Accidental pharmacological poisonings in young

Clinical Toxicology
ISSN: 1556-3650 (Print) 1556-9519 (Online) Journal homepage: http://www.tandfonline.com/loi/ictx20
Accidental pharmacological poisonings in young
children: population-based study in three settings
Jane C. Bell, Jason P. Bentley, Catriona Downie, Rose Cairns, Nicholas A.
Buckley, Annette Katelaris, Sallie-Anne Pearson & Natasha Nassar
To cite this article: Jane C. Bell, Jason P. Bentley, Catriona Downie, Rose Cairns, Nicholas
A. Buckley, Annette Katelaris, Sallie-Anne Pearson & Natasha Nassar (2018): Accidental
pharmacological poisonings in young children: population-based study in three settings, Clinical
Toxicology, DOI: 10.1080/15563650.2017.1422509
To link to this article: https://doi.org/10.1080/15563650.2017.1422509
View supplementary material
Published online: 15 Jan 2018.
Submit your article to this journal
Article views: 102
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at
http://www.tandfonline.com/action/journalInformation?journalCode=ictx20
CLINICAL TOXICOLOGY, 2018
https://doi.org/10.1080/15563650.2017.1422509
POISON CENTRE RESEARCH
Accidental pharmacological poisonings in young children: population-based
study in three settings
Jane C. Bella , Jason P. Bentleya , Catriona Downieb, Rose Cairnsc,d
Annette Katelarisd , Sallie-Anne Pearsona,d,e
and Natasha Nassara
, Nicholas A. Buckleyd
,
a
Menzies Centre for Health Policy, School of Public Health, University of Sydney, Sydney, Australia; bSydney Hospital and Sydney Eye
Hospital, Sydney, Australia; cNew South Wales Poisons Information Centre, The Children's Hospital at Westmead, Sydney, Australia;
d
Sydney Medical School, University of Sydney, Sydney, Australia; eMedicines Policy Research Unit, Centre for Big Data Research in Health,
University of New South Wales, Sydney, Australia
ABSTRACT
ARTICLE HISTORY
Introduction: Pharmacological poisonings in young children are avoidable. Previous studies report calls
to poisons centres, presentations to emergency departments (ED) or hospital admissions. There are limited data assessing concurrent management of poisonings across all three settings. We aimed to
describe accidental pharmacological poisonings in young children across our Poisons Information
Centre (PIC), EDs and hospitals.
Methods: A population-based study in New South Wales, Australia, of PIC calls, ED presentations and
hospital admissions for accidental pharmacological poisoning in children aged <5 years, 2007–2013.
We examined trends, medicines responsible and subsequent management. Medicines were coded
using ICD10-AM diagnosis codes (T36-50).
Results: Over 2007–2013, pharmacological poisonings accounted for 67,816 PIC calls, 7739 ED presentations and 2082 admissions. Rates (per 10,000 children) of PIC calls declined from 220 to 178; ED presentations were stable (22–24), with a decrease in emergency cases offset by an increase in semi- or
non-urgent presentations; hospital admissions declined (8–5). Most PIC calls related to “non-opioid
analgesics” (25%), and “topical agents” (18%). Nearly every day, one child aged <5 years was admitted
to hospital for poisoning. “Benzodiazepines”, “other and unspecified antidepressants”, “uncategorised
antihypertensives”, and “4-aminophenol derivatives” accounted for over one-third of all admissions.
Most PIC calls (90%) were advised to stay home, 6% referred to hospital. One-quarter of ED presentations resulted in admission.
Conclusions: Poisonings reported to PIC and hospitals declined, however, non-urgent ED presentations
increased. Strategies to reduce therapeutic errors and access to medicines, and education campaigns
to improve Poisons Centre call rates to prevent unnecessary ED presentations are needed.
Received 29 August 2017
Revised 18 December 2017
Accepted 22 December 2017
Published online 13 January
2018
Introduction
Pharmacological poisoning in young children remains a common [1–3], sometimes fatal [4,5], yet preventable injury.
Reports of poisoning prevalence and trends, and medicines
responsible are usually based on single data sources, such as
poisons centres [6–10] or emergency department (ED) presentations [2,11–17], or both [1,18,19]. Findings from these
two settings are dependent on population access and utilization and therefore subject to under-reporting, and differential
reporting by medicine type, making changes over time difficult to interpret. In contrast, population-based hospitalization
data [20–23] comprise all severe poisonings requiring inpatient treatment. Therefore, while less subject to reporting
bias, these data do not reflect all community poisoning
exposures.
We aimed to describe the burden of accidental pharmacological poisonings in young children, and the most common
medicines implicated, using population-based data from
KEYWORDS
Poisons centers; children;
pharmacological poisonings
three state-based health services in Australia managing
poisonings.
