapres
[clonidine], a high blood pressure medicine, can be very hazardous
because it takes very little to produce life-threatening problems in
children. One tablet may do it.
"Antidepressant drugs have a high degree of toxicity," he continues.
"They are cardiac and central nervous system toxins, and it doesn't take
much of them to do harm, particularly in children. They are prescribed
fairly ubiquitously. One of the things we look at when we get kids'
poisonings is who had the medicine, and why."
Rodgers also urges extra caution when antidepressant drugs are
prescribed for teenage patients who may have behavioral or emotional
problems.
"Antidepressant drugs are commonly given to adolescents with behavioral
problems, and often a month or two- month supply is prescribed. Teens
should not be given more than a week's supply to begin with, and parents
need to monitor their usage," he says.
The marketing of pediatric vitamins is also a cause of concern for
Rodgers. "Because they're marketed to look like candy or cartoon
characters, it looks like candy and doesn't seem like medicine," he
explains.
In addition, children frequently mimic the behavior of their parents.
Children who watch their parents take pills may want to do it, too- with
potentially fatal results.
Poison-Proofing Your Home
Poison-proofing your home is the key to preventing childhood poisonings.
In the case of iron-containing pills or any medicine:
* Always close the container as soon as you've finished using it.
Properly secure the child-resistant packaging, and put it away
immediately in a place where children can't reach it.
* Keep pills in their original container.
* Keep iron-containing tablets, and all medicines, out of reach-and out
of sight-of children.
* Never keep medicines on a countertop or bedside table.
* Follow medicine label directions carefully to avoid accidental
overdoses or misdoses that could result in accidental poisoning.
For other substances, buy the least hazardous products that will serve
your purposes. When buying art supplies, for example, look for products
that are safe for children. For hazardous products such as gasoline,
kerosene, and paint thinners that are often kept on hand indefinitely,
buy only as much as you need and safely get rid of what you don't use.
Never transfer these substances to other containers. People often use
cups, softdrink bottles, or milk cartons to store leftover paint thinner
or turpentine. This is a bad idea because children associate cups and
bottles with food and drink.
The kitchen and bathroom are the most likely unsafe areas. (Medicines
should never be stored in the bathroom for another reason: a bathroom's
warm, moist environment tends to cause changes or disintegration of the
product in these rooms.) Any cabinet containing a potentially poisonous
item should be locked.
"Bathrooms with medicines, kitchens with cleaning products, even
cigarette butts left out, can be toxic to kids," Rodgers explains. "And
remember that child-resistant caps are child-resistant, not childproof.
The legal definition is that it takes greater than five minutes for 80
percent of 5-year-olds to get into it: that means 20 percent can get in
in less time! Kids are inventive, and can often figure it out. And
leftover liquor in glasses on the counter after parties? Don't do it!"
Alcohol can cause drunkenness as well as serious poisoning leading to
seizures, coma, and even death in young children. Children are more
sensitive to the toxic effects of alcohol than are adults, and it
doesn't take much alcohol to produce such effects. Alcohol-laced
products, such as some mouthwashes, aftershaves or colognes, can cause
the same problems.
Garages and utility rooms should also be checked for potential poison
hazards. Antifreeze, windshield washing fluid, and other products should
be stored out of children's reach in a locked cabinet. Childproof
safety latches can be purchased at your local hardware store.
In the living room or family room, know your plants' names and their
poison potential. Although most houseplants are not poisonous, some are.
To be on the safe side, keep houseplants out of the reach of young
children. Although much has been made of problems with poinsettias
(blamed for a death as early as 1919), recent studies indicate it is not
as highly toxic as was once believed. Although ingesting it may cause
some stomach irritation and burning in the mouth, it's unlikely to be
fatal.
"Plants are mostly a problem for children, since it's a natural response
for children to taste things. Few adults eat houseplants," Rodgers
points out. "Plants have a high capacity for making you sick, but they
are usually low-risk for producing life-threatening symptoms." After
poison-proofing your home, prepare for emergencies. Post the numbers of
your regional poison control center (which can be found on the inside
cover of the Yellow Pages or in the white pages of your phone directory)
and your doctor by the phone. Keep syrup of ipecac on hand-safely
locked away, of course. (See accompanying article, "Antidotes.") Never
administer any antidote without first checking with your doctor or
poison control center.
