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2005;25:35-44Crit Care Nurse Robin Wilkerson, LaDonna Northington and Wanda FisherKnow Can HurtIngestion of Toxic Substances by Infants and Children : What We Don't  

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CRITICALCARENURSE Vol 25, No. 4, AUGUST 2005 35

Robin Wilkerson and LaDonna Northington are associate professors of nursing andWanda Fisher is an assistant professor of nursing at the University of Mississippi MedicalCenter School of Nursing, Jackson, Miss.

To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.

found within a child’s environment.

The most common categories of

agents ingested by children younger

than 6 years old during 2001 are

listed in Table 1. Table 2 lists the pri-

mary agents involved in fatal poison-

ings in children up to 12 years old

during 2001.

Many descriptive terms are used

in the literature on the phenomenon

Robin Wilkerson, RN, PhD, BC

LaDonna Northington, RN, DNS, BC, CCRN

Wanda Fisher, RN, MSN

Despite advances such as child-

proof caps on medications, childproof

packaging, increased educational

efforts, and increased awareness of

commonly ingested substances, deaths

due to unintentional poisonings still

occur. Unintentional poisonings are

an unfortunate and usually preventa-

ble cause of death and disability in

infants and children. According to

Litovitz et al,1

in the 2001

annual report

of the Ameri-

can Associa-

tion of Poison

Control Cen-

ters, children

aged 12 years

and younger

accounted for

58.5% of per-

sons poisoned

and

accounted for

3.5% (38) of

all the deaths

due to poisoning reported that year.

Many categories or classifications of

potentially toxic substances can be

ClinicalArticle

To receive CE credit for this article, visit the American Association of Critical-Care Nurses’ (AACN) Web site at http://www.aacn.org, click on “Education” and select “Continuing Education,” or call AACN’s Fax OnDemand at (800) 222-6329 and request itemNo. 1115.

Authors

Ingestion of Toxic Substances by Infants and Children

What We Don’tKnow Can Hurt

Online

Table 1 Agents most commonly ingested by children youngerthan 6 years old in 20011

Drugs 26.5Analgesics 7.1Cold/cough preparations 5.1Vitamins 3.6Gastrointestinal preparations 3.0Antimicrobials 2.8Antihistamines 2.6Hormones/hormone antagonists 2.3

Cosmetics and personal care products 13.2Cleaning substances 10.5Foreign bodies 7.1Topical agents 6.6Plants 6.3Pesticides 4.0Arts/crafts/office supplies 2.7Hydrocarbons 0.9

Agent % of all agents ingested

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of children and poisoning. Terms used

include accidental ingestions, acci-

dental poisoning, accidental overdose,

accidental exposures, therapeutic

errors, and therapeutic overdosage.

Depending on the situation, any one

or all of the descriptors could be

accurate. However, most recently,

Osterhoudt2 suggested that the term

“unintentional poisoning” might be

the most appropriate term to use.

For the purpose of this article, we use

the terms unintentional poisonings and

therapeutic errors.

The 2001 data for the Toxic Expo-

sure Surveillance System (TESS) are

compiled from 64 cooperating poison

control centers across the United

States.1 The TESS database has vari-

ous classifications for ingestions, but

most cases in infants and children

are classified as unintentional and

include exposures classified as general,

environmental, occupational, thera-

peutic error, unintentional misuse,

bites/stings, food poisoning, and

unintentional unknown. The Ameri-

can Association of Poison Control

Centers1 defines therapeutic error as

“an unintentional deviation from a

proper therapeutic regimen that

results in the wrong dose, incorrect

route of administration, administra-

tion to the wrong person, or admin-

istration of the wrong substance.”

Therapeutic errors include errors

made both in the natural environment

of a child and in healthcare settings.

The number of unintentional poison-

ings of children continues to warrant

an increased awareness among health-

care providers. Parents and healthcare

providers must have a high index of

suspicion when children have signs

or symptoms indicative of ingestion

of toxic substances. In this article, we

present an overview of unintentional

poisonings, the influence of growth

and development, therapeutic errors,

commonly ingested substances

(medicinal and household products),

and the role of healthcare providers.