Methods
We conducted a population-based study to evaluate accidental pharmacological poisonings occurring in children
aged <5 years, in New South Wales (NSW) Australia over
the period 2007–2013. NSW is the most populous state in
Australia, comprising around 8 million people, one-third of
the national population [24]. We ascertained pharmacological poisonings from three independent data sources:
the NSW Poisons Information Centre (PIC), presentations to
NSW hospital EDs and admissions to NSW hospitals. If children accessed more than one of these health settings,
they were included in analyses for each health setting as
individuals could not be linked across the three data
sources.
CONTACT Jane C. Bell
jane.bell@sydney.edu.au
Menzies Centre for Health Policy, Level 2, Charles Perkins Centre D17, University of Sydney, Sydney, NSW
2006, Australia
Supplemental data for this article can be accessed here.
ß 2018 Informa UK Limited, trading as Taylor & Francis Group
2
J. C. BELL ET AL.
Data sources
The NSW PIC provides advice to health professionals and the
public on the management of poisoned and envenomed
patients [25]. The PIC is staffed by pharmacists and medical scientists with additional training in toxicology; and consultant
medical toxicologists manage complex cases. The PIC handles
all calls within NSW from 6 am-midnight, and all calls in
Australia for seven nights each fortnight. For each call, demographic information of the exposed person (age, sex), characteristics of the caller (source: family, community, hospital;
Australian state), and exposure details (substance/s involved,
route, dose, timing, exposure intent [for example, accidental,
therapeutic error]) are collected. Only calls from within NSW
were included in analyses.
The NSW Emergency Department Data Collection includes
information on patient demographics; timing, urgency and
referral source of presentation; mode of arrival and separation. Data are collected by staff in EDs of public hospitals. In
2010 (approximate midpoint of our study period), around 90/
150 EDs participated in the ED data collection. As the larger
EDs all participated, a substantial proportion of the NSW
population is covered (estimated to be 82–87% of all ED presentations). During the study period, there were only three
private EDs in NSW, and all EDs at designated paediatric hospitals were included [26].
The NSW Admitted Patient Data Collection is a census of
all admissions to all NSW public and private hospitals and
collects individual demographic and clinical information with
diagnoses and external causes (circumstances in which the
poisoning occurred) coded according to the 10th revision of
the International Classification of Disease, Australian Modified
version (ICD10-AM). Procedures are coded using the
Australian Classification of Health Interventions. Data are
abstracted from hospital records by trained and certified
medical coders.
Pharmacological poisoning diagnosis, management and
outcomes
To compare pharmacological poisonings across the three data
collections, we coded the medicine responsible to the ICD10AM, as this system was common to hospital admissions and
ED presentations. We defined pharmacological poisonings as
those with diagnostic codes T36-T50. For each PIC call, we
coded the substance responsible to the ICD10-AM diagnosis
code. However, calls for children exposed to more than one
pharmacological substance were classified as ‘multiple
exposures’ and not assigned a specific diagnostic code, as the
primary exposure could not be determined. Each ED uses one
of three classification systems for coding the clinical diagnosis:
ICD9-CM (Clinical Modification), ICD10-AM or Systematized
Nomenclature of Medicine-Clinical Terms (SNOMED-CT) [27].
Given the lack of sensitivity of SNOMED-CT coding, where
over half of diagnoses are defined by symptom (e.g. nausea or
vomiting) [28], we identified presentations for pharmacological poisoning using only ED presentations coded using
ICD9-CM (and mapped to ICD10-AM) or ICD10-AM. We used
this subset of ED poisonings coded with ICD10-AM to describe
the characteristics of children affected by poisonings, and the
medicines involved. To calculate ED presentation rates for
accidental poisoning in NSW as a whole, we extrapolated
annual numbers and rates from presentations coded using
ICD10-AM to those coded with SNOMED-CT. We included hospital admissions with a primary diagnosis of pharmacological
poisoning accompanied by external cause codes (X40-X44)
indicating that the poisoning was accidental. For hospital
admissions, we also identified whether the poisoning occurred
at home or elsewhere, using the Y92 code.
To evaluate management and outcomes, we described
the recommended management (refer to hospital, stay at
home, other) for each PIC call. For ED presentations, we
explored the proportion of presentations arriving by ambulance services, the medical urgency (emergency, requiring
care immediately or within 10 minutes; urgent, requiring
attention within 30 min; semi-urgent, care required within
60 min; and non-urgent, needing care within 2 h) of each
presentation, and proportion admitted to hospital. For hospital admissions, we examined the source of referral (from
another hospital, from ED), length of stay, interventions performed, admissions to intensive care (ICU), re-admissions
within 28 days, and in-hospital mortality. We also identified
deaths within 30 days of discharge from hospital by linking
hospital records to death registration data.
