Prevention of poisoning in children

INTRODUCTION — Most poisonings that occur in young children are unintentional. Though sometimes referred to as "accidental," the preferred term in the injury prevention literature is "unintentional" because the term "accident" implies a random, uncontrollable act of fate [1]. Poisonings, like other types of injuries, are understandable, predictable, and preventable events. (See "Pediatric injury prevention: Epidemiology, history, and application".)

This topic discusses the epidemiology of poisoning and poisoning prevention in children. The approach to the child with occult toxic exposure is discussed separately. (See "Approach to the child with occult toxic exposure".)

The clinical features and management of specific ingestions are discussed in individual topic reviews; for example:

●(See "Clinical manifestations and diagnosis of acetaminophen (paracetamol) poisoning in children and adolescents" and "Acetaminophen (paracetamol) poisoning: Management in adults and children".)

●(See "Potentially toxic plant ingestions in children: Clinical manifestations and evaluation" and "Toxic plant ingestions in children: Management".)

EPIDEMIOLOGY

Risk and type of exposure — Poisoning is a significant public health issue for children. Each year in the United States, approximately 886,000 to 1 million poison exposures among children younger than six years of age are reported to the American Association of Poison Control Centers (AAPCC) [2-6]. In addition, approximately 121,000 to 134,000 exposures are reported for children 6 to 12 years and 166,000 to 177,000 exposures for teenagers 13 to 19 years [2-6]. Because not all poisoning exposures are reported to poison control centers, these numbers are most likely an underestimate.

Over 90 percent of poisoning exposures occur in homes [2-6]. The pattern of poisonings varies by age and sex. For preadolescents, poisoning occurs slightly more often in males than females, but this trend reverses in teenagers, with approximately 64 percent of all poisonings in the 13- to 19-year age group occurring in females [6]. The majority of poisonings involving young children are classified as unintentional (eg, exploratory ingestions, therapeutic errors) [5-8]. In contrast, more than 60 percent of poisoning exposures involving teenagers are intentional (64 percent in 2020) [6].

Fatalities — Poisoning exposure typically causes minor symptoms in young children; death is a relatively rare occurrence. In 2020, the AAPCC reported 21 exposure-related fatalities in children <6 years old [6]. In addition, there were 7 reported deaths in the 6- to 12-year age group and 68 in the 13- to 19-year age group [6].

●Among the 21 fatalities in children younger than six years, 18 were reported as unintentional, 1 as malicious, and 2 as unknown reason [6].

●Among the 7 fatalities in children aged 6 to 12 years, 4 were reported as unintentional, 2 as suspected suicide, and 1 as unknown reason [6].

●Among the 68 fatalities in the 13- to 19-year age group, none was due to unintentional exposure; 16 were associated with intentional abuse, 42 were suspected suicides, 1 was intentional misuse, 3 were categorized as intentional-unknown, and 6 as unknown reason [6].

In 2020, analgesics were the most common pharmaceutical involved in fatalities in adolescents, followed by antidepressants, "unknown drug," stimulants and street drugs, cardiovascular drugs, hormones and hormone agonists, antihistamines, muscle relaxants, sedatives/hypnotics/antipsychotics, and asthma therapies. Common nonpharmaceuticals associated with fatalities in teens 13 through 19 years were fumes/gases/vapors, chemicals, household cleaning substances, and pesticides.

Another analysis was conducted on the National Fatality Review-Case Reporting System database from 2005 to 2018 [9]. During this period, 731 poisoning fatalities were reported for children ≤5 years old. Among the group where supervision was recorded, 51 percent of the children were within sight of a supervising individual at the time of the ingestion. Children <1 year represented 42 percent of the fatalities, and nearly one-half of all fatalities were caused by opioids.

Ingested substances — In 2020, the substances most frequently involved in pediatric (≤5 years old) exposures were cosmetics/personal care products (12 percent), household cleaning products (11 percent), analgesics (8 percent), foreign bodies/toys/miscellaneous (7 percent), and dietary supplements/herbals/homeopathic remedies (6 percent) (table 1) [6].

Ingestions of over-the-counter cough and cold preparations among young children declined after the labels of these products were revised to warn against use in children younger than four years [10,11]. (See 'Legislation' below.)