Unintentional PoisoningsThe very nature of a young child

predisposes the child to explore the

surrounding environment. As chil-

dren grow and learn to become

independent, they are compelled to

investigate new and interesting items,

places, and objects. The influence of

growth and development upon unin-

tentional poisonings becomes espe-

36 CRITICALCARENURSE Vol 25, No. 4, AUGUST 2005

Table 2 Primary agents involved in fatal poisonings in children up to 12 years oldin 20011

Type of agent

NonpharmaceuticalAlcohols

Automotive products

Chemicals

Cosmetics, personal care products

Deodorizers

Fumes, gases, vapors

Hydrocarbons

Pesticides

PharmaceuticalAnalgesics

Anesthetics

Anticonvulsants

Antidepressants

Cardiovascular drugs

Cough or cold products

Gastrointestinal preparations

Miscellaneous

Stimulants or street drugs

Topical agents

Reason for ingestion

Unknown

Unintentional

Unintentional

Unintentional

Unintentional

Environmental

Unintentional

Unintentional

Therapeutic errorTherapeutic error

UnintentionalUnintentional

Therapeutic errorUnintentionalUnknown

Adverse reaction

Therapeutic error

Intentional unknown†

Therapeutic errorUnintentional

Unknown

Unintentional

Therapeutic error

Therapeutic errorAdverse reaction

UnintentionalIntentional unknown†

Unknown

Specific agent*

Methanol

Battery acid

Hydrofluoric acid

Baby oil

Air freshener

Carbon monoxide (5)

Lamp oil

Endosulfan

Acetaminophen (2)Acetaminophen with

methamphetamineAspirin (3)Methadone, promethazine

diphenhydramineMorphineOxycodoneOxycodone

Sevoflurane/isofluranenitrous oxide, fentanyl

Fosphenytoin

Desipramine

Digoxin (2)Metoprolol, losartan,

pioglitazoneVerapamil

Benzonatate

Sodium phosphate/sodiumbiphosphate

Sodium phenylbutyrateSuccinylcholine

HeroinHeroin

Methyl salicylate

*Numbers in parentheses are numbers of cases.†Exposure determined to be intentional, but motive unknown.

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CRITICALCARENURSE Vol 25, No. 4, AUGUST 2005 37

cially important during the toddler

and preschool age years. During the

toddler years, children are refining

gross and fine motor skills. Addition-

ally, they are testing their behavior

against the reactions of adults in con-

trol. Toward the end of the toddler

period, children are using experimen-

tation, accompanied by previously

learned skills, as a way of dealing with

new situations. This experimentation,

a part of normal growth and develop-

ment, can cause serious consequences

if the dangerous behaviors go unno-

ticed by adults. Toddlers’ sense of

taste is not well defined, so they may

ingest larger quantities of what adults

would consider unpalatable products.3

As children move into the pre-

school age years, curiosity about the

environment increases. The preschool

period is a stage of active learning;

however, the cognitive ability to

understand words lags behind the

ability to use words. Although a child

may be able to say the word poison,

the ability to reason what the term

means is lacking. At this age, children

often may mimic the actions of others,

such as taking medications. The sub-

stances found commonly around the

home are often in colors or containers

that are familiar to a child. Medica-

tions for children are generally for-

mulated with flavors to improve

compliance. Once a child’s taste is

more defined, these flavors may lead

to an increase in unintentional poi-

sonings. Cognitive abilities of children

at this stage make them unable to dis-

criminate medications from food or

candy, and harmful substances can be

mistakenly ingested.4

Children with cognitive impair-

ments present a similar challenge.

Developmentally, children with cog-

nitive impairment, despite their

chronological age, may not under-

stand the dangers inherent in ingest-

ing poisons or may still be in a stage

of mouthing objects. However, phys-

ically, such children may be taller

and have the fine and gross motor

skills that allow them easier access to

poisons. For example, in the summary

of fatal exposures reported to TESS

in 2001, a 5-year-old with Angel-

man syndrome, a genetic disorder

with cognitive impairment, ingested

an air freshener containing propylene

glycol and ethoxylate and subse-

quently died of the ingestion.1

Commonly Ingested

Pharmaceutical Substances

By and large, the most common

category of unintentional poisonings

related to pharmaceutical substances

in children occurs with analgesics,

specifically antipyretic analgesics such

as acetaminophen. Other commonly

ingested medications include ibupro-

fen, methadone, oxycodone, salicy-

lates, and morphine. The 2001 TESS

statistics report 9 deaths involving

single-agent analgesics (2 acetamin-

ophen, 3 aspirin, 1 methadone, 1

morphine, and 2 oxycodone; Table 2).1

Acetaminophen can be given

safely in therapeutic doses of 10 to

15 mg/kg every 4 hours. Most of the

medication is conjugated in the liver;

a small amount is excreted in the

urine. Liver damage can occur when

children ingest 150 mg/kg or more

in a single dose.5,6 Early signs and

symptoms (within the first 24 hours)

of acetaminophen poisoning are

nonspecific and include decreased

appetite, nausea, and vomiting or

general malaise. After 24 hours, signs

of poor hepatic function (elevated

liver enzyme levels) begin to emerge.

