Medication Safe

Every year during the holidays, Poison Control Centers nationwide field numerous calls concerning ingestion of poinsettias and mistletoe. They just aren’t the killers that everyone thinks they are. The American Association of Poison Control Centers urges people to ”Treat Poinsettias and Mistletoe with Respect Rather Than Fear This Holiday Season”.

Poinsettias and mistletoe, while lovely symbols of the holiday season, have long been thought to be gravely poisonous.

But while ingesting these holiday plants can cause discomfort, data from the American Association of Poison Control Centers indicates they are not quite the deadly hazards they’ve long been believed to be.

The entire article can be found here: http://www.earthtimes.org/articles/show/american-association-of-poison-control,1085047.shtml.

If you think your child has tasted, touched or breathed something harmful, call your local poison control center. Poison Control Centers nationwide are accessed by calling 1-800-222-1222.

Data analyzed from calls taken by the New York City Poison Control Center, provide yet more evidence that special attention needs to be taken to prevent poisonings. Medications, as the leading cause of childhood poisoning, are particularly concerning.

From the article:

In fact, poisoning is the third leading cause of hospitalizations for injury among children ages one to four. Each year, New York City’s Poison Control Center (PCC) receives approximately 4,000 calls reporting poisonings of children under the age of 15 serious enough to require referral to, or treatment by, a health care professional. An overwhelming 75% of these calls involve children younger than five.

These are among the findings of a new report by the New York City Health Department, “Unintentional Poisoning in New York City Children,” that analyzes PCC phone traffic from 2000 through 2007. Although many incidents of poisoning are managed at home, the new report focuses on child poisonings that require treatment at a health care facility.

“From prescription drugs to oven cleaner, common household products can be deadly in a child’s hands,” said Dr. Thomas Farley, New York City Health Commissioner. “Even a relatively low dose of an otherwise harmless substance can cause serious injury. Storing household chemicals and medications where children can’t get to them, carefully following medication dose instructions, and storing all hazardous products in child-resistant containers are three ways parents can help protect their young children from potential poisoning.”

Medications are leading cause of childhood poisoning

Medications, including both prescription and non-prescription drugs, are the leading cause of poisoning in young children, accounting for nearly half of all PCC cases. Household cleaning products and pest control chemicals follow at 21%. The remaining poisoning calls received by the PCC usually involve cosmetics, vitamins and dietary supplements.

The full article can be found here:
http://www.emaxhealth.com/2/50/32831/most-unintentional-childhood-poisonings-occur-home.html

This article ran in the Atlanta Journal constitution. Based on a report from the CDC, the leading cause of accidental poisonings among American children can be found in the family medicine cabinet.

TUESDAY, Aug. 4 (HealthDay News) — The leading cause of accidental poisonings among American children can be found in the family medicine cabinet, a new government report shows.

Each year in the United States, more than 71,000 children aged 18 and younger are seen in emergency rooms for unintentional overdoses of prescription and over-the-counter drugs, the researchers found.

In fact, more than two-thirds of emergency department visits are due to poisoning from prescription and over-the-counter medications — that’s more than double the rate of childhood poisonings caused by household cleaning products, plants and the like, the team from the U.S. Centers for Disease Control and Prevention said.

“Medication overdoses are most common among 2-year-olds,” added lead researcher Dr. Daniel Budnitz, director of the CDC’s Medication Safety Program in the division of health-care quality promotion. “About one out of every 180 2-year-olds visits an emergency department for a medication overdose each year.”

Dr. Robert Geller, a professor of pediatrics at Emory University School of Medicine and medical director of the Georgia Poison Center, said that “the number children seen in the emergency room due to overdoses that are unintentional or medication errors is remarkable.”

Geller noted that many more people reach out to poison control centers for help than show up at the hospital. “Right now, poison centers are having their funding cut,” he noted. “If poison centers are less available, the number of children going to emergency rooms will rise.”

More than 80 percent of these overdoses are due to unsupervised ingestion, Budnitz noted. “Basically, it’s young children finding and eating medicine without adult supervision,” he said. “They are found with an empty bottle or pills in their mouth or something, and they are taken to the emergency department.”

