Uncommonly common poisonings in children

Pediatrics for Parents, Sept, 1997 by John E. Monaco

Occasionally a frighteningly unarousable child is brought into the emergency department and the challenge is to determine the cause for this stuporous state. Recently, I had two such cases, one of which resulted in the need for mechanical ventilation because of severe respiratory depression.

The first case involved a three year old boy who was brought in by his grandfather with the chief complaint that he was asleep and could not be awakened. The child had stable vital signs but very shallow respirations. He was, as described, deeply somnolent and not even arousable to painful stimulation.

In the fury to determine his diagnosis, a blood sugar was checked and found to be zero. In an otherwise very healthy child, this was highly unusual, but easily treatable. In fact, after an IV bolus of glucose solution the child rapidly awakened and acted as if nothing whatever was wrong.

After the dust settled, and it was clear that the child would survive, a more detailed history revealed the diagnosis behind this child's profound and potentially life threatening hypoglycemia (low blood suger). It seemed that his grandfather had an affinity for Jack Daniels mixed with Coke and a tumbler full of the solution had been left on the kitchen table. The inquisitive three year old, wishing to emulate his grandfather, sampled the concoction, leading to hypoglycemia.

Children, it turns out, are highly susceptible to the glucose lowering effects of alcohol, much more so than adults, and with potentially much more serious consequences. Another common scenario for alcohol toxicity in children involves the slightly older child who empties all the glasses following parents' cocktail party.

Therefore, besides the obvious reasons for children to avoid alcohol, here is an immediate, very dangerous consequence of alcohol ingestion that is often not known by parents and caregivers.

The other recent example of serious toxicity involves the presumed innocent use of cough suppressants in children. Parents, with only the best intentions, will sometimes stop at nothing to abolish the symptoms of cough or fever. The loss of objectivity that results from watching our children "act sick" without considering the causes and consequences of treatment can sometimes have disastrous results.

This child, also three, came to the ER in full respiratory arrest. She had an acceptable heart rate and blood pressure but was unable to breathe without mechanical support and she, too, was completely unresponsive to painful stimuli.

A history from the mother, obtained earlier in the course of therapy, revealed that she had been administering to the child frequent and rather large doses of cough medicine containing codeine. What she didn't realize was that codeine is a narcotic, meaning it is in the morphine family. In large doses, respiratory arrest can result. Luckily, narcotics are easily reversible by the competitive inhibitor naloxone, therefore it is one of the few poisons with a true "antedote." We administered naloxone to the child and she, almost immediately, sat up in bed, pulled out her endotracheal tube and, quite wide eyed and alert, asked, "Where's my mom?"

Both of these cases represent rapid diagnoses of common but not universally known causes of poisoning in children that, thankfully, are easily treatable. In both cases, without an accurate history and timely intervention, the results could have been disastrous. Although rapid cures are always dramatic, prevention is still a much better bet!

John E. Monaco, M.D., is board certified in both Pediatrics and Pediatric Critical Care. He lives and works in Tampa, Florida. His column appears monthly in Pediatrics for Parents. He welcomes your comments, suggestions, and criticisms.