After 48 hours, pain develops in the

right upper quadrant, along with

alterations in mental status, jaundice,

marked elevations of liver enzyme

levels, and signs and symptoms of

renal failure. Death can occur within

7 days. Children have less liver dam-

age than adults do.7,8

Treatment for acetaminophen

overdose includes gastrointestinal

decontamination with activated

charcoal and N-acetylcysteine, the

antidote for acetaminophen overdose.

N-acetylcysteine is administered in a

regimen of 140 mg/kg as a loading

dose (orally) and then 70 mg/kg

every 4 hours for 17 total doses, and

for maximal efficacy, it must be given

within 8 hours of the overdose.5-7,9

Activated charcoal is rarely useful

because of the rapid gastrointestinal

absorption of acetaminophen and

the availability of N-acetylcysteine.7

Chronic toxic effects may occur when

children receive 60 to 150 mg/kg daily

of acetaminophen for 2 to 8 days.8

Other commonly used pain med-

ications such as nonsteroidal anti-

inflammatory drugs, other than

aspirin, are generally of low toxicity.

If nonsteroidal anti-inflammatory

drugs are consumed in toxic quanti-

ties, signs and symptoms produced

include acute renal failure, gastroin-

testinal upset, headache, dizziness

and/or tinnitus, and vision distur-

bances. More serious effects can

include hypotension, tachycardia,

hypothermia, bradycardia, hepatic

dysfunction, electrolyte imbalance,

metabolic acidosis, central nervous

system depression, and respiratory

depression. Infants and children

with suspected or known ingestion

of toxic quantities of these drugs

should be observed for 4 to 6 hours

for progression of toxic effects and

can be discharged if no toxic effects

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occur. Hospitalization is required for

symptomatic children.9,10

Several other categories of med-

ications commonly related to unin-

tentional poisonings in children

include cough medications, antihis-

tamines, and antidepressants. Most

cough medications include more

than a single ingredient. Ingredi-

ents such as acetaminophen, dex-

tromethorphan, codeine,

guaifenesin, and sympathomimetics

are present to various degrees and

in small amounts. Therefore,

because of the small amounts

ingested, toxic effects are usually

minimal. However, signs and symp-

toms such as hypertension, brady-

cardia, arrhythmias, seizures, and

gastrointestinal upset can occur.

Most often, the treatment for over-

doses of these drugs is supportive.

Symptomatic children should be

hospitalized, observed, and treated

if necessary.11 Table 3 lists com-

monly ingested pharmaceutical

substances, clinical signs and

symptoms, and management.

Commonly Ingested

Household Products and Plants

Increased attention in the media

and lay magazines during the past

decade has increased awareness of

ingestions of household products and

plants. Most parents and caregivers

are aware of these dangers and

attempt to make homes safe by keep-

ing these substances out of the reach

38 CRITICALCARENURSE Vol 25, No. 4, AUGUST 2005

Table 3 Commonly ingested pharmaceutical substances, clinical signs and symptoms, and management

Agent

Nonsteroidal anti-inflammatory drugs

Compound analgesics and opioids

Aspirin

Sympathomimetics

Antibiotics

Benzodiazepines

Antihistamines

Antidepressants

Iron

Common clinical signs and symptoms

Gastrointestinal upset, headache, dizziness, tinnitus,visual disturbances, hypotension, tachycardia,hypothermia, and prolonged prothrombin time. Iflarge doses are ingested, signs of electrolyte distur-bances, metabolic acidosis, central nervous systemdepression, and respiratory failure can occur.10

Nausea, vomiting, convulsions, central nervous systemdepression, and respiratory compromise.10 Liver damage if compound contains acetaminophen.