Data analyses
Given all data sources are independent, we conducted separate analyses for each health setting. Using the number of calls,
presentations and admissions, we calculated annual, age- and
sex-specific rates using the annual NSW estimated resident
population aged 0–<5 years as the denominator [24]. We
examined frequency, proportion and changes in pharmacological poisonings in each health setting by ICD10-AM categories, and identified the most common medicines implicated
within each group. For PIC calls, we described these by
pharmacological substance. We also calculated annual rates in
poisonings for the most common medicines identified and
compared characteristics of pharmacological poisonings
between infancy (age <1 year) and early childhood (age 1–<5
years). We described management (including in-hospital treatment) and outcomes of poisonings in each health setting. To
prevent individuals from being identified and preserve confidentiality, we did not present the precise number of children
affected when the numbers were low (<5).
Ethics approval
The NSW Population and Health Services Research Ethics
Committee and the Sydney Children's Hospitals Network
Human Research Ethics Committee approved access to data,
and the study.
Results
From 2007 to 2013, accidental pharmacological poisonings in
children aged <5 years in NSW accounted for 67,816 calls to
CLINICAL TOXICOLOGY
3
Table 1. Characteristics of calls to PIC, ED presentations and hospital admissions, for accidental pharmacological poisoning, NSW 2007–13.
PIC
N ¼ 67,816
Age (years)
<1
1
2
3
4
Sex
Male
Female
ED
N ¼ 3901
Admissions
N ¼ 2082
n
%
Ratea
nb
%
Ratec
n
%
Rate
7188
15,808
25,062
13,022
5434
10.6
23.3
37.0
19.2
8.0
106.1
238.1
383.9
201.8
85.2
341
1180
1459
648
273
8.7
30.2
37.4
16.6
7.0
10.0
35.8
45.4
20.5
8.7
120
501
885
418
158
5.8
24.1
42.5
20.1
7.6
1.8
7.5
13.6
6.5
2.5
33,834
30,312
49.9
44.7
201.0
190.2
2133
1768
54.7
45.3
25.1
22.0
1117
965
53.7
46.4
6.6
6.1
Rate per 10,000 children. Admissions, admissions to hospitals; ED, presentations to Emergency Departments; PIC, calls to Poisons Information Centre.
a
PIC rate: 1302 calls excluded: age unspecified, but known to be aged 1–<5 years.
b
ED – numbers of presentations coded to ICD10-AM.
c
ED rate has been extrapolated to all presentations, based on presentations coded to ICD10-AM.
the PIC, an estimated 7739 ED presentations and 2082 hospital admissions (Table 1); an annual average of 9684 calls,
1106 ED presentations and 297 hospital admissions. Of children admitted to hospital, 74.7% of their poisonings occurred
at home. Only a small proportion of children had >1 hospital
admission for poisoning (1.3%). The distribution of calls, ED
presentations and admissions by age was similar with agespecific rates highest among 2-year-old children (Table 1).
The majority of PIC calls (n ¼ 65,958, 97.3%) involved
exposure to a single medicine. Most calls (89.6%) were made
by family or community members and 6.4% by a health professional from a hospital. Just over half (54.9%) of infants'
exposures were defined as accidental ingestion, and 44.3% as
therapeutic error. In contrast, 87.2% of poisonings for 1–<5
year olds, were recorded as accidental ingestion.
The most common calls to the PIC (Figure 1,
Supplementary Table 1) related to “non-opioid analgesics,
antipyretics and antirheumatics” (24.6% of calls); with paracetamol-containing medicines comprising three-fifths and
ibuprofen-containing medicines implicated in one-third of
these cases (Supplementary Table 2). This medicine class was
also responsible for 12.8% of hospital admissions (the fourth
most frequent medicine category for admissions to hospital).
“Topical agents” (18.3% of calls) were the second-most common exposure resulting in calls, with 1 in 4 attributable to
nappy rash preparations (Supplementary Table 2).
Of ED presentations coded to ICD10-AM, over half
(n ¼ 2114, 54.2%) were ascribed to the code representing
'diuretics, other and unspecified medicines' (Figure 1,
Supplementary Table 1). As such, further subclassification
and analysis by medicine type was not possible.
Four medicines groups were responsible for more than
half of all hospital admissions (Figure 1, Supplementary
Table 1): “antiepileptic, sedative-hypnotic and anti-parkinsonism drugs”, “psychotropic drugs not elsewhere classified
(NEC)”, “medicines primarily affecting the cardiovascular system”, and “non-opioid analgesics, antipyretics and antirheumatics”. Within each of these groups, respectively, four
ICD10 subcategories, “benzodiazepines”, “other and unspecified antidepressants”, “uncategorised antihypertensives”, and
“4-aminophenol derivatives” were the most common.
Together, they accounted for over one-third of all
admissions.
When stratifying by age, calls to PIC concerning infants
were most common for “non-opioid analgesics, antipyretics
and antirheumatics” (33.5%) and for medicines designated
for “topical application” (31.5%) (Table 2). Exposures to similar medicines were also common for children aged 1–<5
years, and resulted in 40% of calls to the PIC. As infants were
rarely hospitalised (around nine per year), the pattern of
admissions in children aged 1–<5 years (Table 2) was similar
to that for all children in our study.