Lead Poisoning
Although lead levels in food and drink are the lowest in history,
concern remains about lead leaching into food from ceramic ware.
Improperly fired or formulated glazes on ceramic ware can allow lead to
leach into food or drink.
Long recognized as a toxic substance, adverse health effects can result
from exposure to lead over months or years.
After a California family suffered acute lead poisoning in 1969 from
drinking orange juice stored in a pitcher bought in Mexico, FDA
established "action levels" for lead in ceramic ware used to serve food.
Over the years, these original action levels have been revised as
research has shown that exposure to even small amounts of lead can be
hazardous. The last revision for ceramic foodware was in 199 1. On Jan.
12, 1994, FDA published a regulation for decorative ceramic ware not
intended for food use, requiring a permanently affixed label on
high-lead-leaching products.
"Most lead toxicity comes from multiple exposure and is a slow
accumulation over time," says Robert Mueller, a nurse and poison
information specialist at the Virginia Poison Center, headquartered at
The Medical College of Virginia Hospitals in Richmond. "Refusing to
eat, vomiting, convulsions, and malaise can all be symptoms of lead
poisoning." Because lead poisoning occurs over time, such symptoms may
not show up right away. A blood test is the surest way to determine
that your child has not been exposed to significant amounts of lead.
"In general, if a consumer purchases ceramic ware in the U.S.
marketplace today, it meets the new action levels," says Julia Hewgley,
public affairs specialist with FDA:s Center for Food Safety and Applied
Nutrition. "But if you travel abroad and buy ceramic ware, be aware
that each country has its own safety regulations. Safety can be terribly
variable depending on the type of quality control and whether the piece
is made by a hobbyist." To guard against poisonings, Hewgley advises
that ceramic ware not be used to store foods. Acidic foods-such as
orange, tomato and other fruit juices, tomato sauces, vinegar, and
wine-stored in improperly glazed containers are potentially the most
dangerous. Frequently used products, like cups or pitchers, are also
potentially dangerous, especially when used to hold hot, acidic foods.
"Stop using any item if the glaze shows a dusty or chalky gray residue
after washing. Limit your use of antique or collectible housewares for
food and beverages," she says.
"Buy one of the quick lead tests available at hardware stores and do a
screening on inherited pieces."
Iron Poisoning
Iron-containing products remain the biggest problem by far when it comes
to childhood poisoning. In October 1994 FDA proposed regulations for
unit-dose packaging requirements for iron-containing products with 30
milligrams or more of iron per dosage unit. The agency also proposed
requiring warning labels about the adverse effects of high-dose iron
ingestion by children for all iron-containing products taken in solid
oral dosage forms. Because of the time and effort needed to open
unit-dose products, FDA believes unit-dose packaging will discourage a
youngster, or at least limit the number of tablets a child would
swallow, reducing the potential for serious illness or death.
FDA's proposed requirements would be in addition to existing U.S.
Consumer Product Safety Commission regulations, which require
child-resistant packaging for most iron-containing products. FDA issued
a supplementary proposed rule in February 1995. At press time, a final
rule regarding iron-containing products was expected soon.
Iron is an essential nutrient sometimes lacking in people's diets, which
is why iron is often recommended for people with conditions such as
iron-deficiency anemia. Taken as indicated, iron is safe. But when
tablets are taken beyond the proper dose in a short period, especially
by toddlers or infants, serious injury or death may result.
Children poisoned with iron face immediate and long-term problems.
Within minutes or hours of swallowing iron tablets, nausea, vomiting,
diarrhea, and gastrointestinal bleeding can occur. These problems can
progress to shock, coma, seizures, and death. Even if a child appears
to have no symptoms after accidentally swallowing iron, or appears to be
recovering, medical evaluation should still be sought since successful
treatment is difficult once iron is absorbed from the small intestine
into the bloodstream. And children who survive iron poisoning can
experience other problems, such as gastrointestinal obstruction and
liver damage, up to four weeks after the ingested poisoning.