In addition, medication errors by caregivers or adults and misuse of drugs by preteens and teens cause about 14 percent of accidental poisonings, Budnitz said. “Basically, that’s not following directions,” he said.

The full news article can be found here: http://www.ajc.com/health/content/shared-auto/healthnews/drab/629675.html. 

We will attempt to link to the published article when it becomes available.

Update, the full text of the published article,

Medication overdoses leading to emergency room visits in children. Schillie SF, Shehab N, Thomas KE, Budnitz DS., Am J Prev Med. 2009 Sep;37(3):181-7., can be found here: http://www.ajpm-online.net/article/PIIS0749379709003894/fulltext.

If it’s made for the eyes it’s got to be safe right.

Sometimes not. When it comes to safe guarding your child, eyedrops need to be treated just like any other medication. If your child is exposed to any medication, call your local poison control center, 1-800-222-1222, immediately.

Glaucoma can effect people of all ages although the elderly are at higher risk. Glaucoma is the leading cause of visual impairment. A commonly prescribed eyedrop called brimonidine could cause serious harm and lead to admission to the hospital if a child were to be accidentally exposed.

A recent article, authored by Drs. Becker, Huntington and Woolf from Cambridge Hospital, Harvard Medical School and Children’s Hospital Boston, was published in Pediatrics, Official Journal of The American Academy of Pediatrics. They looked at brimonidine exposures in children < 6 years old. The data comes from the American Association of Poison Control Centers, 1997 to 2005 and is provided by the 61 member centers.

Of the 176 cases of unintentional brimonidine poisoning, 28 had to be hospitalized for treatment. The most common symptom reported was drowsiness. Less frequently reported but potentially more serious symptoms included included pallor, irritability, low blood pressure, breathing difficulties and prolonged slowing of the heart rate.

Please continue to keep all medications inaccessible to your child.

More details of the study can be found here: http://www.health.am/ab/more/glaucoma-eye-drops-can-harm-kids/.

The published article can be found here: http://pediatrics.aappublications.org/cgi/content/full/123/2/e305.

Article published in:

Annals of Emergency Medicine

 2008 Sep 5. [Epub ahead of print]

 http://www.annemergmed.com/article/S0196-0644(08)01503-5/abstract

Bailey JE, Campagna E, Dart RC; The RADARS System Poison Center Investigators.

Rocky Mountain Poison and Drug Center-Denver Health, Denver, CO.

ABSTRACT

STUDY OBJECTIVE: The impact of prescription opioid abuse on young children is underrecognized and poorly documented. We hypothesize that poisoning of young children from prescription opioids occurs regularly in the United States and is associated with serious health events, including death.

METHODS: Using data from poison centers participating in the Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS) System, exposures in children younger than 6 years, involving buprenorphine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, and oxycodone (January 2003 to June 2006), were quantified and described.

RESULTS: We identified 9,179 children exposed to a prescription opioid. The median age was 2.0 years (range newborn to 5.5 years), and 54% were boys. Nearly all exposures involved ingestion (99%) and occurred in the home (92%). Exposures to any opioid were associated with 8 deaths, 43 major effects, and 214 moderate effects. Of 51 patients who experienced a major effect or death, 35 were treated with naloxone: a beneficial response was documented in 34 patients. All 5 exposures to buprenorphine associated with a major effect were treated with naloxone, and a beneficial response was recorded in all 5. Nearly all exposures were to medications prescribed for adults in the household. The number of prescriptions filled for an opioid in an area correlated well with exposures in young children in the same area; children have access to household members’ prescription drugs.

CONCLUSION: Young children are exposed to prescription opioids, typically prescribed for other patients, resulting in major health effects and death.

Article published in:

Pediatrics-Official Journal of The American Academy of Pediatrics

2007 Aug;120(2):e346-53. Epub 2007 Jul 3.

http://pediatrics.aappublications.org/cgi/content/full/120/2/e346

ABSTRACT

OBJECTIVES: Residential injuries cause significant morbidity and mortality in infants and young children. The American Academy of Pediatrics recommends initiating injury-prevention counseling during health supervision visits in the first 6 months of life. The objectives of this study were to describe and compare self-reported and observed home safety practices in urban, low-income families who were expecting or had a child <12 months old and to assess the feasibility of using safety products depending on the design and repair of urban homes.

