Poisoning in children: Indian scenario | SpringerLink

Symposium

: Toxicology and Poisoning-II

Indian J Pediatr 1998; 65 : 365-370

Poisoning in Children : Indian Scenario A.K. Dutta ~, A. Seth ~, P.K. GoyaP, V. Aggarwal-', S.K. Mittal 2, R. Sharma 3, L. BahP, J.S. T h a k u r 4, M. Verma 5, J. ChhatwaP, B. Chacko 5, V. SainP, A. SinghaP, P. Sharma 6, U. Sharma 6, P. Chaturvedi 7, S. K u m a r 7, N.C. Prajapati 7, J. Vaidya 7, N. Garg 7, S. N. Basu a, M. Lahiri s, C.K. Das s, D.K. Pal s, M.K.C. Nair 9, V.H. Sankar 9, Sabarinathan '~, S. B. LalP ~

1Department of Pediatrics, Kalawati Saran Children's Hospital, New Delhi; 2Department of Pediatrics, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi; 3Department of Pediatrics, LG. Medical College, Shimla; 4Department of Community Medicine, P.G.I.M.E.R., Chandigarh; 5Department of Pediatrics, Christian Medical College and Hospital, Ludhiana, Punjab; 6Department of Pediatrics, S.M.S. Medical CollEge, Jaipur; 7Department of Pediatrics, Mahatma Gandhi Institute of Medical S~iences, Sevagram, Wardha, Maharashtra; 8B.C. Roy Memorial Hospital for Children, Calcutta; 9Department of Pediatrics, S.A.T. Hospital Trivandram; 1~ of Pharmacolongy, All India Institute of Medical Sciences, New Delhi Abstract. The retrospective data on childhood poiso~,,,,u from eight regional hospitals in India has been reviewed. The demographic features and types of poisonings encountered have been compared. The analysis of the data indicated that pediatric poisonings constituted 0.23-3.3% of the total poisoning. The mortality ranged from 0.64-11.6% with highest being from Shimla. Accidental poisoning was common involving 50-90% of children below 5 years of age and males ouinumbered the females. Suicidal poisoning was seen after 13 years of age and was due to drugs and household chemicals. One of the hospitals in Delhi recorded a very high incidence (66.6%) of drug poisoning in children. The drugs consumed belonged to phenothiazines, antiepileptics and antipyretics. Iron poisoning was seen in younger children. Kerosene was one of the causes of accidental poisoning at all hospitals except Shimla and rural Maharashtra where probably wood charcoal is widely used. Pesticide poisoning was more prevalent in Punjab and West Bengal whereas plant poisoning was very common in Shimla. Significant number of snake envenomation has been recorded from rural Maharashtra. Other less common accidental poisonings in children included alcohol, corrosives, heavy metals, rodenticides, detergents and disinfectants. Thus various regions in the country showed some variation in types and frequency of childhood poisoning which could be attributed to different geographical and socio-economic background. (Indian J Pediatr 1998; 65 : 365-370)

Key words : Accidental poisoning; Drugs; Corrosives.

Poisoning in children is a global problem. In a large majority of cases it is the accidenReprint requests : S.B. Lall, Additional Professor, Department of Pharmacology, All India Institute of Medical Sciences, Ansari Na~:ar, New Delhi-110 029.

tal poisoning which confronts the pediatrician, and is an important cause of morbidity and mortality. It constitutes 0.33% to 7.6~ of the total admissions in pediatric wards at various hospitals is India. However, the incidence of childhood poisoning m a y be m u c h higher than w h a t has been