FDA regulates iron-containing products as either drugs or foods,
depending on the product formulation and on intended use, as defined by
labeling and other information sources. Iron products are regulated as
drugs if they are intended to affect the structure or function of the
body, or are used in the diagnosis, cure, treatment, or prevention of
disease and are listed in the U.S. Pharmacopeia. All other products are
regulated as foods.
Some iron-containing products have been regulated as prescription drugs
because they included pharmacologic doses of folic acid and usually were
prescribed to meet high nutritional requirements during pregnancy.
Between June 1992 and January 1993, five toddlers died after eating iron
supplement tablets, according to the national Centers for Disease
Control and Prevention's Morbidity and Mortality Weekly Report of Feb.
19, 1993. All tablets involved in the reported deaths were prenatal
iron supplements. The incidents occurred in a variety of ways: Children
ate tablets from uncapped or loosely capped bottles, swallowed tablets
found spilled on the floor, and, in one case, a 2-year-old fed an 11
-month-old sibling tablets from a box found on the floor.
Iron is always included in prenatal vitamins prescribed for pregnant
women, and is sometimes included in multivitamin formulas. Often
available without prescription, iron supplements can be found in grocery
stores, drugstores, and health food stores in a wide variety of
potencies, ranging from 18 milligrams (mg) to 150 mg per pill. For a
small child, as little as 600 mg of iron can be fatal.
Because iron supplements are typically brightly colored and may look
like candy, they are particularly attractive to children. In 1993, the
Nonprescription Drug Manufacturers Association (NDMA), which
manufactures about 95 percent of nonprescription OTC medicines available
to Americans today, adopted formulation provisions for iron products
containing 30 mg or more of elemental iron per solid dosage form. These
provisions also stipulated that such products would not be made with
sweet coatings. That same year, NDMA manufacturers also independently
agreed to develop new voluntary warning labels for these products. The
voluntary labels read: "Warning: Close tightly and keep out of reach of
children. Contains iron, which can be harmful or fatal to children in
large doses. In case of accidental overdose, seek professional
assistance or contact a poison control center immediately."
Signs of Poisoning
How can you tell if your child has ingested something poisonous? "Most
poisons, with the exception of lead, work fairly quickly. A key is when
the child was otherwise well and in a space of hours develops unusual
symptoms: They can't follow you with their eyes, they're sleepy before
it's their nap time, their eyes go around in circles. Any unusual or
new symptoms should make you think of poisoning as a possibility,"
Rodgers advises. "Poisonings typically affect the stomach and central
nervous system. If a child suddenly throws up, that can be more
difficult to diagnose."
Other signs of poison ingestion can be burns around the lips or mouth,
stains of the substance around the child's mouth, or the smell of a
child's breath. Suspect a possible poisoning if you find an opened or
spilled bottle of pills.
If you suspect poisoning, remain calm. For medicines, call the nearest
poison control center or your physician. For household chemical
ingestion, follow first-aid instructions on the label, and then call the
poison control center or your doctor. When you call, tell them your
child's age, height and weight, existing health conditions, as much as
you know about the substance involved, the exposure route (swallowed?
inhaled? splashed in the eyes?), and if your child has vomited. If you
know what substance the child has ingested, take the remaining solution
or bottle with you to the phone when you call. Follow the instructions
of the poison control center precisely.
Progress Against Poisonings
The nation's first poison control center opened in Chicago in 1953,
after a study of accidental deaths in childhood reported a large number
were due to poisoning. Since that time, a combination of public
education, the use of child-resistant caps, help through poison control
centers, and increased sophistication in medical care have lowered
overall death rates.
Often, calling a poison center simply reassures parents that the product
ingested is not poisonous. In other cases, following phone instructions
prevents an emergency room trip.
Children are not the only victims of accidental poisonings: Older people
in particular are at risk because they generally take more medicines,
may have problems reading labels correctly, or may take a friend's or
spouse's medicine.
In June 1995, the U.S. Consumer Product Safety Commission voted
unanimously to require that child-resistant caps be made so
adults-especially senior citizens-will have a less frustrating time
getting them off. Because many adults who had trouble with
child-resistant caps left them off, or transferred their contents to
less secure packaging that endangers children, officials say the new
caps will be safer for children.