PARTICIPANTS AND METHODS: Women who were pregnant or had an infant <12 months old and who were enrolled in East Baltimore’s Healthy Start home-visiting program were eligible for the study. For this pilot project, we used a prospective predesign/postdesign. Maternal self-report and investigator home observations documented the use of working smoke alarms on each level of the home, stair gates or doors blocking the top and bottom of all staircases, adult medication storage in locked cabinets, and the environmental feasibility of safety-product use.

RESULTS: Home safety practices were higher by maternal self-report than by investigator observation. Fifty-five percent of families who reported a working smoke alarm on every level of the home had nonworking or absent smoke alarms noted during investigator observation. Of assessed staircases, 67% could not accommodate a wall-mounted gate at the top of the stairs, and 38% could not accommodate a pressure-mounted gate at the bottom of the stairs. Although most families reported locked storage of medications, 77% had unlocked medication storage documented during home observation.

CONCLUSIONS: In this sample of urban families, implementation of American Academy of Pediatrics-recommended safety practices is low. The structural design of urban homes may be a significant barrier to home safety-product use. The American Academy of Pediatrics Injury Prevention Program sheets, manufacturers of safety products, and legislators need to address injury-prevention issues unique to urban, low-income families.

Article published in:

Health Promotion Practice

2006 Oct;7(4):388-95. Epub 2006 Aug 21

http://hpp.sagepub.com/cgi/reprint/7/4/388

McDonald EM, Solomon BS, Shields WC, Serwint JR, Wang MC, Gielen AC.

Department of Health, Behavior and Society, Center for Injury Research and Policy at the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

OBJECTIVE: To assess childhood injury risk and parents’ injury interests, and the association between the two.

METHOD: A cross-sectional computer and telephone survey was conducted as part of a randomized controlled trial. The authors enrolled parents of children being seen at an urban pediatric primary care practice and measured selected injury knowledge, beliefs and safety practices. Parents were asked to select two of four topics of interest and recommendations regarding them were included in a computer-tailored report.

RESULTS: Participants (N = 105) were assessed as being at risk for all four areas: poisoning (88%), fires (85%), falls (55%), and car crashes (18%). Parents were interested in poisoning (81%) and car crashes (49%); their interests were unrelated to child’s assessed risk.

CONCLUSION: Soliciting parents’ interests prior to counseling may help to identify priority areas for counseling as well as dispel myths and unfounded fears regarding childhood injury risks.

Article published in:

The Journal of the American Osteopathic Association

2006 Jul;106(7):405-11

http://www.jaoa.org/cgi/content/full/106/7/405

McFee RB, Caraccio TR.

Long Island Regional Poison and Drug Information Center, Winthrop University Hospital, 259 First Street, Mineola, NY 11501-3957, USA. rbmcfee@pol.net

Context: Although the circumstances are not well studied, grandparents’ medications account for 10% to 20% of unintentional pediatric intoxications in the United States.

Objectives: To characterize circumstances leading to and outcomes from pediatric pharmaceutical exposures. To identify preventable risk factors associated with this pattern of injury, referred to as the “granny syndrome.”

Design, Setting, and Participants: Retrospective review of records of telephone calls made to a certified regional poison control center in the United States. Records were analyzed for all calls concerning children aged 6 years or younger who were exposed to grandparents’ medication(s). For statistical analysis, regression and chi square analysis as well as Fisher exact tests were used. The sample size provided 80% power to detect a 10% difference at the 5% level of significance. Statistical significance was set at P<.05.

Main Outcomes Measured: Use of child-resistant containers (CRCs), the location of pharmaceuticals prior to pediatric ingestion, and drug classes involved (eg, analgesics, cardiovascular drugs).

Results: Of the 200 incidents analyzed, 90 (45%) cases involved CRCs, and 110 (55%) involved containers that were not child resistant. For these incidents, the average age of the child was 18.8 months; the grandparent was aged on average 58.7 years. Most medications had been placed on tables or countertops (91 [46%]), low shelves (57 [29%]), or in pocketbooks (34 [17%]). The type of container in which the pharmacologic agent was stored (CRC vs non-CRC) was not statistically significant (P>.1). Ease of access to medication, regardless of the type of container used, was the only statistically significant outcome (P<.001). In the present study, accidental pediatric exposures most frequently involved cardiovascular (90 [45%]), analgesic (84 [42%]), and psychotropic (32 [16%]) medications.