Rates of calls to PIC declined from a high in 2008 to a low
in 2013 (233 and 178 calls per 10,000 children, respectively),
and a decline was also seen for hospital admissions (Table 3).
Over the same period, presentations to ED remained stable
at around 22–24 per 10,000 children. However, estimated
rates of presentations classified as semi- or non-urgent
increased from 3.9 to 8.5, urgent presentations were stable at
around 12, while rates of presentations classified as emergency fell from 6.1 to 4.2 per 10,000 children.
Annual rates of calls (per 10,000 children) to the PIC fell in
two of the common medicine groups over the study period,
2007–13. “Topical agents” fell from 40 to 30 and “medicines
acting on smooth and skeletal muscles and respiratory system” (particularly the anti-common cold medicines) halved
from 30 to 14. However, there was little change in call rates
for “non-opioid analgesics” and annual rates in calls for exposures to opioid medicines were low and stable at around 3–4
calls per 10,000 children per year.
Similarly, rates in hospital admissions fell in three of the
four medicine groups responsible for most admissions. For
“antiepileptic, sedative-hypnotic and antiparkinsonism drugs”,
rates per 10,000 children declined from 1.3 to 0.6; for
“psychotropic drugs NEC”, from 1.1 to 0.7; and for “non-opioid analgesics, antipyretics and antirheumatics”, from 1.2 to
0.6. Annual admission rates due to “medicines primarily
affecting the cardiovascular system” were relatively stable at
around 0.8 per 10,000 children.
Of the calls to the PIC not originating from the hospital
setting, 89.9% were advised to stay at home, and 6.2% were
referred to hospital. Referrals to hospital most frequently
involved exposures to “non-opioid analgesics, antipyretics
and antirheumatics” (17.7%, almost all were paracetamolbased); “psychotropic drugs NEC” (13.4%, with a wide range
of different medicines responsible); and “systemic and
4
J. C. BELL ET AL.
Figure 1. Proportion of pharmacological poisonings in each setting, by medicine category (ICD10-AM T39-T50 codes).
hematological agents, NEC” (12.6%, iron containing preparations implicated in one quarter of these). Of ED presentations, an estimated 15.3% arrived by ambulance services,
23.8% were classified as emergency and one-in-four were
admitted as an inpatient.
Most admissions to hospital presented first to ED
(n ¼ 1758, 84.4%) and 8.5% were transferred from another
hospital. The mean length of stay was less than one day
(15.7 h). Interventions were reported for 201 (9.7%) admissions; with the majority (n ¼ 157) being an allied health intervention for social work. A small proportion (n ¼ 51, 2.4%) of
children were admitted to ICU. The overall 28-day readmission rate during the study period was 2.5%. Children aged <1
year were more likely to be readmitted (6.5%), with a lower
rate of readmissions (2%) for children 1–<5 years. There
were too few (n <5) deaths in-hospital to report, and no
child died within 30 days of discharge from hospital.
Discussion
This study, used concurrent state-wide data from three health
services (PIC, ED presentations and hospital admissions),
to provide a comprehensive evaluation of pharmacological
poisonings and related health service use in young children
in NSW, Australia, over a 7-year period. Information from
each of these services highlights the value each provides to
evaluating poisonings at the population level. For every
admission to hospital, there were four ED presentations and
32 calls to the PIC (Figure 2). Rates for ED presentations classified as “emergency” and hospital admissions both declined,
suggesting that there has been a true decline in more serious poisoning. Use of child resistant closures and safer storage of medicines may have contributed to this, but we have
no direct evidence of this. A similar pattern in declining hospitalization rates has also been reported Australia-wide [29]
and in England [20]. However, information about hospital
admission rates from other countries is lacking.
Decreased hospital admissions were accompanied by
steady rates of ED presentations and falling rates of calls to
the PIC. As ED presentations and calls to the PIC are subject
to access and utilization, changes in rates of pharmacological
poisonings in these health services are more difficult to interpret. For example, PIC utilization may reflect population
awareness, rather than true incidence of poisoning [30].
CLINICAL TOXICOLOGY
5
Table 2. Pharmacological poisonings during infancy and early childhood, by medicine category (ICD10-AM T39-T50 codes), NSW PIC and hospital admissions
2007–2013.