Hyperventilation, tinnitus, dizziness, decreased hearing,nausea, vomiting, pyrexia, metabolic acidosis, respiratory alkalosis, initial excitation of the centralnervous system followed by respiratory depressionand coma.9,10

Severe cases include hypertension, reflex bradycardia,arrhythmias, convulsions, and coma.11

Transient gastrointestinal disturbance.12 Nephrotoxic, oto-toxic, and central nervous system effects in large doses.7

Drowsiness, ataxia, hallucinations, confusion, agitation,respiratory depression, bradycardia, hypotension.12

Central nervous system depression, anticholinergiceffects, hypotension, muscle weakness, convulsions,cardiac arrhythmias.12

Tricyclic compounds can cause cardiac arrhythmias,hypotension, seizures, coma, respiratory depression,and hallucinations.7,12

Vomiting, diarrhea, abdominal pain, mucosal irritation,gastrointestinal bleeding.12

Treatment*

Single dose of activated charcoal 15-25 g ifindicated; if asymptomatic, observe for 4-6hours.9 Symptomatic treatment includes correction of dehydration and monitoring of electrolyte levels, prothrombin time, and acid-base status; treat seizures with diazepam.10

Activated charcoal; observation for asympto-matic children; naloxone for respiratory compromise,10 N-acetylcysteine.7

Correction of dehydration; activated charcoal ifingested ≥150 mg/kg; monitoring of acid-basestatus, electrolyte levels, clotting, renal func-tion, and glucose level; administer intravenoussodium bicarbonate to keep urine pH >7.5.9,10

Treatment is supportive.11

Usually no treatment required.12

Activated charcoal; if asymptomatic, observefor 4 hours; hospitalization and supportivetreatment are required for symptomatic treat-ment.12 Flumazenil may be used.8

Activated charcoal; intravenous fluids, benzodi-azepine for seizures; electroencephalographicmonitoring, sodium bicarbonate for QT pro-longation.12

Activated charcoal; sodium bicarbonate forcompromising arrhythmias and hypotension;observation for asymptomatic children.7

Monitoring for asymptomatic children; otherwise, whole-bowel irrigation, gastriclavage, endoscopic removal of pill fragmentsvisible radiologically.12

Serum iron levels >500-600 μg/dL requireintravenous deferoxamine.7,8,12

*These treatments would be implemented in a healthcare facility, not in a home setting.

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40 CRITICALCARENURSE Vol 25, No. 4, AUGUST 2005

of children. Despite these efforts, a sig-

nificant number of ingestions of com-

mon household products still occur.

The components of the various

products ingested vary. Most, how-

ever, have an unpleasant taste and

therefore are consumed only in small

amounts. Effects of unintentional

poisonings are typically dose depend-

ent; therefore, as children get older

and their sense of taste becomes

more defined, the risk of large-dose

unintentional poisonings decreases

because they are better able to dis-

criminate the unpleasant taste.

With substances such as bleach,

the main concerns are oropharyn-

geal damage and the risk of aspira-

tion pneumonia.13 Children should

be monitored for drooling, difficulty

swallowing, noisy respirations, or

any indications of respiratory distress.

Any suggestion of aspiration requires

monitoring in a hospital setting.

Some household products may con-

tain an acid or alkaline component.