"Childhood poisoning will always be a focus, because children are so
vulnerable, especially children under age 5," says Ken Giles, public
affairs spokesman for the Consumer Product Safety Commission. "The
first two or three years of a child's life are the highest-risk time for
all kinds of injuries, so there is a special need to educate new
parents. It's essential we keep raising these safety messages that
medicines and chemicals can be poisonous."
Protect Yourself Against Tampering
With FDA's new proposed regulations regarding packaging of high-dose,
iron-containing pills in mind, it's important to remember that no
packaging or warnings can protect without your involvement.
Nonprescription OTC drugs sold in the United States are among the most
safely packaged consumer products in the world, but "child-resistant"
and "tamper-resistant" do not mean "childproof" and
"tamperproof."
FDA adopted "tamper-resistant" packaging requirements after seven people
in the Chicago area died from taking cyanide-laced Extra-Strength
Tylenol capsules in 1982. Although the product met all FDA requirements
at the time, it wasn't designed so tampering would leave visible
evidence. FDA swiftly enacted new regulations requiring most OTC drug
products to be packaged in "tamper-resistant" packaging, defined as
"packaging having an indicator or barrier to entry that could reasonably
be expected to provide visible evidence that tampering had occurred,"
and required OTC product labeling to alert consumers to tamper-resistant
packaging. In 1989, FDA regulations were amended to require two-piece
hard gelatin capsules to be packaged using at least two tamperresistant
features unless sealed with a tamper-resistant technology.
"Consumer vigilance is part of the equation," says Lana Ragazinsky,
consumer safety officer with FDA:s Center for Drug Evaluation and
Research, division of drug quality evaluation, office of compliance.
"The consumer is being led into a false sense of security because they
see 'tamper-resistant.' ... 'Tamper evident' means you, the consumer,
need to look for evidence of tampering."
FDA has proposed changing the term "tamper-resistant" to
"tamper-evident" to underscore the fact that no package design is
tamperproof. The most important tool to detect tampering is you! Here
are a few tips to help protect against tampering:
* Read the label. OTC medicines with tamper-evident packages tell you
what seals and features to look for.
* Inspect the outer packaging before you buy.
* Inspect the medicine when you open the package, and look again before
you take it.
If it looks suspicious: be suspicious.
* Look for capsules or tablets different in any way from others in the
package.
* Don't use any medicine from a package with cuts, tears, slices, or
other imperfections.
* Never take medicine in the dark. Read the label and look at the
medicine every time you take a dose.
-A.T.H.
Antidotes
If you suspect childhood poisoning, call the nearest poison control
center or your physician first, and follow their instructions precisely.
To induce vomiting in case of accidental poisoning, experts recommend
keeping on hand syrup of ipecac safely stored away from children, of
course! Syrup of ipecac induces vomiting, thus ridding the body of the
swallowed poison. It usually works within a half-hour of ingestion.
Some medical experts also recommend that parents keep activated charcoal
on hand as well: You may have to ask your druggist for it, because it
may not be on store shelves. Although some poison control experts
recommend having activated charcoal on hand, there is a difference of
opinion on its use by consumers. The U.S. Consumer Product Safety
Commission, for example, does not recommend that consumers use activated
charcoal because it is less palatable to young children.
Activated charcoal (or charcoal treated with substances that increase
its absorption abilities) absorbs poison, preventing it from spreading
throughout the body. One advantage of activated charcoal is that it can
be effective for a considerable time after the poison is swallowed. But
activated charcoal should never be used at the same time you administer
syrup of ipecac: The charcoal will absorb the ipecac.
For children ages I to 12, give one tablespoon of syrup of ipecac
followed by one or two glasses of water. Children ages 12 and over
should get two table spoons, followed by one or two glasses of water.
Activated charcoal is usually found in drugstores in liquid form in
30-gram doses. For children under 5, give one gram per every two pounds
of body weight. Older children and adults may require much higher
doses.
Both antidotes should only be used on conscious poison victims; an
unconscious victim should always be treated by professionals.
"Remember to call your local poison control center first before giving
your child any at-home antidote," says Robert Mueller, poison
information specialist at the Virginia Poison Center in Richmond, Va.
-A.T.H.
Audrey T Hingley is a writer in Mechanicsville, Va.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service Food and Drug Administration
FDA on the Internet: http://www.fda.gov/
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