Infancy (<1 year)
PICa
N ¼ 7118
Systemic antibiotics
Other systemic anti-infectives and antiparasitics
Hormones and their synthetic substitutes and antagonists,
NEC
Nonopioid analgesics, antipyretics and antirheumatics
Narcotics and psychodysleptics (hallucinogens)
Anaesthetics and therapeutic gases
Antiepileptic, sedative-hypnotic and antiparkinsonism drugs
Psychotropic drugs, NEC
Drugs primarily affecting the autonomic nervous system
Primarily systemic and hematological agents, NEC
Agents primarily affecting the cardiovascular system
Agents primarily affecting the gastrointestinal system
Agents primarily acting on smooth and skeletal muscles and
the respiratory system
Topical agents primarily affecting skin and mucous membrane
and by ophthalmological, otorhinolaryngological and dental
drugs
Diuretics and other and unspecified drugs, medicaments and
biological substances
Early childhood (1–<5 years)
n
%
n
323
24
186
4.5
0.3
2.6
b
2385
63
33.5
0.9
19
8
15.8
6.7
54
115
60
263
61
360
629
0.8
1.6
0.8
3.7
0.9
5.1
8.8
6
14
10
8
10
5.0
11.7
8.3
6.7
8.3
2243
31.5
11
348
4.9
16
b
PICa
N ¼ 58,840
Admissions
N ¼ 120
%
N
%
3132
1109
5369
5.3
1.8
9.1
7
18
75
0.4
0.9
3.8
13,846
1162
55
1470
2506
881
5605
1727
1712
6743
23.5
2.0
0.1
2.5
4.3
1.5
9.5
2.9
2.9
11.5
248
122
8
322
276
150
157
258
29
67
12.6
6.2
0.4
16.4
14.1
7.7
8.0
13.1
1.5
3.4
9.2
9824
16.7
86
4.4
13.3
3699
6.3
139
7.1
%
b
b
b
b
b
n
Admissions
N ¼ 1962
NEC, not elsewhere classified.
a
PIC ¼ single pharmacological exposures.
b
Results for cells with numbers 5 suppressed.
Table 3. Annual ratesa of calls to PIC, presentations to ED and hospital admissions for pharmacological poisonings, per 10,000 children aged 0–<5 years,
NSW.
EDb
PIC
Admissions
Year
n
Rate
n
Rate
n
Rate
2007
2008
2009
2010
2011
2012
2013
9743
10,583
10,170
9773
9327
9554
8666
220.0
233.0
218.3
206.1
197.0
199.0
178.1
977
1231
1132
1103
1041
1074
1181
22.1
27.1
24.3
23.3
22.0
22.4
24.3
353
359
379
271
220
249
251
8.0
7.9
8.1
5.7
4.6
5.2
5.2
Admissions, admissions to hospitals; ED, presentations to Emergency
Departments; PIC, calls to Poisons Information Centre.
a
Rate per 10,000 children.
b
Numbers and rates of presentations to ED are extrapolated, based on presentations coded to ICD10-AM.
Variations in rates over time may also reflect variations in
case ascertainment—the fall in rate of calls to the PIC may
indicate fewer poisonings, or may be related to less frequent
use over time. During our study period, three national 24 h/7
days primary healthcare triage helplines were established
(2007, 2010, 2011) [31], and these may have contributed to
lower numbers of calls in the later years of our study. Data
from 2014 indicated that of help-line medication-related calls,
only 3.3% were referred to a PIC [32]. Calls to poisons centres
have been shown to improve triage, allowing home management of many unintentional exposures, thereby reducing the
number of people entering the health care system [33,34]
and health care expenses [35,36]. In our study, the decrease
in rates of calls to the PIC coincided with steady rates of ED
presentations, but increasing rates of semi- or non-urgent
presentations, suggesting that families may be bypassing
Figure 2. Pharmacological poisonings pyramid, NSW 2007–2013.
referral to the PIC, and attending ED as their first contact
with the health system. In the USA, inability to speak English
well, Black/African American race, and lower parental educational levels are associated with lower penetrance of regional
poisons centres [30]. Similar factors may need to be targeted
in NSW to focus families' attention on the benefits of triage
by the PIC.
We found exposure to “non-opioid analgesics, antipyretics
and antirheumatics” to be the leading source of pharmacological poisoning for young children. While admission rates
in Australia for these medicines have been falling for over 10
years, these medicines remain predominant, as they do in
other countries [2,11,37]. The use of paracetamol, the most
common analgesic of this group is ubiquitous, and for children, various forms and strengths exist [38]. While therapeutic doses are very safe, unintentional exposure at a high
dose may induce severe toxic effects [38].
6
J. C. BELL ET AL.
While the decline in hospital admissions is encouraging,
each year in NSW there are still approximately 10,000 children unintentionally exposed to pharmaceutical medicines,
leading to around 250 hospital admissions. Previous studies
have demonstrated that exposures and poisonings in children are strongly correlated with adult medication prescriptions [10,39]. While admissions in early childhood for three of
the four major contributors to hospital admissions have fallen
in NSW, admissions related to medicines affecting the cardiovascular system (such as statins, angiotensin-converting
enzyme inhibitors and angiotensin II receptor antagonists)
have not. Of note, 8 of the top 10 subsidized medicines dispensed in Australia belong in this category [40]. In the USA,
the increased prescription use of opioids has coincided with
a large increase in opioid poisonings in children, and children's opioid poisonings are now the most frequent medicine
implicated in hospitalizations for pharmacological poisonings
[14,23]. In contrast, opioid poisonings were low in our study.
As changes in medicines use occur within the Australian
health system (for example, the increasing use of opioids)
[41], we need to continue to monitor available data sources
for any changes in childhood poisonings.
