While respiratory illnesses like asthma and bronchiolitis are often the “bread and butter” of the Pediatric ER, drug overdoses and poisonings are rising at an alarming rate. Between 2019 and 2020, overdose-related deaths among children and adolescents surged by over 80%, making poisonings the third leading cause of death in this population—behind firearms and motor vehicle collisions.
Pediatric ingestions occur in two primary forms: accidental (more common in toddlers and young children) and intentional (more common in older children and adolescents). Ingestions can occur via inhalation, dermal exposure, or oral consumption, making early recognition and rapid intervention critical in ED management. Given their smaller body mass, children are particularly susceptible to toxic effects, even at low doses, making thorough history-taking a life-saving skill for providers.
Acetaminophen and Ibuprofen: Common Yet Dangerous
Most households stock acetaminophen (Tylenol) and ibuprofen (Motrin) for fever or pain relief. However, acetaminophen is the leading cause of acute liver failure. The antidote, N-acetylcysteine (NAC), is most effective when administered within 8 hours of ingestion.
For delayed presentations or severe toxicity, an old drug is finding a new use: fomepizole. Traditionally used for ethylene glycol and methanol poisoning, fomepizole acts as a CYP2E1 inhibitor in early phases and a JNK pathway inhibitor in later metabolism, showing promise in preventing renal injury and supporting hepatic regeneration. However, more studies are needed to confirm its efficacy in humans.
While ibuprofen toxicity is often perceived as less severe, ingestions exceeding 400 mg/kg can cause gastrointestinal hemorrhage, hepatotoxicity, renal failure, metabolic acidosis, and thrombocytopenia.
THC Ingestions: Candy or Crisis?
With increasing legalization of marijuana, THC (tetrahydrocannabinol) exposure in children has surged, primarily through edible products. These often resemble candy, leading to unintentional ingestions and altered mental status presentations in the ED. See some examples of edibles that resemble snacks or candy here.
Although some states regulate THC edibles (capping individual doses at 10 mg), many products exceed these limits and lack proper labeling. This has contributed to a growing number of pediatric hospitalizations. More on THC-related injuries can be found here and here, through the Children’s Hospital of Philadelphia.
Opioids: The Unseen Epidemic in Pediatrics
As the opioid crisis continues, exposure to fentanyl and other opioids is increasingly affecting children. While respiratory distress is common in the ER due to bronchiolitis and asthma, providers should have a high index of suspicion for opioid toxicity in any child with miotic pupils.
Naloxone (Narcan) is life-saving, particularly in fentanyl overdoses, where mortality rates can reach 50%. Intranasal naloxone at 2 mg per dose is generally well tolerated, with minimal risk of noncardiogenic pulmonary edema in pediatrics. Rapid bag-mask ventilation and naloxone administration remain the cornerstones of resuscitation.
Prevention and Emergency Management
From Tylenol to THC and opioids, toxic ingestions are an increasing concern in the Pediatric ED. Prevention remains the best treatment—since most ingestions occur at home, educating caregivers about proper medication storage is crucial. All medications and household products should be clearly labeled, locked, and kept out of children’s reach.
Upon presentation to the ED, essential management steps include:
- Obtaining a thorough history: Identify the ingested substance, dose, and timing.
- Supporting airway, breathing, and circulation.
- Administering appropriate antidotes when indicated.
- Consulting Poison Control (1-800-222-1222) or a medical toxicologist for expert guidance.
By staying vigilant and proactive, we can improve outcomes and reduce the impact of toxic ingestions in children.
Rosemary Beggins, CRNP, is a Pediatric Nurse Practitioner in the Emergency Department at the Children’s Hospital of Philadelphia. She can be reached at BEGGINSRC@chop.edu.