Conclusion: Pediatric exposure to pharmaceutical agents is a preventable cause of injury. Physicians have an important opportunity to assist in preventing pediatric pharmaceutical exposures by instructing parents and grandparents on how to better limit children’s access to medications as an essential component to enhance child safety.

Article published in:

American Family Physician – A peer reviewed journal of the American Academy of Family Physicians

2006 Dec 1;74(11):1864-9.

http://www.aafp.org/afp/20061201/1864.html

Schnitzer PG.

University of Missouri-Columbia Sinclair School of Nursing, Columbia, Missouri 65211, USA.

ABSTRACT

Injuries are the leading cause of death in children and teenagers in the United States. The leading causes of unintentional injury vary by age and include drowning, poisoning, suffocation, fires, burns, falls, and motor vehicle, bicycle, and pedestrian-related crashes. Most injuries are preventable by modifying the child’s environment (e.g., use of stair gates) and having parents engage in safety practices (e.g., keeping matches or lighters out of reach of children). Effective injury prevention methods include the use of childproof caps on medications and household poisons, age-appropriate restraints in motor vehicles (i.e., car seats, booster seats, seat belts), bicycle helmets, and a four-sided fence with a locked gate around residential swimming pools.

EXCERPTS

Childhood injuries are responsible for approximately 16,000 deaths each year in the United States, and more than 70 percent of these deaths are the result of unintentional injuries. Nonfatal unintentional injuries also are a significant cause of childhood morbidity. More than 20 million nonfatal injuries are estimated to occur in U.S. children each year, costing $347 billion and accounting for more than 300,000 hospital admissions.

A shift in semantics from “accident prevention” to “injury prevention and control” was initiated in the 1970s to focus attention on preventable health outcomes. Injury prevention strategies generally are classified into three types: education, engineering and environmental modification, and legislative interventions. Active interventions are those that require action on the part of an individual person to confer protection (e.g., buckling a seatbelt), whereas passive interventions provide automatic protection regardless of individual behavior (e.g., automobile airbags).

Parent-focused and environmental strategies are effective in preventing injuries, particularly those occurring in young children at home. However, most parents cannot identify specific prevention strategies and believe that simply “being careful” is adequate protection from injury. Although little research has addressed the direct effect of counseling parents on the reduction of injury rates, there is evidence that clinical counseling can influence car seat use, at least in the short term, and can positively influence the rates of owning a functioning smoke alarm. The U.S. Preventive Services Task Force found fair evidence to support counseling parents of young children on measures to reduce injury risk. Anticipatory guidance topics should be considered an important component of medical care for children and families.

TODDLERS

Almost one third of injury-related deaths in toddlers result from motor vehicle crashes, and more than one fourth are the result of drowning. Fires and burns also contribute significantly to injury-related mortality rates. Falls and poisonings are the leading causes of nonfatal injuries requiring hospitalization in this age group, followed by scald burns and motor vehicle-related injuries.

POISONING

Poisoning continues to be a leading cause of injury-related hospitalization among toddlers, even after implementation of the Poison Prevention Packaging Act of 1970. The American Association of Pediatrics (AAP) recommends against using syrup of ipecac, which is not effective in completely removing poison from the stomach. Syrup of ipecac often is administered when it is contraindicated or not necessary, and it may result in intractable vomiting that prohibits the use of other orally administered poison treatments, such as activated charcoal and acetylcysteine.
Another ineffective poison prevention strategy for toddlers is the use of “Mr. Yuk” poison warning stickers. These stickers display a green scowling face with a protruding tongue and were designed to be placed on hazardous substances to discourage children from handling the containers or ingesting the poison. However, studies have shown that supplying the stickers to families with young children does not reduce the risk of poisoning. Furthermore, labeling containers with the stickers does not deter young children from touching, holding, or attempting to open the labeled containers.