A number of local and international initiatives are underway to optimize preventive strategies [42–44]. Continuing to
educate caregivers, as well as improving methods to ensure
accurate doses can be measured and administered—for
example consistent volume measures for all liquid medicines
may reduce likelihood of error [43,45]. Although child resistant closures on bottle of medicines have reduced unintentional poisonings in children [46], new forms of packaging,
such as flow restrictors for liquid formulations and double
packaging of pills in blister packs within child-resistant containers, or single dose or tablet dispensing packs may further
reduce accidental poisonings [1,46]. Limiting new safety features to medicines that are both commonly available in the
community and most toxic may limit the cost and inconvenience to adults [1].
We have found no other study describing the total population burden of pharmacological poisonings across three levels of the health care system, using complementary data
sources covering the same time period. The very small number of calls for NSW children handled by another poisons
centre for seven nights (midnight-6am) in every 2 weeks is
unlikely to have underestimated numbers and rates of calls,
and unlikely to have biased our results. While ED data coverage is comprehensive, it is not complete, and the lack of
data from the few public hospitals not participating in the
ED data collection may have biased ED results. While nearly
all ED presentations in NSW were included in our data,
around 50% were coded using SMOMED-CT. We have
assumed that the rates of ED presentations for pharmacological poisoning occurring in hospitals using ICD10-AM coding were the same as those in hospitals using SNOMED-CT
coding, but this may not be the case. In addition, ED data
were coded by staff in ED and this may have contributed to
the large proportion of medicines categorized as “diuretics
and other and unspecified drugs, medicaments and biological substances”, thus limiting our ability to investigate
medicines implicated in ED presentations. This lack of detail
about the medicines involved limits the ED setting for
pharmacological poisoning surveillance. In addition, ED poisonings may be underestimated if coded as symptoms and
signs without a diagnosis (for example, nausea and vomiting)
rather than as pharmaceutical poisoning, leading to an
underestimation of poisonings, and potential under-ascertainment of admissions after ED presentation.
The ICD10-AM coding system, on which our medicine categories were based, is in wide use, but is not ideal for surveillance of pharmacological poisonings. While reporting of
some medicines may be accurate [47], many newer medicines, and medicines in common use with potentially serious
consequences if used inappropriately, are grouped without a
specific category. For example, newer medicines such as sertraline, venlafaxine, and fluoxetine are not identifiable under
the current ICD10 coding system (Supplementary Table 2). In
other subcategories, medicines with different pharmacological actions are grouped together, such as antacids with
anti-gastric secretion medicines, and fibrates with statins. In
addition, the category of diuretics and other unspecified
drugs, medicaments and biological substances is broad,
including a wide range of pharmacological substances with a
variety of pharmacological actions and clinical uses. While
newer classification systems have been proposed [48,49],
these medicine-specific coding systems are not applicable to
all medicine types.
Conclusions
Using data from three health settings managing pharmacological poisonings, our study provides a comprehensive picture of early childhood poisonings. The decline in
accidental pharmacological poisonings, especially in severe
poisonings measured by hospital admissions and emergency ED presentations is encouraging. However, it may be
off-set by the increased use of ED for semi- and non-urgent
cases. In NSW specifically, use of the PIC for pharmacological poisonings triage needs to be encouraged to reduce
possible unnecessary ED presentations for less severe poisonings. Future studies should explore whether these falling
rates are seen across all population subgroups. Our findings
highlight the importance of monitoring pharmacological
poisonings using more than one data source, as results
based on a single source may be misleading. Despite
improvements, pharmacological poisonings in young children remain a problem and ongoing targeted strategies to
reduce therapeutic errors and access to medicines by
young children are needed.
Acknowledgements
This research was supported by the use of population data from the
NSW Ministry of Health and the NSW Poisons Information Centre. The
authors thank both the NSW Ministry of Health and the NSW Poisons
Information Centre for providing access to data, and the NSW Centre for
Health Record Linkage for linking the datasets. The findings and views
reported in this study, however, are those of the authors and should not
CLINICAL TOXICOLOGY
be attributed to the NSW Ministry of Health or the NSW Poisons
Information Centre.
[12]
[13]
Disclosure statement
Annette Katelaris is a co-inventor and owner of Juno Childsafe, a childproof bag for medications. No potential conflict of interest was reported
by other authors.
[14]
[15]
Funding
Mr Bentley was supported by an Australian Postgraduate Award
Scholarship, Sydney University Merit Award, and a Northern Clinical
School Scholarship Award. Dr Cairns and Prof Buckley were supported by
an Australian National Health and Medical Research Council (NHMRC)
Program grant (APP1055176) and Prof Nassar was supported by a
National Health and Medical Research Council Career Development
Fellowship (APP1067066).