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POISONING IN CHILDREN : INDIAN SCENARIO

documented as, there is no standard system for reporting cases of childhood poisoning; secondly all the available studies are hospital based data which m a y not be true representatives of the c o m m u n i t y at large. Moreover, many cases from rural area may never get reported in a hospital due to ignorance, illiteracy and non-availability of primary health centres at vicinity and of transport facility. Further, introduction of new drugs and chemicals and industrial growth has widened the spectrum of toxic products to which children may get exposed. However, accidental poisoning is mainly due to household products, which may vary according to the socio-cultural background of the family. Further variations are due to geographical differences leading to variations in plant and animal poisoning. Therefore, periodic review of data on pediatric poisoning from various centres is essential for providing the everchanging information. The retrospective data from 8 different hospitals in India was reviewed to assess the demographic features and pattern of toxicity in different geographical areas and are presented together as there appears to be a similar trend at many centres though a substantial degree of variation in the toxicity pattern is observed. These centres included Kalawati Saran Children's Hospital INew Delhi), Lok Narayan Jai Prakash Hospital (New Delhi), Indira Gandhi Medical College (Shimla), Christian Medical College and Hospital (Ludhiana), Padampat Mother and Child Health Institute (Jaipur), Kasturba Hospital from rural Maharashtra attached to Mahatma Gandhi Institute of Medical Sciences (Sevagram), S.A.T Hospital (Trivandrum), Medical College Hosptial, Calcutta (West Bengal), B.C. Roy Memorial Hospital and Burdwan

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Medical College Hospital (West Bengal). The records from last 3 hospitals are presented under one group. Amongst all the cases of childhood poisoning from various centres, 50-90% were below 5 years. Children between 1-3 years of age were the most vulnerable group in all the records; and all the poisoning cases were accidental. This is because children at this age become more inquisitive and exploratory in nature aided by their newly acquired hand skills and mobility. Negligence or ignorance on part of the parents and caretaker is an important contributory factor in making the environment of the child conducive for poisoning. Increased number of male patients in all the studies (M : F = 1:65 : 1 to 2.65 : 1), except from Trivandram (M : F = 1.07 : 1) could be due to their natural tendency to be more exploratory, active and restless than their female counterparts. In small houses with limited space, the household chemicais, disinfectants and kerosene are most likely to be ingested by children. Alcohol intoxication in young children is often accidental and due to lack of experience in adolescents. Drug intake and other household chemicals with the suicidal intent is often seen after 13 years of age. In these vulnerable adolescents, conflicts with parents, school stress, and unsuccessful affairs make them emotionally insecure. These problems may increase with increasing ~rbanization. The incidence of Poisoning in children at the 8 centres under study, varied between 0.23~ to 3.3%. The lowest incidence was recorded at KSC. A variable incidence of deaths due to poisoning was observed in these centres (range 0.64% to 11.6~ The highest rate of mortality was recorded from Shimla. Various plants and insecticides were

Vol. 65, No. 3, 1998

A.K. DUTTAET AL

common offending agents in this region where a large proportion of the population is dependent upon horticulture and allied activities. Although, there is a considerable heterogeneity in the frequency and type of poisoning observed in the records at different centres, kerosene was the commonest agent reported from Rajasthan (43.2%), West Bengal (33.3%) and Trivandrum (30.97%). Maximum cases of kerosene poisoning were reported from Kalawati Saran Children's Hospital (KSC), Delhi, accounting for 54% of the total poisoning cases. However, another major centre from Delhi i.e LNJP hospital reported only 28.5% cases due to kerosene poisoning, which is similar to the reports from other centres. The enormously high incidence of cases with kerosene poisoning from KSC hospital could be due to the high percentage of patients coming to this centre from economically backward class where kerosene is still used as the main cooking fuel. Although a similar incidence of kerosene poisoning was also recorded from Punjab (28.6%), it was not the commonest cause of childhood poisoning in the state. A comparatively low incidence of kerosene oil poisoning was observed in Shimla (8.3%) and rural Maharashtra (14.9%) where probably wood charcoal is being used as fuel. Virtually, every k n o w n drug has been described as poisonous on one or the other occasions. However, few drugs with low margins of safety are the usual culprits in most childhood poisonings. A very high incidence of toxicity caused due to d r u g / medicine intake is seen in records from LNJP (66.8%) followed by Punjab (41.6%), Shimla (35%), KSC (23.5%), and Trivand r u m (29.0%). The commonest group of drugs involved was phenothiazines followed by anti-pyretics, anti-epileptics and