Because of the small percentage of

poison present, the most common

indication that requires monitoring

is related to local oral damage. Addi-

tionally, these products may cause

some gastrointestinal upset.13

Household products such as alco-

hol, many food flavorings, colognes,

perfumes, and mouthwash contain

ethanol. Some products contain small

amounts of ethanol; however, mouth-

washes may contain up to 75% ethanol

in the most concentrated form (gen-

erally they contain 10%-25% ethanol),

and colognes usually are composed

of 40% to 60% ethanol.7-9 Although

the concentration of the ethanol

varies, the greatest danger lies in the

amount consumed. Because mouth-

washes often have a palatable taste,

they may be consumed in large

amounts. The major complication to

be monitored is depression of the

central nervous system, which can

lead to respiratory compromise. The

other major complication is related

to the competition of ethanol for

glucose stores, so children must be

monitored closely for hypoglycemia.14

Rat and mouse poisons are also

unintentional causes of poisoning in

children. The active ingredient in

most of these products is a warfarin-

like long-acting anticoagulant (super-

warfarin).8 Unlike in the past when

warfarin was used in rodenticides,

these superwarfarins are very potent

and have anticoagulant effects for up

to 7 weeks even after a small inges-

tion.7-9 Although most rodenticides

have enough superwarfarin to poison

a child, most children do not ingest

enough of the rodenticide to cause

significant toxic effects.9 Sympto-

matic children should be evaluated

and should have prothrombin times

monitored at 24 and 48 hours. Treat-

ment for children who are sympto-

matic includes administration of

vitamin K.7-9

Another common household

danger that is often overlooked in

children is household plants. Most

parents are unaware of poisons within

plants. According to data in the 2001

TESS report,1 among infants and

children, plants accounted for 73 287

exposures to toxic substances, which

was about 6.3% of all exposures to

toxic agents. One of the difficulties

in dealing with toxic plants is the

variety of possible effects. Many

plants have poisonous and nonpoi-

sonous parts. It is also difficult to

determine the amount of plant con-

sumed, and whether that amount

will produce any signs and symptoms

or toxic effects. According to the 2001

TESS report,1 the top 6 plants that

most commonly are the source of

exposure to toxic substances are the

pepper plant, peace lily, philoden-

dron, holly, poinsettia, and pokeweed

(inkberry). Signs and symptoms of

ingestion include burning and irrita-

tion of oral mucosa, nausea, vomiting,

gastric irritation, jitteriness, breath-

ing difficulties, and change in level

of consciousness. Any child with

suspected ingestion of a poisonous

plant substance should be evaluated

and treated according to an estab-

lished management protocol for that

substance.15 Table 4 lists the most

commonly ingested household plants

and products and common signs and

symptoms after ingestion.

Role of Healthcare Providers

in Unintentional Poisonings

It is incumbent on healthcare

providers to approach any child who

has ingested a toxic agent in a quick

and accurate manner to reduce fatal-

ity and long-term consequences.

Such a child may enter the healthcare

system either after the child’s parent

or guardian knows or suspects that

the child has ingested a poison or

with clinical manifestations that may

indicate a poisoning has occurred,

but with no documented poisoning.

After ensuring that the child has a

stable airway with adequate oxygena-

tion, and that the child’s condition is

stabilized, the next steps are to deter-

mine what substance was ingested

and to try to rid the body of the toxic

substance. Signs and symptoms

should also be treated during this

time. Healthcare providers must ask

probing questions of the family mem-

ber seeking care either by telephone or

personal contact. Fortunately, many of

the commonly ingested substances in

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a child’s environment have low toxicity.

Thus, children who ingest toxic substances

often may require several hours of obser-

vation rather than hospitalization. How-

ever, for those substances that can yield

long-term effects or cause death, hospi-

talization is required and at times inten-

sive care monitoring may be necessary.

Once it is determined that a poi-

soning has occurred, analysis of a

urine or blood sample may supply an

indication of what antidote and

treatment may be required. However,

most toxic substances are not

detectable on common toxicology

screenings, and such screenings

rarely add information that has not

already emerged from the history

and clinical manifestations.9 On the

contrary, if the specific toxic sub-

stance is known, serum concentra-

tions of that substance are useful in

management of the patient.8,9 Tradi-

tionally, the most common approach

has been gastric decontamination,

which involves the use of substances

to prevent absorption, enhance gas-

tric emptying, and promote cathar-

sis.17 In the past, the most common

interventions used to treat ingestions

included syrup of ipecac to induce

emesis and activated charcoal to

absorb the toxic agent.

According to the 1997 position

statement of the American Academy

of Clinical Toxicology,18 however, the

use of ipecac syrup and activated char-

coal as routine interventions should be

limited. The scientific evidence of the

efficacy of syrup of ipecac is consid-

ered questionable. Studies reviewed

indicated too much variability in the

amount of toxic substance removed.