Child self-ingestion of pharmaceutical agents increased between 2004 and 2010 with the rising availability of prescription medications, but decreased between 2010 and 2013 [12-14]. Based on national surveillance between 2007 and 2011, it is estimated that nearly 9500 children younger than six years are hospitalized each year for unsupervised ingestion of prescription medications [15]. Opioids (particularly buprenorphine) and benzodiazepines were the most commonly ingested medications. Among children who presented to the emergency department with unsupervised medication exposure between 2010 and 2013, opioids and benzodiazepines were the most commonly ingested prescription solids; acetaminophen, cough and cold remedies, ibuprofen, and diphenhydramine were the most commonly ingested liquid over-the-counter medications [14].

Child self-exposure to illicit drugs (eg, marijuana, methamphetamines) and electronic cigarettes also appears to be increasing [16]. These ingestions and lung disease associated with e-cigarette products are discussed separately. (See "Cannabis (marijuana): Acute intoxication" and "E-cigarette or vaping product use-associated lung injury (EVALI)" and "Nicotine poisoning (e-cigarettes, tobacco products, plants, and pesticides)" and "Idiopathic acute eosinophilic pneumonia", section on 'Etiology' and "Methamphetamine: Acute intoxication".)

The categories of substances most frequently involved in fatalities in children ≤5 years of age during 2020 included analgesics, fumes/gases/vapors (primarily carbon monoxide), cardiovascular drugs, batteries, and chemicals [6].

The "hazard factor" is a measure that was devised to objectively assess the poisoning hazard of various products based upon the potential acute toxicity of individual ingredients and the frequency and extent of injuries following actual exposures [17]. It was derived through analysis of more than 3.8 million exposures that were reported to the AAPCC from 1985 through 1989 among children younger than six years. In this analysis, significant hazards were limited to a few products. These included:

●Iron supplements (see "Acute iron poisoning")

●Antidepressants (see "Tricyclic antidepressant poisoning")

●Cardiovascular medications (see "Digitalis (cardiac glycoside) poisoning" and "Beta blocker poisoning" and "Calcium channel blocker poisoning")

●Methyl salicylate (see "Salicylate (aspirin) poisoning: Clinical manifestations and evaluation")

●Hydrocarbons (see "Acute hydrocarbon exposure: Clinical toxicity, evaluation, and diagnosis")

●Pesticides (see "Organophosphate and carbamate poisoning")

Additional specific products have been identified as causing severe symptoms or death in children with ingestion of only a small amount (table 2) [18,19]. These included the following:

●Sulfonylureas (see "Sulfonylurea agent poisoning")

●Calcium channel blockers (see "Calcium channel blocker poisoning")

●Toxic alcohols (see "Ethanol intoxication in children: Epidemiology, estimation of toxicity, and toxic effects" and "Ethanol intoxication in children: Clinical features, evaluation, and management" and "Methanol and ethylene glycol poisoning: Pharmacology, clinical manifestations, and diagnosis" and "Isopropyl alcohol poisoning")

●Clonidine (see "Clonidine, xylazine, and related imidazoline poisoning")

●Opioids (see "Opioid intoxication in children and adolescents")

●Liquid nicotine

The safety and efficacy of cough and cold medications for young children are discussed separately. (See "The common cold in children: Management and prevention", section on 'Over-the-counter medications'.)

Multiple magnet ingestion also is discussed separately. (See "Foreign bodies of the esophagus and gastrointestinal tract in children", section on 'Magnets'.)

Site of management — The majority of poisoning cases in children can be managed safely at home after consultation with a poison control center specialist. Of the more than 2 million poisoning exposures reported to United States poison control centers in 2020, 69 percent were managed at a nonhealth care facility, which was usually the site of exposure, primarily the home of the patient [6]. Between 80 and 90 percent of cases in children <13 years were managed outside a health care facility. In contrast, 67 percent of cases in teenagers and 43 percent of cases in adults (≥20 years) required management in a medical facility.

Cost to society — Poisoning is a financial burden to society. Numerous studies have shown that poison control centers reduce health care spending [20]. Poison control centers provide a mechanism for safe management of most poisonings at home, expedite referral to a health care facility when necessary, decrease unnecessary emergency department visits, and reduce hospital length of stay for patients with poison exposure [21-27]. This is likely an underestimate of the benefits of poison control centers, in that studies rarely take into account decreased morbidity and mortality, reduction in caregiver anxiety, or caregiver time saved.

RISK FACTORS — Age and sex are factors to consider in evaluating a child or adolescent's risk for poisoning. In addition, developmental and environmental factors may contribute to the risk of a poisoning event.

Developmental factors — The normal developmental progression of young children, including exploration of their environment, places them at risk for poisoning [28].