367

iron preparation. Such high incidence of toxicity due to drug intake suggests that parents should be made aware of this aspect of child care and they should be advised about proper storage of the medicines and their likely hazards. Additionally, the relative immaturity of the metabolic functions in children make them easy victims of drug poisoning at relatively minimaI overdosages. Besides, toxicity due to oral or parental overdosages, certain medications meant for topical use or wound irrigation, if ingested accidentally can lead to toxicity even at a very low dosage. Frequency of poisoning cases due to snake and scorpion bites has reduced considerably which is largely attributed to the deforestation, urbanization, building up of proper high mounted cemented houses etc. Howevei, snake bites still contribute to significant number of poisoning cases from rural area. High incidence of snake bite cases are recorded in a hospital from rural Maharashtra accounting for 34.3% and a further 10.4% cases were admitted due to scorpion bites. This has been observed as the commonest cause of acute poisoning from this hospital. However, the incidence of snake or scorpion bites is very low at other centres (upto 5.7%). Food poisoning is also quite common in children. In rural Mahal"ashtra, 47% of the total admissions were due to food poisoning. In all the instances, toxicity resulted due to contaminated milk feeding in rural schools at 2 occasions and due to mass feeding at a marriage party on third occasion. Cases of food poisoning were also observed in hospital records of Punjab (20%), Rajasthan (17.6%) and West Bengal (3.86%). Mostly this was represented as a group or by members of one family. Records from other centres did not include food poisoning cases.


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Vol. 65, No. 3, 1998

A.K. DUTTAE T A L

Opium, dhatura and mushrooms have b e e n identified in the c o m m o n e s t p l a n t p o i s o n i n g cases. M a x i m u m n u m b e r of cases w e r e r e c o r d e d f r o m Shimla hills which constituted 18.3% of the total admissions d u e to p l a n t p o i s o n i n g . Pesticides a n d insecticides w e r e also significant factors contributing to c h i l d h o o d poisoning. It w a s m o r e p r e v a l e n t in S h i m l a (15%) a n d Punjab (17%) w h e r e a g r i c u l t u r e a n d fruit f a r m i n g is d o n e largely a n d people tend to k e e p p e s t i c i d e s at h o m e to p r e s e r v e v a r i ous f o o d grains a n d fruits. 12.5% cases of p e s t i c i d e p o i s o n i n g h a v e also b e e n obs e r v e d f r o m West Bengal. Toxicity d u e to o p i u m ingestion is still c o m i n g into picture i n d i c a t i n g the u s e of this d r u g as a treatm e n t ~o~ diarrhoea. Besides a b o v e m e n t i o n e d factors, various other toxins h a v e also b e e n implicated

309

in childhood poisoning although with relatively low frequency. These include alcohol intoxication, m e r c u r y ingestion (Parad tablets), corrosives, h e a v y metals, r o d e n t i cides, various h o u s e h o l d substances as detergents, disinfectants, cleansers etc. There are cases of h e a v y m e t a l p o i s o n i n g resulting f r o m use of c o n t a m i n a t e d t r a d i t i o n a l m e d i c i n e s , ingestion of excessive a m o u n t of food s u p p l e m e n t s and herbal medicines. Two outbreaks of tri-ortho-cresyl p h o s p h a t e (TOC) p o i s o n i n g h a v e b e e n rec o r d e d f r o m West Bengal. The first outb r e a k was r e c o r d e d in 1972 affecting o v e r 200 people including children, with paralysis in D u m D u m area of Calcutta. All the affected p e r s o n s w e r e f o u n d to h a v e cons u m e d cooking oil f r o m a p a r t i c u l a r shop in the locality. The second similar outbreak t o o k place in 1988 w h e n the p e o p l e f r o m

TABLE2. Incidence of Different Types of Poisoning at Eight Different Hospitals in India Type of poisoning

Kerosene Food-poisoning Drugs/medication

Delhi (KSC)

New Delhi (LNJP)

54.9 28.5 . . . . 23.4 66.0 e

Pesticides

2.0

2.7

Insecticides Rodenticides Corrosives

. . 3.0

1.2 . . 1.7

Plant toxins Animal bites Alcohol Miscellaneous

Shimla Punjab (IGMC) (CMC)

8.3 . 35.0

.

