This week the DFTB team have been invited to run a conference within a conference in Sydney. Resus @ the Harbour is a multidisciplinary resuscitation conference combining powerful patient stories with cutting edge care – just the sort of thing we love at DFTB.
This week the DFTB team have been invited to run a conference within a conference in Sydney. Resus @ the Harbour is a multidisciplinary resuscitation conference combining powerful patient stories with cutting edge care – just the sort of thing we love at DFTB.
A 6-month-old male is brought to ED by his mother with multiple episodes of profuse vomiting after eating lunch. No diarrhoea, fevers or unwell contacts. He is usually a well child and had a normal neonatal period.
He is immunised and otherwise thriving from a growth and developmental perspective. The mother, a nurse, reports that the infant was mottled, pale and lethargic at home but began to pick up whilst being triaged in ED.
When people approach me to ask about writing for DFTB I usually suggest that they write about what they know. That is certainly my approach and why I started to write the Normal Neonate series a year ago. The littlest Tagg has just had her year’s check up with the maternal and child health nurse. She thought that tiny Tagg had uneven buttock creases and wanted her assessed for DDH. But how sensitive is this sign?
Mary had a little taste…
Common non-toxic exposures (and what to expect)
As clinicians, we will occasionally come across someone with a case of Toxicophobia – the fear of being poisoned. In paediatrics, this usually presents in the parents of a little one who has explored their way into something they shouldn’t have. Whilst developmentally normal, it can be hard to tell what to be worried about (and given the last post, there are definitely things to be worried about!). It may seem that something will surely happen (you can blame television for that feeling), but in many cases, a patient is going to be just fine.
Before looking further into the various substances that can cause problems for our young patients, I thought it would be interesting and a bit of fun to talk about some of the non-toxic exposures the Poison Information Centre receives calls about – sometimes on a daily basis. In the instances where patients and their parents find themselves in front of you, it’s useful to know a little about what you needn’t worry about. Or in some cases, only worry about a little…
Topical antiseptics and hand sanitisers
With all this talk about hand hygiene and killing germs, it’s not surprising that someone would worry about someone getting into one of these.
From a Toxicology perspective, there are two ingredients in these products that can be problematic – the first are quaternary ammonium compounds. A prime example is benzalkonium chloride, found in products such as Dettol. The concentrations for most household products are low (less than 7.5%) and likely to cause GI irritation at best with perhaps a vomit and some diarrhoea so supportive treatment will suffice.
Not surprisingly, deliberate overdoses can be clinically more significant with sequelae including corrosive injury, hypotension, renal injury and aspiration. Hand sanitisers containing alcohol, typically ethanol, and can cause intoxication if a large amount is ingested. In scenarios, where a child has had a taste, lick or swallow, significant toxicity is very unlikely
In the end, Paracelsus still holds true – the dose makes the poison and in the vast majority of these cases, it will not be a problem.
Silica gel packets
Containing sodium silicate to prevent excess moisture build-up and food spoilage, these little white packets are everywhere you look in the pantry. It is not surprising people get worried when they read the warning ‘DO NOT EAT’ all over the packet. Fortunately, silica is non-toxic however; it can be a choking hazard so a medical assessment is recommended if there are any signs suggestive of inhalation (e.g. cough, wheeze).
Dish-washing detergents
Dishwashing detergents contain soaps to help get rid of dirt and grease but luckily not people. Like other household products, they only cause mild GI upset, a ‘scratchy’ throat and aspiration if vomiting occurs.
Toilet bowl cleaners
The usual suspects are the toilet discs (see below). Given their job is to help clean yucky organic matter from the inside of a toilet; these are rather pretty in appearance.
As a parent, I do not know what would horrify me more – my child putting his finger into a disc or into the toilet! Maybe the latter…
These discs contain detergent and perfume but the method of exposure is usually a ‘finger dip’ so minimal exposure occurs. If anything, mild GI upset may occur with a larger ingestion. Important advice for parents is that the next poo might be a more psychedelic colour than usual.
Glow sticks
I suspect the majority of calls come around New Year’s or Moomba (if you live in Melbourne). Glow sticks glow thanks to an ester called cyalume, which luminesces when mixed with hydrogen peroxide. Some products have a plastic casing that contains an inner glass capsule that when broken allows the cyalume (in the glass capsule) to mix with the hydrogen peroxide (surrounding the capsule). An accidental chew will lead to a bitter taste, a dry mouth and perhaps a vomit with some nausea, but not much else.