●As children become mobile, they are able to maneuver through the home; they learn to open cabinets and to examine the contents

●As children begin to walk, they may be able to grab items that were previously out of reach (eg, on countertops)

●Improved fine motor skills enable toddlers to open simple screw-on caps or bottle tops

●Normal curiosity and desire for oral stimulation may cause children to place new objects directly into the mouth for tasting or swallowing

●Well-meaning preschoolers may try to "help" by using toxic cleaning products or by attempting to self-administer medication

Although they have the motor skills to ingest these substances and perhaps the social skills to desire to please, young children do not yet understand danger or the concept of poisoning. Preschool children, who typically understand the concept of danger and can understand and follow simple rules, may become victims of poisoning if left unsupervised. In addition, the impulsivity of some children puts them at even greater risk for poisoning.

Developmental issues and pressures also contribute to the increased risk of poisoning among adolescents. The goal of independence and the tendency to believe that they are indestructible may cause adolescents to take undue risks in experimenting with illicit drugs, other substances of abuse, or potentially dangerous fads (eg, the "cinnamon challenge") [29]. Peer pressure and desire to conform also contribute to this problem. In addition, teenagers (more commonly females than males) may take an overdose of medication as a suicide attempt or gesture [28,30]. This may be related to an acute personal crisis or a reflection of more chronic issues. (See "Suicidal behavior in children and adolescents: Epidemiology and risk factors".)

Environmental factors — Environmental factors also contribute to poisoning events [28]. Most homes contain numerous potentially toxic substances, particularly in the kitchen (eg, dishwasher detergent packets/pods), bathrooms, laundry room (eg, laundry detergent pods), and garage. Items used frequently, such as cleaning products, may be stored in low cabinets for easy access. Some products are so commonly used and seem so familiar that caregivers may not appreciate their toxicity. The risks of laundry and dishwasher detergent pods are discussed separately. (See "Caustic esophageal injury in children", section on 'Esophageal injury'.)

Products or medications that are used or taken frequently may be stored properly, but during use may be left momentarily within a child's reach (eg, medication organizers [31]). Child self-exposure accounted for 95 percent of visits to a health care facility for evaluation of exposure to a potentially toxic dose of a pharmaceutical agent reported to the American Association of Poison Control Centers between 2001 and 2008 [12].

Look-alikes also pose a problem for small children. Some medications look identical to candy. Similarly, some cleaning products may look like or be stored in containers that resemble those of food or juice. The availability of medications, drugs, or other substances of abuse at school or home may put vulnerable teenagers at further risk [28].

PREVENTION — Prevention strategies for poisonings, as for other types of injury, can be divided into primary (pre-event), secondary (event), and tertiary (post-event) prevention strategies. (See "Pediatric injury prevention: Epidemiology, history, and application", section on 'Principles of injury prevention and control'.)

The discussion below will focus on primary prevention. Secondary prevention strategies are mentioned briefly and discussed in detail separately. Tertiary prevention strategies depend upon the individual exposure and are discussed in the specific topic reviews.

Primary prevention — Primary prevention encompasses all of the activities that prevent a poisoning event from occurring. Activities such as legislation, product engineering, and educational efforts are included. Passive primary intervention strategies (eg, legislation that limits the number of baby aspirin tablets per container) are more effective than active intervention strategies (educating caregivers to keep baby aspirin out of the reach of children). (See "Pediatric injury prevention: Epidemiology, history, and application", section on 'Principles of injury prevention and control'.)

Legislation — In the United States, legislation and regulatory means were implemented to protect children, adolescents, and adults from toxic exposures beginning in 1906. Significant reductions in poisoning events and child deaths may be attributed to these regulations and legislation [32-35].

●In 1906, the Pure Food and Drug Act ("Wiley Act") created the Food, Drug, and Insecticide Administration, which became the US Food and Drug Administration (FDA) in 1930 [36]. This act required federal approval for foods and drugs meant for human consumption.

●In 1927, the Caustic Poison Act required labels to warn caregivers of the dangers of lye (used to make soap) and 10 other caustic substances.

●In 1951, the FDA defined and restricted certain medications to prescription status.

●In 1961, Public Law 87-319, which designates the third week of March each year as National Poison Prevention Week, was signed into effect [37]. National Poison Prevention Week provides national recognition of this serious health issue and entails widespread public education about poison prevention.

●In 1966, packaging of baby aspirin was regulated to limit the number of tablets (81 mg) per single container to 36 [36]. This occurred in response to the recognition that unintentional aspirin ingestion was a significant cause of morbidity and mortality in young children. Between 1960 and 1980, deaths from aspirin dropped from 144 to 12 [38].