COUNSELING RECOMMENDATIONS

Priority topics for office-based injury prevention counseling include the use of motor vehicle restraints, smoke detectors, and pool fencing; reducing residential hot water temperature; the hazards of infant walkers; the safe storage of poisons and medications; and parental supervision. The AAP has created the Injury Prevention Program for parents of children 12 years and younger. It can be accessed at http://www.aap.org/family/tippmain.htm. The program includes injury prevention counseling guidelines and schedules for providers, safety surveys designed to assess parents’ specific educational needs, and age-specific parent education handouts for use in providing anticipatory guidance in primary care offices. This program has been shown to be cost-effective.

Article published in:

MMWR Morbidity and Mortality Weekly Report – published by the Centers for Disease Control and Prevention

2006 Jan 13;55(1):1-5.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5501a1.htm

Centers for Disease Control and Prevention (CDC).

Young children are vulnerable to inadvertent exposure to prescription and over-the-counter (OTC) medications, especially when these items are not stored securely. In 2002, according to death certificate data, 35 children aged <4 years died from unintentional medication poisonings in the United States (CDC, unpublished data, 2005). In 2003, according to reports to U.S. poison control centers, pharmaceuticals accounted for 1,336,209 (55.8%) of unintentional chemical or substance exposures. Of those pharmaceutical exposures, 568,939 (42.6%) involved children aged <6 years. For this report, CDC analyzed 2001-2003 data from hospital emergency department (ED) visits reported by the National Electronic Injury Surveillance System–All Injury Program (NEISS-AIP). The results of this analysis indicated that, during 2001-2003, an estimated 53,517 children aged <4 years were treated annually in U.S. EDs for unintentional medication exposures. An estimated 72% of these exposures were in children aged 1-2 years. Children aged <4 years can reach items on a table, in a purse, or in a drawer, where medications are often stored; young children also tend to put objects they find in their mouths. Parents and others responsible for supervising children should store medications securely at all times, keep them out of the reach of children, and be vigilant in preventing access by children to daily-use containers such as pill boxes.

NEISS-AIP is operated by the Consumer Product Safety Commission and collects data on all types and causes of injuries in patients treated in hospital EDs. Data are collected from a nationally representative subsample of 66 of the 100 NEISS hospitals that were selected as a stratified probability sample of hospitals in the United States and its territories. NEISS-AIP provides data on approximately 500,000 injury-related and consumer-product-related cases each year.

Cases were defined as those involving children aged <4 years treated at a NEISS-AIP hospital ED for nonfatal, unintentional exposures to medications, including all types of prescription and OTC medications. Cases involving only illicit drugs or alcohol were excluded. Cases resulting from the adverse effects of therapeutic use of medications, medical errors (e.g., misprescribed by doctor or pharmacist), or drug exposure of infants from maternal drug use during pregnancy or breastfeeding also were excluded. A brief narrative abstracted from the medical record was used to code, where possible, the route of exposure (e.g., ingestion, inhalation, or external contact), likelihood of exposure (i.e., probable or possible [one case was classified as unclear]), source of medication (e.g., pill box or purse), intended user (e.g., grandparent or parent), and class of medication.

Each case was assigned a sample weight based on the inverse of the probability of selection; these weights were summed to provide national estimates of nonfatal medication exposures. Estimates were based on weighted data for 3,632 patients aged <4 years treated at NEISS-AIP hospital EDs for medication exposures during 2001-2003.

During 2001-2003, an estimated 53,517 (95% CI = 43,166-63,868) children aged <4 years were treated annually in EDs for nonfatal, unintentional medication exposures, an annual rate of 273.5 per 100,000 age-specific population (CI = 220.5-326.4). Children aged 1 year and 2 years had the highest rates (444.4 and 534.6, respectively) and accounted for 72.0% of medication exposure cases. Nearly one in 10 children (9.7%) were hospitalized or transferred for specialized care for their medication exposure. The majority of the cases occurred in the home (75.4%). Among the medication exposures, 85.6% were classified as probable; 98.9% of the exposures resulted from ingestion.

