B-QuiCK: Childhood poisonings

Paediatric household poisonings: B-QuiCK

Assessment

After confirming that the child’s airways, breathing and circulation are stable, initial considerations include:

• The substance
  • Solid, liquid or gas (modified or slow-release formulations if the exposure involved medicines)
  • Amount/duration of exposure – consider maximum possible exposure if the exact quantity is unknown
  • Container characteristics – can aid with estimating quantity ingested
  • Concentration and overall toxicity of substance
  • Route of exposure (may be multiple routes, e.g. ingestion and dermal)
  • Time of exposure – if unknown, assume the earliest possible time the exposure could have occurred
  • Container labels – ask caregivers to take pictures of the labels front and back; this information may also be able to be found online
• The child
  • Their current clinical condition – does it fit with the alleged substance ingested and the timeline provided?
  • Age and weight – may be required for weight-based toxicity calculations
  • Co-morbidities that could compromise treatment or the child’s ability to tolerate or recover from the exposure
  • Monitoring and recovery – can this child be managed at home, and can the caregivers seek further care if required?
• Medical centre
  • Facilities and staff – appropriate resources and training to manage worst-case scenarios
  • Distance/time to a major regional hospital with appropriate emergency and intensive care facilities – transport options available

Management

N.B. The following is general advice for managing exposures to common household hazards. Refer to the main article for specific examples of hazards and their management.

• Ingestions
  • Toiletries, hand dishwashing liquid and glow stick contents are not expected to cause more than mild gastrointestinal upset, e.g. nausea, vomiting or diarrhoea
  • Parents/caregivers should be advised to rinse the child’s mouth, but withhold food and fluid for a short time
  • Close monitoring at home by a reliable observer is appropriate
  • Referral to the emergency department would only be required in rare cases where the child was at risk of dehydration from severe gastrointestinal upset or if they develop symptoms of aspiration, e.g. persistent cough, stridor, dyspnoea
  • Although most household exposures are benign, primary care clinicians should be aware of substances that can cause significant toxicity with very small doses/volumes (Table 1). Children who have ingested these substances have the potential to become severely unwell and will likely require immediate referral for assessment and monitoring in the emergency department.

• Dermal exposures
  • Most household products are unlikely to result in significant injury (exception: oven cleaners)
  • Affected areas of skin should be flushed with large amounts of water
  • Children with mild, localised erythema and pruritus can be monitored at home
  • Children who have ongoing pain after decontamination, blistering or persistent irritation should be medically assessed
  • Management for chemical burns, e.g. from oven cleaners, follows the same process as for thermal burns
• Ocular exposures
  • Toiletries, personal cosmetic products, dishwashing liquid and glow stick contents unlikely to cause more than mild irritation
  • Household grade bleaches and dishwasher powder and tablets have the potential to cause corrosive damage
  • Flush the affected eye(s) with running water for up to 15 minutes, e.g. under the shower, over the sink with a jug/bottle or from a garden hose
  • Following decontamination, caregivers should monitor the condition of the child’s eye(s)
  • Erythema will likely settle in one to two hours. If this persists, the child appears bothered by the eye, e.g. constantly rubbing, watery eyes, difficulty calming infants or non-verbal children, or there is evidence of vision disturbance, the child should be medically assessed
  • Exposures involving alkali products, e.g. household bleaches and dishwasher powders require medical assessment, even if the child is asymptomatic after decontamination.

Caregiver advice

If children can be monitored at home, advice for the caregiver should include:

• A specific time period for monitoring the child
• Instructions to not induce vomiting if the child has ingested a substance; corrosive products can cause further damage moving back up the oesophagus and in some cases aspiration of the product may be more harmful than simple ingestion
• A discussion on whether to give food and fluid following exposure
  • o Giving children large volumes of fluid immediately following an ingestion to ‘dilute the poison’ is not recommended
• A discussion regarding sleeping during the monitoring period; it is usually appropriate for the child to sleep/nap as per their normal schedule, but caregivers should regularly check if the child responds to cues, e.g. stirs when gently touched
• A management plan for minor (expected) symptoms that do not require medical attention
• A timeline for the development of concerning symptoms and where to seek further medical attention, e.g. the emergency department
• Symptoms that would warrant calling an ambulance
• When medicines can be re-initiated (if relevant)
• Instructions to phone the NPC if further information is required