Likewise, the evidence was inconclu-

sive on general administration of acti-

vated charcoal and improvement of

patients’ outcomes. The position

statement did recommend that acti-

vated charcoal be used when the sub-

stance ingested is known to be

affected by activated charcoal and

the charcoal can be administered

within 1 hour of the ingestion.18

Common substances that are

not affected by activated charcoal

CRITICALCARENURSE Vol 25, No. 4, AUGUST 2005 41

Table 4 Commonly ingested household plants and products and the commonsigns and symptoms

Material ingested1

Plants (10 most common)1

Pepper

DieffenbachiaPhilodendronPeace lily

Pokeweed

Holly

Poinsettia

Rubber tree /weeping fig

Poison ivy

Jade plant

Household products

Products with <10% hypochlorite

Disinfectants

Soaps and detergents

Ethanol (alcohol, perfumes, mouthwash)

Rat and mouse poisons

Hydrocarbons

Essential oils

Oral decongestants

Nail polish remover with acetone

Electric dishwasher powder orliquid

Common manifestations7,8,16

Gastric mucosal irritation; dermal and ocular irritation

Burning and irritation with edema of lips, mouth,tongue, pharynx, and stomach; can cause nausea,vomiting, or diarrhea; biting of large mature plantscan cause laryngeal edema

Nausea, persistent vomiting, intense cramping andlater diarrhea (usually occurs after 2-3 hours)

Hemolysis

Gastroenteritis

Nausea, vomiting

Nontoxic

Dermal irritation

Nontoxic

Nausea, vomiting, diarrhea; large volumes of <10%or concentrated solutions of hypochlorite maycause oropharyngeal damage

Ingestions of large amounts or concentratedamounts may cause corrosive effects, acidosis,central nervous system depression, aspirationpneumonia, or hepatic and renal damage

Observe for respiratory symptoms if aspiration offoam is suspected

Commercial disinfectants (cationic)—if concentrated,may cause corrosive effects; most common isgastrointestinal upset

Central nervous system depression; respiratorycompromise, hypoglycemia (primary concern)

Usually contain warfarinlike long-acting anticoagulant, but small amounts may not have immediate effects

Respiratory signs and symptoms indicative of aspiration

Mucosal irritation, vomiting, epigastric pain, diarrhea,aspiration, seizures, respiratory depression

Oropharyngeal irritation, central nervous systemeffects, respiratory distress, gastrointestinal irritation

Local irritation, vomiting, central nervous systemdepression, ketosis

Corrosive injury of oral mucosa, lips, and tongue

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42 CRITICALCARENURSE Vol 25, No. 4, AUGUST 2005

include those represented by the

acronym PHAILS: some pesticides,

hydrocarbons, alcohols, acids or

alkali, iron preparations, lithium,

and solvents.14,15,17 Repeated doses of

activated charcoal powder may be use-

ful for ingestions of carbamazepine,

barbiturates, dapsone, quinine, theo-

phylline, salicylates, slow-release

preparations, digoxin and digitoxin,

phenylbutazone, phenytoin, sotalol,

piroxicam, and Amanita phalloides

(death cap mushroom).14

The recommended dosage of acti-

vated charcoal is 1 g/kg in children up

to 1 year old and 25 to 50 g per dose in

children 1 to 12 years old, given either

by mouth or by nasogastric tube.15

The powder of activated charcoal

should be mixed with water, which

will produce a gritty preparation that

should be well shaken. Activated char-

coal should not be given with ice

cream, milk, or sherbet because these

additives decrease its absorptive prop-

erties.19 Potential complications of the

use of activated charcoal include aspi-

ration and vomiting.11 Gastric lavage is

contraindicated in patients who are

not intubated and in those who have

lost the gag reflex.15

The American Academy of Clini-

cal Toxicology18 does not recommend

the routine use of a cathartic in con-

junction with activated charcoal. If a

cathartic is used, it should be limited

to a single dose to minimize compli-

cations of dehydration, hyperna-

tremia, or hypermagnesemia. The

recommended dose for sorbitol is 1

to 2 g/kg (4.3 mL/kg of a 35% solu-

tion) for children more than 1 year

old. The recommended dose for mag-

nesium citrate in children is 4 mL/kg

of a 10% solution.15,18

For a few substances, specific anti-

dotes are necessary or beneficial.

The antidote

may decrease

the potential

for morbidity

or mortality

associated

with ingestion.

Table 5 lists

the most com-

mon toxic

agents and

antidotes.

TherapeuticErrors

The smaller

physical size of

infants and

children, as compared with adults,

increases the risk for unintentional

poisonings and therapeutic errors.

All medications for infants and chil-

dren are individualized, with the

dose calculated on the basis of body

weight or body surface area. There-

fore, all these medications involve

the calculation of dosage with the

resultant increased potential for

errors in the computation of a dose.