15.0 . . . . . . .

1.8 -18.3 . . . . . . . . . . . 15.0 23.4

Rajas- Rural W. Trivanthan Mahara- Bengal drum (PMCHI) sbtra (MCHC, (SAT) (KH) BMCH, BCRMH)

16.8 12.1 46.5

43.2 17.6 7.9

10.0

3.8

. . . .

15.0 37.5* 13.5

12.5 10.5

1.6 4.3 5.9 1.8 0.6 6.4

33.3 9.9 14.0

30.9 -29.0 -9.2

..... 9.3

4.3 5.4

8.0 45.0

3.1 20.2

11.9

8.0

7.0

7.8 0.8 13.0

@ The common group of drugs involved phenothiazines, antipyretics, antiepileptics and iron preparation * Incidence of food poisoning has been excluded from the total cases of acute poisoning All the values are expressed as % of the total

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Behalla Tollygunj area in Calcutta consumed rape seed oil contaminated with TOC from a local ration shop. A large n u m b e r of patients were reported with chronic arsenic p o i s o n i n g from contaminated drinking tube well water in 7 districts of West Bengal. The patients suffered from dermatoses and showed skin pigmentation like rain drops on neck, arm-pits, trunk and keratosis of the palm and soles. The first case of chronic arsenical dermatoses was detected at the skin OPD of the Calcutta School of Tropical Medicine in July 1983. Since then increased number of cases have been detected in different hospitals. The area of arsenic contaminated ground water is said to extend over 3000 sq. km. and more than one lakh people are said to be affected including children. Depth of affected tube wells varied from 110-150 fts. The mean concentratton of arsenic in tubewell water consumed by affected people was estimated to be 0.32 u g / L and the duration for the symptoms to develop varied from 6 months - 2 years or more. No case was found below 6 months of age. There is a moderate degree of variation in the type and frequency of poisoning reported from different centres in India. These minor variations are attributed largely to geography and socio-economic background of the victims. An increased incidence was noted in very y o u n g children in the records from all hospitals. Their inherent curiosity and tendency for exploration places them in high risk group. This emphasizes the need that young children should be kept under strict supervision and constant vigilance. Generating awareness and educating the parents for safe keeping of household toxic materials and drugs would be the best way of prevention.

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Keeping the household toxic products and supplying drugs in the child resistant closure would also be a useful modality. Iatrogenic poisoning must be minimised by giving legible prescriptions, properly labelled drugs, explaining the dose in detail to caretakers and avoiding indiscriminate use of drugs. There were less cases between 6-10 years as by this time most children can differentiate harmful drugs and chemicals. Least number of cases were above 10 years of age. In this age group, cases of deliberate self poisoning and alcohol intoxication are usually encountered. Kerosene poisoning was the commonest source of accidental poisoning reported from all the centres except Simla and rural Maharashtra where wood charcoal is perhaps used more frequently. A very high incidence of snake/scorpion bite was seen in rural area of Maharashtra. The pesticide ingestion was more commonly reported from Punjab and West Bengal being the agrarian states. A significant number of cases of plant poisoning was reported from Simla where a large proportion of the population is dependent upon horticulture and allied activities. Two outbreaks of TOC poisoning in Calcutta necessitates the steps to prevent food adulteration. Moreover, exemplary punishment of the culprits and health education of the people are considered essential. Chronic arsenic poisoning is a burning problem of the millions of people living in areas with arsenic contaminated ground water in West Bengal. A multidisciplinary coordinated approach for thorough medical examination and identification of all victims, epidemiological survey including demarcation of the areas with arsenic contaminated ground water are necessary. But more urgent task would be providing arsenic free drinking water for all.