Poisoning in the first 2 years of life makes up 4 % of all cases consulted at the bedside by medical toxicologists participating in the ToxIC registry. Our data demonstrate that, contrary to expectations based from AAPCC data, cardiovascular and psychotropic medications were the drug classes responsible for a significant proportion of poisonings.
The capturing of infant and toddler poisoning cases is especially important for several reasons. These children are vulnerable and helpless in protecting themselves from accidental or intentional environmental hazards, as well as communicating the events leading to injury. About 13 % of our patients were exposed to recreational drugs, alcohols, or controlled narcotic drugs. These data raise the concern of neglect, unsafe environment and child maltreatment. This is most relevant in first-year-of-life exposures, where purposeful motor and coordination skills required to access drugs are largely limited. In malicious pediatric poisonings, an age of less than 2 years is associated with life threatening symptoms, residual disability, and increased risk of death [5
]. Such cases are unlikely to be voluntarily reported to PCCs by caregivers, and clinicians should have high index of suspicion for non-accidental poisonings when confronted with these scenarios. Thus, toxico-surveillance systems, such as the ToxIC registry, can play a potential role in identifying these cases as well as other exposure trends. Similar to our findings, a recent study suggested that the majority (>80 %) of infant poisonings that attended the ED were classified as “toxic”, having a significant potential for an adverse effect. Only a small proportion (19 %) of exposure cases presenting to the ED was reported to the regional PCC [6
At the same time, capturing infant poisonings may be challenging. Epidemiological estimates from both the AAPCC data and from nationwide ED records via the National Electronic Injury Surveillance System–All Injury Program (NEISS–AIPO) are both believed to significantly underestimate the true magnitude of the problem [7
]. In that respect, the ToxIC and AAPCC registries complement each other, providing an effective, real-time toxico-surveillance coverage in the United States. However, they differ in several aspects. First, AAPCC data rely on voluntary self-reporting. In children less than 5 years of age, there is an estimated sevenfold under-reporting of poison-related fatalities to PCCs and an even higher under-estimation of non-fatal cases [5
]. Guardians of poisoned infants that attend the ED are not likely to have previously contacted a PCC [6
]. The ToxIC case registry addresses that gap by documenting all inadvertent exposure presenting to participating sites and requiring bedside consultation.
Second, there are major differences between the type of exposures reported to AAPCC and those captured by the ToxIC Case Registry (Table ). In the APPCC database, the most common possible exposures for children younger than 5 years are to household items, such as cosmetics and personal care (13 %), cleaning products (9.3 %), and foreign bodies/toys (7 %), and the majority were managed at home without referral to a healthcare facility [2
]. The most common category of pharmaceutical exposure was analgesics (9.7 %) and only a small percentage was related to prescription psychotropic medications (2.3 %; Table ). Many of the AAPCC cases are reported as “possible” exposures, where ingestions were not witnessed by the infant’s guardian and have no analytical confirmation, and about 90 % are perceived mild enough to be managed at home [2
]. In contrast, ToxIC registry patients typically represent serious exposures, where front-line clinicians feel the greatest concern and request toxicology expertise. The ToxIC data show a profile of poisonings dominated by classes of medications and compounds associated with potentially high morbidity. Our findings are corroborated by a recent study in children younger than 6 years, which investigated exposures to a single pharmaceutical agent. The authors found that exposure to prescription medications is on the rise, and concluded that prevention efforts to date are inadequate [3
In recent years, awareness to the risks of poison or chemical exposure and bioterrorism has increased, and a number of highly publicized terrorist events have heightened community fears. This has led to the establishment of several mechanisms for population surveillance outside the US, such as the Alerting and Surveillance Using Poisons Information Systems [11
] as well as other medical informatics platforms [12
]. Recent attempts to explore patterns and magnitude of consequential pediatric poisonings have also been made outside North America: the Spanish Society of Paediatric Emergencies reported 91 poisonings in children younger than 5 years over 1 year through their Toxicology Surveillance System–Intoxications Working Group [13
]. Of the 91 cases, 70 % were exposed to acetaminophen or cough and cold medications. Another recent retrospective study from Istanbul, Turkey reported on 330 poisoning hospitalizations in children up to 14 years [14
]. The majority of exposures were to pharmaceutical agents (76 %). Of the 330 cases, 29 (9 %) were below 1 year of age, and all the latter were considered accidental. Of the 28 infants that had available data, 16 were exposed to pharmaceutical agents.
The main limitation of the study stems from the fact that the ToxIC registry is a sentinel system in mostly academic tertiary care institutions and, therefore, may not be representative of the experience and practice in primary healthcare facilities. However, its strength is that it is intended to describe confirmed, clinically significant and important poisonings. In summary, using a novel toxico-surveillance tool, we identified substances that produce significant poisoning morbidity and mortality in infants and toddlers. The often-cited established toxico-surveillance [2
] system describes potential rather than actual poisonings. These findings raise, once again, the issue of infant access to medications and the need to establish a safer environment, both on the personal level (e.g., open containers left at hand-reach) as well as the role of industry and regulatory agencies in ensuring patient safety by targeted efforts (e.g., child-resistant packaging). There may be a need for specific interventions targeted at the high-risk medications, for example, blister or other types of unit dose packaging. Clinicians should maintain high index of suspicion to the possibility of unusual exposures in infants and toddlers, such as illicit drugs and alcohol.