●In 1970, the Poison Prevention Packaging Act (PPPA) required child-resistant packaging for certain types of opiates and other dangerous drugs, drain cleaners and oven cleaners, lighter fluid, turpentine, and a variety of solvents and other household products [39]. Child-resistant containers separate the child from the toxic product by imposing a physical barrier [40]. The physical barrier is not necessarily childproof but is designed to delay the child's ability to open the container long enough for an adult to discover the child before ingestion can occur.

The PPPA has been one of the most important achievements in poisoning prevention. Although the PPPA has been associated with decreased rates of toxic ingestions, including medications, in children [35,41-43], its effectiveness depends upon toxic substances being kept in their original containers. In a survey of 4496 adults who called poison control centers regarding ingestion of solid medication exposures among children <5 years of age, approximately one-third of all exposures and one-half of prescription medication exposures occurred after the medication was removed from child-resistant packaging (eg, transferred to another container, left out for someone else to take) [44]. The medication usually belonged to a parent (approximately 40 percent) or grandparent (approximately 30 percent). These observations underscore the importance of anticipatory guidance in addition to child-resistant packaging to prevent toxic exposures in young children. (See 'Anticipatory guidance' below.)

●In 1997, the FDA passed a regulation requiring unit-dose packaging for iron-containing products with >30 mg of iron per unit dose, but this regulation was withdrawn in 2003 [36,45]. In the five years after introduction, there was a decrease in the number of calls to poison centers regarding iron ingestion in children younger than six years and a decrease in the number of deaths due to iron poisoning compared with the 10 years before [46]. Unit-dose packaging has also been associated with decreased pediatric ingestions of buprenorphine-naloxone [47,48]. (See "Acute iron poisoning".)

●In 2008, the FDA recommended that over-the-counter cough and cold medications not be used in children younger than two years, and the Consumer Healthcare Products Association issued warnings about the use of these medications in children younger than four years [49]. Ingestions of these products among young children declined after the labels were revised to warn against use in children younger than four years [10,11].

●In 2011, the FDA issued guidance to improve the consistency between dosing instructions and dosing devices for orally ingested liquid over-the-counter medications, as well as the clarity of the markings on dosing devices [50].

●In 2016, the Child Nicotine Poisoning Prevention Act of 2015 became law. This requires child resistant packaging for liquid nicotine used with electronic cigarettes. Liquid nicotine products are now subject to the same packaging standards that were put in place by the 1970 Poison Prevention Packaging Act [39].

Product engineering — In addition to child-resistant containers and unit-dose packaging, other products have been engineered to prevent poisoning events. These include:

●Storage and locking devices designed to prevent access of children to toxic materials. Examples include boxes that permit easy access for adults but prevent access by children (eg, a tackle or tool box with an external latch and lock), devices that secure cabinet doors, and door locks [28].

●The use of flow restrictors for bottles of liquid medication. In a small randomized trial, adding flow restrictors to open or incompletely closed bottles of test liquid decreased the proportion of preschool children who accessed the test liquid, decreased the amount of test liquid removed from the bottle, and increased the amount of time it took to empty the bottle [51].

●The addition of bittering agents to make dangerous substances unpalatable, potentially reducing the amount of substance that is ingested or forcing it to be expelled [52-54]. Although this would seem to be an effective poison prevention strategy, the ability of bittering agents to reduce the incidence or severity of childhood poisoning is unproven [55,56].

●Changing the packaging of toxic substances to reduce unintentional exposures, such as the voluntary safety standards for single-use liquid laundry detergent packets requiring them to be opaque (or otherwise mask the visibility of the packet), be labeled with a warning statement, and be more difficult to open by children [57,58].

●The use of poison warning labels or stickers that may alert adults and older children to the toxic hazard of various substances. However, they do not deter young children from playing with medication containers, nor do they reduce the rate of poisoning [59,60].

●Due to the increase in fatalities related to ingestion of button batteries, some researchers have called for product manufacturers to 1) secure the battery compartment of household products that use button batteries so that children cannot remove the battery and the battery will not be released if the product is dropped, 2) develop child-resistant, unit-of-use battery packaging, and 3) provide warnings on products and battery packaging to inform consumers that ingestion of button batteries can cause serious injury or death [61]. (See "Button and cylindrical battery ingestion: Clinical features, diagnosis, and initial management", section on 'Prevention'.)