The source of the medication was not specified for 3,100 (85.4%) of the NEISS-AIP cases and the intended user was not specified for 2,982 (82.1%). On the basis of unweighted data, the most common sources of medication exposure were pills left out or pill bottles left open, which was reported in 215 (5.9%) cases. Other incidents involved medications administered in error by a parent or caregiver (3.5%) and children opening pill boxes (2.7%) or purses (3.0%). Among cases with intended users identified, the medications were intended most commonly for use by the child’s grandparent (7.5%) or parent (6.6%). Exposures from OTC medications (42.2%) were slightly more common than from prescription medications (39.2%). Among the approximately 92% of cases for which the class of medication could be identified, the most common medications were central nervous system agents (e.g., acetaminophen or antidepressants) (26.9%), respiratory agents (e.g., cough and cold or anti-asthma agents) (11.6%), and musculoskeletal agents (e.g., nonsteroidal anti-inflammatory agents or muscle relaxants) (8.4%). Other common classes were cardiovascular agents (7.8%), dermatologic agents (e.g., topical antibacterial or analgesic agents) (5.3%), antihistamines (4.9%), and vitamins and therapeutic nutrients (4.5%). Prescription medications accounted for 67% of admissions to hospitals or transfers for specialized care. Among those agents specified, the most common medication classes involved in hospital admissions or transfers were anticonvulsant agents (9.6%), calcium-channel blocking agents (6.8%), antidepressant and mood-stabilizing agents (6.2%), and oral hypoglycemic agents (6.2%).

Editorial Note:
Data in this report indicate that, during 2001-2003, an estimated 53,517 children aged <4 years were treated in U.S. hospital EDs each year for unintentional exposure to prescription and OTC medications. Consistent with previous studies, most of these exposures occurred in the home among children aged 1-2 years. Certain exposures involved common household medications such as acetaminophen, nonsteroidal anti-inflammatory agents, cold and cough preparations, and vitamin and mineral supplements. Some of these agents can be highly toxic (e.g., acetaminophen or opiod analgesics), and ingestion by young children can lead to death. Children aged <4 years treated in EDs for medication exposures were nearly four times as likely to be hospitalized or transferred for specialized care as children in this age group treated for all unintentional causes of injury (9.7% versus 2.5%).

During the last 3 decades, emphasis on preventing unintended medication exposures has reduced the number of deaths from childhood poisonings. Multiple factors likely have contributed to this decline, including improved packaging, product substitutions and reformulations, education programs, accessibility of poisoning information, and treatment advances. Child-resistant packaging, mandated by the Poison Prevention Packaging Act of 1970, has been credited with reducing prescription medication deaths in children aged <4 years by 45% from 1974 to 1992.

Despite the progress in reducing the number of fatal poisonings, unintentional medication exposures remain a serious threat to the health of young children. Data from this report indicate that, in 2002, approximately 1,500 ED visits and 150 hospital admissions or transfers from EDs occurred for each of the 35 fatalities reported among children aged <4 years. National data on fatal and nonfatal medication exposures should be used to set prevention priorities and develop interventions. Although requirements for child-resistant packaging are mandated by the Poison Prevention Packaging Act, this study determined that at least 12% of ED visits for medication exposures resulted from children gaining access to medications left in the open, in pill boxes, or in purses. Because medication users often transfer medications from their original child-resistant containers to other containers for daily use, manufacturers are encouraged to improve container designs and promote strategies that allow convenient access for the intended user while also protecting children.

The findings in this report are subject to at least three limitations. First, NEISS-AIP provides only national estimates of unintentional medication exposures and not state or local estimates. Second, NEISS-AIP provides data only for patients treated in hospital EDs and does not include children treated in outpatient settings or not treated at all. Finally, narratives abstracted from medical records provided information regarding the source of the medication and the intended user for only 15% and 18% of the cases, respectively; for the remaining cases, the source and intended user of the medication were unknown.

Continued promotion of established prevention measures can help reduce morbidity and mortality from unintentional medication exposures. However, to help develop new prevention strategies and assess their effectiveness in reducing the most common and most severe incidents among young children, additional data on the incident circumstances, specific medications involved, and patient outcomes are needed. More complete incident information will be available through the recently implemented NEISS Cooperative Adverse Drug Event Surveillance project (NEISS-CADES), which collects detailed information (e.g., drug dosage, laboratory testing, and clinical treatment) on all types of adverse drug events, including unintentional drug ingestions by children.