ORCID
Jane C. Bell
http://orcid.org/0000-0001-6940-6517
Jason P. Bentley
http://orcid.org/0000-0003-0363-8782
Rose Cairns
http://orcid.org/0000-0002-8946-5079
http://orcid.org/0000-0002-6326-4711
Nicholas A. Buckley
Annette Katelaris
http://orcid.org/0000-0002-0482-4854
Sallie-Anne Pearson
http://orcid.org/0000-0001-7137-6855
Natasha Nassar
http://orcid.org/0000-0002-3720-9655
[16]
[17]
[18]
[19]
[20]
[21]
[22]
References
[1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
Bond GR, Woodward RW, Ho M. The growing impact of pediatric
pharmaceutical poisoning. J Pediatr. 2012;160:265–270.e1.
Lovegrove MC, Weidle NJ, Budnitz DS. Trends in emergency
department visits for unsupervised pediatric medication exposures, 2004-2013. Pediatrics 2015;136:e821–e829.
Smith MD, Spiller HA, Casavant MJ, et al. Out-of-hospital medication errors among young children in the United States, 20022012. Pediatrics 2014;134:867–876.
Anderson M, Hawkins L, Eddleston M, et al. Severe and fatal
pharmaceutical poisoning in young children in the UK. Arch Dis
Child. 2016;101:653–656.
Lowry JA, Fine JS, Calello DP, et al. Pediatric fatality review of the
2013 National Poison Database System (NPDS): focus on intent.
Clin Toxicol (Phila). 2015;53:79–81.
Mowry JB, Spyker DA, Brooks DE, et al. 2014 annual report of the
american association of poison control centers' national poison
data system (NPDS): 32nd annual report. Clin Toxicol (Phila).
2015;53:962–1147.
Bentur Y, Lurie Y, Cahana A, et al. Poisoning in Israel: annual
report of the Israel poison information center, 2012. Isr Med
Assoc J. 2014;16:686–692.
Nguyen MB, Pizon AF, Branas CC, et al. Regional variations in
pediatric medication exposure: spatial analysis of poison center
utilization in western Pennsylvania. Clin Toxicol (Phila).
2016;54:47–52.
Dart RC, Bronstein AC, Spyker DA, et al. Poisoning in the United
States: 2012 emergency medicine report of the national poison
data system. Ann Emerg Med. 2015;65:416–422.
Bailey JE, Campagna E, Dart RC. The underrecognized toll of prescription opioid abuse on young children. Ann Emerg Med.
2009;53:419–424.
Azab SM, Hirshon JM, Hayes BD, et al. Epidemiology of acute poisoning in children presenting to the poisoning treatment center
at Ain Shams University in Cairo, Egypt, 2009-2013. Clin Toxicol
(Phila). 2016;54:20–26.
[23]
[24]
[25]
[26]
[27]
[28]
[29]
[30]
[31]
[32]
[33]
[34]
7
Ahmed A, AlJamal AN, Mohamed Ibrahim MI, et al. Poisoning
emergency visits among children: a 3-year retrospective study in
Qatar. BMC Pediatr. 2015;15:104.
Cohen AL, Budnitz DS, Weidenbach KN, et al. National surveillance of emergency department visits for outpatient adverse drug
events in children and adolescents. J Pediatr. 2008;152:416–421.
Lovegrove MC, Mathew J, Hampp C, et al. Emergency hospitalizations for unsupervised prescription medication ingestions by
young children. Pediatrics 2014;134:e1009–e1016.
Li C, Martin BC. Trends in emergency department visits attributable to acetaminophen overdoses in the United States: 19932007. Pharmacoepidemiol Drug Saf. 2011;20:810–818.
Willy M, Kelly JP, Nourjah P, et al. Emergency department visits
attributed to selected analgesics, United States, 2004-2005.
Pharmacoepidem Drug Safe. 2009;18:188–195.
Nalliah RP, Anderson IM, Lee MK, et al. Children in the United
States make close to 200,000 emergency department visits due
to poisoning each year. Pediatr Emerg Care. 2014;30:453–457.
Naun CA, Olsen CS, Dean JM, et al. Can poison control data be
used for pharmaceutical poisoning surveillance? J Am Med
Inform Assoc. 2011;18:225–231.
Setlik J, Ho M, Bond GR. Emergency department use after pediatric pharmaceutical ingestion: comparison of two national databases. Clin Toxicol (Phila). 2010;48:64–67.
Mbeledogu CN, Cecil EV, Millett C, et al. Hospital admissions for
unintentional poisoning in preschool children in England; 20002011. Arch Dis Child. 2015;100:180–182.
Kim K, Choi JW, Park M, et al. A nationwide study of patients hospitalised for poisoning in Korea based on Korea national hospital
discharge in-depth injury survey data from 2005 to 2009. BMJ
Open. 2015;5:e008823.
Groom L, Kendrick D, Coupland C, et al. Inequalities in hospital
admission rates for unintentional poisoning in young children. Inj
Prev. 2006;12:166–170.
Gaither JR, Leventhal JM, Ryan SA, et al. National trends in hospitalizations for opioid poisonings among children and adolescents,
1997 to 2012. JAMA Pediatr. 2016;170:1195–1201.