In addition, because of the small size

and body surface area of infants and

children, small errors in calculation

can make a huge difference in mor-

bidity and mortality. For example,

a miscalculation of digoxin that

results in 5 μg instead of 0.5 μg or 5

mL instead of 0.5 mL can potentially

be fatal.

The most common agents

involved in therapeutic errors are

single-agent analgesics such as acet-

aminophen, aspirin, methadone,

morphine, and oxycodone. Litovitz

et al1 stated that therapeutic errors

made up 7.4% of the total exposures

to poisonous substances in all age

groups reported to TESS in 2001.

Another 3.7% of exposures were due

to unintentional misuse of nonphar-

maceutical products. Of the 38 deaths

in children aged 12 years and younger

that were reported in 2001, 9 (24%)

of the deaths were due to therapeu-

tic errors. All but 1 of the deaths due

to therapeutic errors occurred in

children younger than 6 years old.1

In the 2001 TESS data for expo-

sures of children aged 12 years and

younger, the majority of therapeutic

errors made by healthcare profes-

sionals were the result of using an

incorrect formulation or concentra-

tion, dispensing-cup errors, or 10-fold

dosing errors.1 More specifically,

therapeutic errors made by health-

care professionals that resulted in

death in children aged 12 years and

younger included 10-fold errors in

morphine sulfate and fosphenytoin

dosing; unintentional administrations

of an excessive dose of intravenous

digoxin; and an inadvertent dosage

of 6.5 times the usual dosage of

sodium phenylbutyrate solution.1

Although therapeutic errors in

children are underreported in the

Table 5 Common toxic agents and their antidotes3,4,8,12,14

Agent

Acetaminophen

Agents with anticholinesterase activity

Benzodiazepines

Carbon monoxide

Digoxin

Iron

Lead

Opioids

Methanol, ethylene gylcol

Tricyclic antidepressants

Warfarin

Antidote

N-acetylcysteine

Atropine, pralidoxime

Flumazenil

Oxygen

Digoxin Fab antibody

Deferoxamine

Dimercaprol (BAL)Calcium disodium edetate

(calcium EDTA) Succimer

Naloxone

Ethanol, fomepizole

Sodium bicarbonate

Vitamin K1

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literature, we are aware of numerous

cases in which parents, caregivers, or

siblings unintentionally gave infants

and children overdoses of prescrip-

tion or over-the-counter medications.

These errors are a result of misun-

derstanding of teaching or lack of

teaching on dosing and correct for-

mulation. Tenfold errors can also

occur when parents or caregivers are

withdrawing medications from a

container to dispense. According to

Lesar,20 10-fold or decimal point errors

may result in 10-, 100-, or 1000-fold

errors in medication dosing. This type

of error may result in either overdoses

or underdoses. Tenfold errors are

potentially devastating, and without

proper attention they are relatively

easy errors to make, especially in

infants and children.

In the study to identify and quan-

tify the characteristics of 10-fold dos-

ing errors, Lesar20 concluded that such

errors are common and are associated

with identifiable risk factors. In the

study, done in a 631-bed tertiary care

teaching hospital (120 beds were

pediatric/neonatal), 200 consecu-

tively detected 10-fold medication

errors were evaluated. The errors

were evaluated on the basis of the

potential for the error to be carried

out and on the pharmacological

potential for adverse effects. All

errors classified as potentially severe,

serious, or significant were included

in the study. Dosing errors in med-

ications for infants and children

accounted for 19.5% of all errors. Of

note, errors in these patients were

detected at a rate of 0.98 per 1000

total patient days as compared with

a rate of 0.77 per 1000 total patient

days in adults. Contributing to the

10-fold errors in the dosages for

infants and children were the dosage

calculation used (92.3%), multiple

zeroes (38.5%), dose less than 1 (28.2%),

and expression or conversion of units

of measure (10.2%). Error mechanisms

included adding a zero (23.1%), omit-

ting a zero (25.6%), and misplacing

decimal points (51.3%).

Another interesting factor evalu-

ated was what Lesar20 labeled error

enablers. These were described as risk

factors that would enable an error,

such as an injectable dose form, an

oral liquid dosage form, and solid

oral dose forms such as capsules and

tablets. In cases of dosing errors in

medications for infants and children,

a wide dose range was considered an

enabler for all errors. Additionally,

injectable and oral liquid medications

were enablers. Antimicrobials were

the most frequent medication for

infants and children ordered in dosages

with 10-fold errors (38.5%). However,

more severe/serious 10-fold dosing

errors were in doses of morphine.