Education — Primary prevention also includes educational efforts targeted toward avoidance of poisoning exposure. As an example, clinicians should consider the risk of poisoning when they prescribe medications and use less toxic therapies when appropriate. Particular precautions should be taken with medications that are commonly involved in fatal ingestions and those that are toxic in small doses (table 2). Other educational efforts may involve community outreach projects, mass media campaigns, or education in a clinical setting. Emergency department visits for poisoning provide another important opportunity for preventive education; unfortunately, this opportunity is often missed [62].

Educational efforts have been shown to change safety-related knowledge and behavior (eg, displaying the poison control telephone number) [63-68]. However, direct evidence that educational counseling results in lower injury rates is lacking [52,68].

Liquid medications — Dosing errors and incorrect use of devices used to deliver liquid medications may result in unintentional pediatric poisonings [69-73]. In 2015, the American Academy of Pediatrics (AAP) Committee on Drugs issued a policy statement regarding dosing of orally administered liquid medications for children [74]. The policy statement recommends:

●Exclusive use of metric dosing for liquid medications, which should be dosed to the nearest 0.1, 0.5, or 1 mL, as appropriate

●Inclusion of the concentration of all liquid medications on the prescription so that the appropriate dose can be calculated

●That clinicians review the milliliter-based doses with caregivers at the time of prescription

●That clinicians and/or pharmacies provide a milliliter-based dosing device that is of an appropriate volume (ie, that would avoid a twofold dosing error)

Anticipatory guidance — Periodic anticipatory guidance for poisoning prevention is recommended by the AAP [28,46,75] and the United States Preventive Services Task Force (USPSTF) [52]. In addition, the USPSTF recommends against the use of poison-warning stickers that are intended to deter children from playing with containers of medicine and other poisons [52]. These stickers neither deter young children from playing with medication containers nor reduce the rate of poisoning [59,60].

Anticipatory guidance for poisoning prevention should begin near the six-month visit and continue throughout childhood [28]. Caregivers should be encouraged to survey the home periodically to evaluate all injury hazards, not just those related to poisoning (table 3) [28]. In each room, caregivers should consider whether toxic or poisonous substances are necessary; those that are deemed necessary should be safely stored, and those that are not should be appropriately discarded. Homes that the child visits, especially grandparents' homes, also should be surveyed by the caregivers at the time the child arrives for a visit. Grandparents' pill organizers are a particular hazard and should be kept out of the child's reach [44,76].

Caregivers should be encouraged to buy the least toxic product that will accomplish the desired task. Toxic products should be purchased in small quantities and disposed of when they are no longer needed. Home use of certain products with high or irreversible toxicity (eg, crystal drain cleaner) should be avoided [28].

The universal poison control telephone number for the United States (1-800-222-1222) should be posted near the phone or entered as a contact in cellular phones. The poison control center should be the first source of information about poisons in an emergency [75].

Clinicians should provide seasonally and geographically appropriate information when indicated. Examples include the risk of carbon monoxide poisoning in cold areas during the winter and the risk of insect repellents in temperate climates or during the temperate season.

Specific "safety rules" for caregivers from Healthy Children webpage of the AAP include the following [77,78]:

●Keep harmful products locked up and out of children's sight and reach.

●Use safety latches or locks on drawers and cabinets where you keep dangerous items.

●Take extra care during stressful times (when you may be distracted).

●Call medicine by its correct name. You do not want to confuse the child by calling medicine "candy."

●Always replace the safety caps immediately after product use.

●Never leave containers of alcohol or electronic cigarettes/nicotine refill cartridges within a child's reach.

●Keep products and medications in their original containers. Never put nonfood products in food or drink containers. Be particularly careful with colorfully packaged products (eg, laundry detergent pods) that may look like candy to children. (See "Caustic esophageal injury in children", section on 'Esophageal injury'.)

●Read labels with care before using any product.

●Teach children not to drink or eat anything unless it is given to them by an adult.

●Do not take medicine in view of small children. Children tend to copy adult behavior.

●Check your home often for old medications and get rid of them; the FDA provides guidelines for drug disposal.

●Get rid of substances used for old-fashioned treatments such as oil of wintergreen, boric acid, ammoniated mercury, oil of turpentine, and camphorated oil.

●Remember that there is more danger of poisoning when a child is away from home, especially at a grandparent's home. (See 'Risk and type of exposure' above.)

Prevention of button battery ingestion is discussed separately. (See "Button and cylindrical battery ingestion: Clinical features, diagnosis, and initial management", section on 'Prevention'.)