Australian Bureau of Statistics. Australian Demographic Statistics.
Canberra: Australian Bureau of Statistics, 2017.
NSW Poisons Information Centre. 2016. Available from: http://
www.poisonsinfo.nsw.gov.au/
Centre for Epidemiology and Evidence. Health Stats (SAPHaRI)
Sydney: NSW Ministry of Health; 2017. Available from:
http://www.healthstats.nsw.gov.au/Indicator/beh_alcedage/beh_
alcedage
The International Health Terminology Standards Development
Organisation. SNOMED CT: IHTSDO. 2016. Available from: http://
www.ihtsdo.org/snomed-ct
Mitchell RJ, Bambach MR, Muscatello D, et al. Can SNOMED CT as
implemented in New South Wales, Australia be used for road
trauma injury surveillance in emergency departments? Him J.
2013;42:4–8.
Pointer S, Trends in hospitalised injury, Australia 1999–00 to
2012–13. Injury research and statistics series No. 95. Cat. no.
INJCAT 171. Canberra: Australian Institute of Health and Welfare;
2015.
Litovitz T, Benson BE, Youniss J, et al. Determinants of U.S. poison
center utilization. Clin Toxicol (Phila). 2010;48:449–457.
healthdirect Australia. healthdirect. 2017. Available from: https://
about.healthdirect.gov.au/our-history
Li L, Lake R, Raban MZ, et al. Medication-related calls received by
a national telenursing triage and advice service in Australia: a
retrospective cohort study. BMC Health Serv Res. 2017;17:197.
Zaloshnja E, Miller T, Jones P, et al. The impact of poison control
centers on poisoning-related visits to EDs-United States, 2003.
Am J Emerg Med. 2008;26:310–315.
Jackson BF, McCain JE, Nichols MH, et al. Emergency department
poisoning visits in children younger than 6 years: comparing
referrals by a regional poison control center to referrals by other
sources. Pediatr Emerg Care. 2012;28:1343–1347.
8
J. C. BELL ET AL.
[35]
Lewin Group. Value of the poison center system: Lewin Group
report. Falls Church, VA: Lewin Group; 2012.
West J, Taylor L, Smith N, et al. Cost savings through community
access to the NSW poisons information centre. Aust Health Rev.
1987;10:238–247.
Ontario Poison Centre. Current Top 10 - Children Under Five
Toronto: Hospital for Sick Children; 2017. Available from: http://
www.ontariopoisoncentre.ca/common-poisons/Current%20Top
%2010/Top-10-Lists.aspx
Mund ME, Quarcoo D, Gyo C, et al. Paracetamol as a toxic substance for children: aspects of legislation in selected countries.
J Occup Med Toxicol. 2015;10:43.
Burghardt LC, Ayers JW, Brownstein JS, et al. Adult prescription
drug use and pediatric medication exposures and poisonings.
Pediatrics 2013;132:18–27.
Australian Prescriber. Top 10 drugs. Aust Prescr 2016; 39:135.
Drug utilisation sub-committee (DUSC). Opioid analgesics: overview. Canberra: Pharmaceutical Benefits Scheme; 2014.
Kidsafe. Poisoning Prevention Sydney: KidSafe NSW Inc. 2017.
Available from: http://www.kidsafensw.org/home-community/poisoning-prevention/
Centers for Disease Control and Prevention. The PROTECT
Initiative: Advancing Children’s Medication Safety: CDC. 2017.
[36]
[37]
[38]
[39]
[40]
[41]
[42]
[43]
[44]
[45]
[46]
[47]
[48]
[49]
Available from: https://www.cdc.gov/MedicationSafety/protect/
protect_Initiative.html
US Food and Drug Administration. Safe use of over-the-counter
pain relievers and fever reducers: US FDA. 2017. Available from:
https://www.fda.gov/Drugs/ResourcesForYou/Consumers/Buying
Using MedicineSafely/UnderstandingOver-the-CounterMedicines/
SafeUseofOver-the-CounterPainRelieversandFeverReducers/
ucm164977.htm
AAP Committee on Drugs. Metric units and the preferred dosing
of orally administered liquid medications. Pediatrics 2015;
135:784–787.
Budnitz DS, Lovegrove MC. The last mile: taking the final steps in
preventing pediatric pharmaceutical poisonings. J Pediatr.
2012;160:190–192.
de Achaval S, Feudtner C, Palla S, et al. Validation of ICD-9-CM
codes for identification of acetaminophen-related emergency
department visits in a large pediatric hospital. BMC Health Serv
Res. 2013;13:72.
Caraci F, Enna SJ, Zohar J, et al. A new nomenclature for
classifying psychotropic drugs. Br J Clin Pharmacol. 2017;83:
1614–1616.
Ghaemi SN. A new nomenclature for psychotropic drugs. J Clin
Psychopharmacol. 2015;35:428–433.