Creams and Lotions
Whilst they keep your skin looking healthy and young, eating these will not do much to your insides apart from a GI upset. Some of these contain small amounts of ethanol but normally not enough to cause clinically significant toxicity.
Perfumes, colognes and after-shaves
Similar to creams and lotions, these products are often in reach of little hands. Little people often do not drink much, if any, due to their strong odour and taste. Small ingestions are irritant in nature but larger ingestions can result in ethanol intoxication. However a lot of these products can be 60-80% ethanol and given the taste, it would be a very rare event for a child to swallow enough to become intoxicated.
As these are volatile products, off gassing of fumes can occur and causes a chemical pneumonitis in larger ingestions but the taste and smell of these is such that this is a rare occurrence.
Pens/Ink
Suddenly I find myself back in high school, swinging from my chair in the back row whilst chatting with friends. The typical patient is a young teenager sucking on a pen. The anticipated adverse effects include discoloration of the tongue, faeces and clothing often with a sense of embarrassment but nothing more.
Bubbles
Whilst we ask you not to forget about the bubbles, I’m happy to add ‘Don’t worry about the bubbles’. These often contain a soap or mild detergent to produce these clear spheres of pure delight so a drink from a container will result only in GI upset and perhaps some irritation if other parts of the body make contact (e.g. eyes). Not to be confused with the champagne variety.
Don’t forget to check out the other posts in this series…
Special thanks to Jeff Robinson for his review and input
Hammond, K., Graybill, T., Spiess, S. E., Lu, J., & Leikin, J. B. (2009). A complicated hospitalization following dilute ammonium chloride ingestion. Journal of Medical Toxicology, 5(4), 218–222. https://doi.org/10.1007/BF03178271 Joseph, M. M., Zeretzke, C., Reader, S., & Sollee, D. R. (2011). Acute ethanol poisoning in a 6-year-old girl following ingestion of alcohol-based hand sanitizer at school. World Journal of Emergency Medicine, 2(3), 232–233. https://doi.org/10.5847/wjem.j.1920-8642.2011.03.014References
Disclaimer: The information published in this post is for medical education only and does not constitute formal Toxicology advice. The information is current at the time of writing and may change with emerging evidence over time. If you have concerns about an individual who may be poisoned, please call your local Poisons Information Centre (13 11 26 for Australia).
A nine year old girl, Skye, comes to see you with her parents. She has a two day history of a red, circular and enlarging rash on her right calf, which they describe as looking like a ‘bull’s eye’. She has also been feeling generally unwell with headaches, muscle aches, fatigue and a fever. They tell you in passing that they came back from holiday, in Scotland, a week ago.
And so we come to the final talk of the final day of DFTB17 in Brisbane.
You can check out any of our other conference talks on our YouTube channel.
This talk was recorded live on the final day of DFTB17 in Brisbane. If you missed out on our first conference then check out our YouTube channel.
You’ve just seen a young lady who managed to swallow a tablet out of Grandma’s handbag, whilst she was over for a visit. Luckily, it was a 20 mg esomeprazole tablet so she’s going to be ok. You go in and reassure her worried family that nothing further will occur. Feeling your job is done, you turn to leave but then her mother asks you ‘How can we prevent this happening in future?’.
What would you say?
Recently JAMA Pediatrics featured an article from their ‘On My Mind‘ section by parent caregivers of children with chronic, complex medical conditions. The authors Angela Carosella, Alexis Snyder and Erin Ward worked with researches to survey and distill many of the challenges of being parents within the health care system. They suggest 10 ways that health care professionals might help parents caring with children with complex needs.
We thought these ideas were important to carry around with us in our day to day practice so we’ve summarised their key points into a A4 infographic poster ’10 Thinks’ below. We recommend you can also check out the original message and research here with their survey report here.
Bacterial co-infection
Andrew Tagg. Bacterial co-infection, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.16783
Often we are asked to look at a febrile infant with what appears to be a viral illness. But could there be something else going on? If you believe in Occam’s Razor or the law of parsimony then you might think the simplest solution, the obvious viral illness, is the cause of the fever. But what about Hickam’s Dictum – the patient can have as many diseases as they please?