Additional resources related to poisoning prevention include:

●American Association of Poison Control Centers (AAPCC)

●Center for Disease Control and Prevention's Medication Safety Program

●Kids Health from Nemours' Household Safety: Preventing poisoning

●Safe Kids Worldwide's Poison prevention tips

Secondary prevention — Secondary prevention involves interventions that prevent injury or illness once a poisoning exposure has occurred. Examples of secondary prevention strategies include the development of poison control centers and various methods of decontamination.

Poison centers — As of 2020, there are 55 poison control centers in the United States [6]. These centers serve the 50 states, District of Columbia, Puerto Rico, the Federated States of Micronesia, American Samoa, Guam, and the United States Virgin Islands. Poison control centers provide 24-hour poison information, telephone management, advice, and consultation about toxic exposures. They also provide professional and public education on poison prevention, diagnosis, and treatment.

Poison control centers provide information on a wide variety of potential exposures including chemicals, medications, herbs, plants, and even snake and spider bites. Consultation with the local poison control center should be the first action for the caregiver of a child who may have ingested a toxic substance [75]. The national toll-free number for poison control centers is 1-800-222-1222. More information about poison control centers can be obtained by visiting the AAPCC's website at www.aapcc.org [79]. In addition, the AAPCC operates an online poison exposure triage tool that is designed for use by individuals who may not be comfortable calling the Poison Control Center for treatment advice.

Education — In order for poison control centers to be helpful as secondary prevention strategies, it is crucial that parents and other caregivers know about poison centers, the services that poison centers provide, and the circumstances under which the poison center should be called.

In one report, 210 caregivers of children evaluated for unintentional poisoning in an emergency center were interviewed [80]. Only 46 percent had contacted the poison center before the emergency department visit. In this study, those who did not utilize the services of the poison center were more likely to be Black residents (adjusted odds ratio [OR] 2.7, 95% CI 1.2-5.8) and caregivers educated outside the United States (adjusted OR 8.2, 95% CI 1.7-38.4). Similar results were reported in a retrospective review comparing sociodemographic characteristics between counties with high and low utilization of regional poison control centers [81].

Reasons accounting for these differences include lack of knowledge about the poison center, as well as perceived barriers and misconceptions about poison centers, such as uncertainty about poison center staff qualifications, fear of being reported for neglect, and fear of inability to carry out recommendations made by poison center staff [82]. Educational programs designed to increase caregiver use of poison centers, especially among underrepresented groups, have had promising results [66,83,84].

Decontamination — Decontamination is another method of modulating poisoning injury after poisoning exposure has occurred. Various methods of decontamination in children, including syrup of ipecac and activated charcoal, are discussed in detail separately. (See "Gastrointestinal decontamination of the poisoned patient".)

Tertiary prevention — Tertiary prevention involves interventions that minimize injury or toxic effects once symptoms have appeared. Examples of tertiary prevention strategies include emergency medical services, inpatient care, and the administration of antidotes. Tertiary prevention strategies, particularly the administration of antidotes, vary depending upon the particular exposure (eg, N-acetylcysteine for acetaminophen exposure). These strategies are discussed in individual topic reviews. As examples:

●Acetaminophen poisoning (see "Acetaminophen (paracetamol) poisoning: Management in adults and children")

●Salicylate poisoning (see "Salicylate (aspirin) poisoning: Clinical manifestations and evaluation", section on 'Pediatrics')

●Iron poisoning (see "Acute iron poisoning")

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Poisoning prevention".)

SUMMARY AND RECOMMENDATIONS

●Poisoning, like other injuries, is a predictable and preventable event. Prevention strategies include legislation, product engineering, and education. Of these, education is most relevant to the pediatric health care provider. (See 'Prevention' above.)

●When less toxic alternatives are available, clinicians should avoid prescribing medications that are commonly involved in fatal ingestions or are toxic in small doses (table 2). (See 'Education' above.)

●Anticipatory guidance for poisoning prevention should begin near the six-month visit and continue throughout childhood. Important components of anticipatory guidance include (see 'Anticipatory guidance' above):

•Encouraging caregivers to survey the home periodically to identify and remove potential poisoning hazards (table 3). Homes that the child visits also should be surveyed for poisoning hazards.

•Encouraging caregivers to avoid home use of products with high or irreversible toxicity; toxic products should be purchased in small quantities and disposed of when no longer needed.

•Provision of the universal poison control telephone number for the United States (1-800-222-1222) and encouraging caregivers to post the number near the phone or enter the phone number into their cellular phone; the poison control center is the best source of information about poisons in an emergency.