Role of Healthcare Providers

in Therapeutic Errors

Errors made in a child’s natural

environment may be prevented by

diligent education of everyone involved

in administration of medications,

particularly in education on correct

formulation and dosage. Anyone who

administers the medications must be

educated, including parents, relatives,

and daycare workers.

Most, if not all, errors made by

healthcare professionals could be

avoided if attention were paid to the

6 rights of medication administration:

right client, right drug, right dose, right

route, right time, and right concentra-

tion. Particular attention should be

given to rules on the use of zeroes and

decimal points. Additionally, staff

members should be made more aware

of the potential for 10-fold errors

and how to avoid them.

Part of the responsibility in admin-

istering medications is knowledge of

safe dosages and expected therapeu-

tic and side effects. Educating par-

ents about the use of prescribed

medications is a large responsibility

for nurses as well. As nurses, we must

be sure that parents understand the

directions for administering medica-

tions and help the parents understand

when it becomes necessary to contact

a healthcare provider.

ConclusionUnintentional poisonings and

therapeutic overdoses are real dan-

gers to infants and children. Increased

awareness and constant reinforce-

ment are needed not only in the lay

community but also in the nursing

community. The responsibility for

prevention lies within the nursing

community to educate itself and oth-

ers within the community who care

for infants and children. Nurses must

be aware of the potential dangers

associated with commonly used

medications. When administering

medications to infants and children,

and when teaching parents to admin-

ister medications, nurses must be

absolutely sure of correct dosages.

When parents are being taught,

anticipatory guidance includes how

to prevent ingestions, the number

for the nationwide poison control

center (1-800-222-1222), early

recognition of common signs and

symptoms of poisoning, and the

importance of never giving remedies

before the poison control center is

contacted. Additionally, parents

should be instructed on various for-

mulations of acetaminophen and

ibuprofen and should be told that

CRITICALCARENURSE Vol 25, No. 4, AUGUST 2005 43

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44 CRITICALCARENURSE Vol 25, No. 4, AUGUST 2005

the dosages for the various formula-

tions are not interchangeable. Sup-

plying written instructions as well as

verbal instructions would be helpful.

Written instructions provide parents

and caregivers with a reference in

case they have a question. It is also

important to discuss with parents

and caregivers the importance of

storing these medications out of the

reach of infants and children, using

safety locks on cabinets, and keeping

purses (or any other places of storage

of these medications) out of the reach

of infants and children who are at

risk for unintentional poisoning.

When parents are provided anticipa-

tory guidance, particular emphasis

must be placed on the prevention of

unintentional poisonings. Guidance

should be given on the basis of devel-

opmental age rather than chronolog-

ical age.

As nurses, part of our role is that of

education. Talking with parents out-

side the healthcare arena would be a

great start. Girl Scout meetings, meet-

ings of parent-teacher associations,

church gatherings, daycare centers,

and other community-based activities

can provide a forum for teaching

and learning, and such training ses-

sions could also provide an opportu-

nity for questions to be answered.

When infants and children are

admitted to healthcare facilities

after possible exposure to toxic sub-

stances, nurses must be gentle in

their approach. Nurses should

impart information without adding

guilt to parents who are already

stressed.

Because of the large number of

exposures that are “therapeutic,” it

behooves nurses to be more aware of

the importance of knowing the 6

rights of medication administration.

Nurses are liable if they give a wrong

medication, even if it was ordered.

Any nurse who is not familiar with

dosages for infants and children

should always double-check with

another colleague or the pharmacist

and should be aware of the potential

for 10-fold errors. In intensive care

units, medications given to infants

and children are almost exclusively

injectable or oral liquids. In these units

especially, nurses must take special

care to eliminate therapeutic errors.

In caring for a child who has been

exposed to a toxic substance, all the

resources at hand, including the poi-

son control system in a local area,

should be used. The overall goal for

infants and children is to prevent

exposure. However, if an uninten-

tional poisoning or therapeutic error

occurs, the goals are to stabilize and

prevent complications related to the

exposure, return the child to optimal

health, and minimize future expo-

sures. With increased awareness and

dedication, members of the health-

care profession and the general com-

munity can continue to reduce the

incidence of exposures of infants and

children to toxic substances.

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