Clinical Profile of Acute Poisoning in Children at a Teaching Hospital in Lalitpur

Address for correspondence: Dr. Ajaya Kumar Dhakal, Lecturer Department of Paediatrics, KIST Medical College, Imadol Lalitpur, Nepal. Email: ajayakdhakal@gmail.com Ph.No: 9841316649 1Dr. Ajaya Kumar Dhakal, MBBS, MD, Lecturer, 2Dr. Devendra Shrestha MBBS, MD, Associate Professor, 3Dr. Arati Shakya MBBS, MD, Lecturer, 4Dr. Subhash Chandra Shah, MBBS, MD, Lecturer, 5Dr. Henish Shakya MBBS, MD, Lecturer. All from KIST Medical College, Imadol, Lalitpur, Abstract


Introduction
A cute poisoning is an important cause of emergency department visits and hospital admission in children 1 and it is one of the poten ally preventable causes of childhood morbidity and mortality in Nepal 1,2 .The eff ects of poisoning have both short and long term health implica ons in children as well as in parents.
In Nepal, poisoning is common in an most household due to ignorance and carelessness of parents while storing poten ally hazardous substances such as drugs, alcohol, hydrocarbons, roden cides and insec cides.Petrol, kerosene and other hydrocarbons, for instance, are stored in water bo les and so drink bo les.Drugs are easily available from drug stores without prescrip ons while insec cides and pes cides are widely used in agriculture but inappropriately stored.Unlike developed countries the drug packagings do not have child locking system in Nepal.Similarly, poten ally toxic substances are likely to be stored with food items in the same place without proper labeling which could also increase the risk of poisoning 2 .In Nepalese society, where many industries are located within the vicinity and even within the same household, chemical substances which are poten ally toxic are in easy reach of children.Children who are in normal developmental stage of explora on and autonomy are o en le una ended which also put them in high risk for these mishaps.Various psychological stressors in adolescents are also now an important emerging cause of poisoning in Nepal.In a retrospec ve study from Nepal, one of most common mode of suicide in adolescents was inten onal poisoning 3 .The problem is prevalent in all geographical regions from the plains of terai to mountainous areas, from lower socioeconomic status to higher, educated to uneducated parents, in all castes and ethnicity and throughout the year 2 .The pa ern of poisoning, however, may diff er with insec cides and pes cides mostly occurring in rural farming regions and with most of drug poisoning occurring in urban area.
This study was performed with objec ves to iden fy the common age and types of the poisoning in children, the knowledge of which could help in decreasing poisoning related mortality and morbidity.

Materials and Methods
It was a descrip ve observa onal study done in a teaching hospital in Lalitpur.Ethical approval was taken from the hospital ethical review board before the ini a on of study.Pa ents aged 1 month to 18 years who visited the emergency department and were admi ed to hospital with history of alleged poisoning from 2009 July to 2014 January were included in the study.Data on age, sex, place of poisoning, type of poisoning, presenta on me to hospital, state at presenta on, dura on of hospital stay were collected from medical records.Pa ents whose records could not be traced or those who presented with food poisoning were excluded from the study.For the study purpose, a pa ent was said to be symptoma c when the par cular signs and symptoms of poisoning were present at the me of presenta on.The dura on of hospital stay included the me between ini al presenta on to hospital to the me when either pa ent is discharged a er improvement or referred or expired.A total of 50 pa ents were enrolled for analysis.Data were entered and analyzed using SPSS 17.

Results
A total of 50 pa ents were included for analysis.The youngest pa ent was 14 months old while the oldest was 18 years with mean age of 7.8 years.There were no pa ents of poisoning below the age of one year in this study.Out of all pa ents included, 54% cases were male while 46 % were female.The maximum number of poisoning 50% (25 out of 50) were within 1 to 5 year age group while 38% (19 out of 50) in the 10 to 18 year age group and 12% in 5 to 10 year group.84 % of poisoning occurred at home while 16% occurred outside home.
The dura on of hospital stay ranged 1 to11 days (mean dura on of 2.1 days) of which 58% of pa ent stayed in hospital for less than 24 hour, 38% of pa ent stayed less than seven days and minority of pa ents 4% stayed for more than seven days.Majority of pa ents, 68% were symptoma c while 32% of pa ents did not have any symptoms of poisoning at presenta on.
The mean me of presenta on to hospital was fi ve hours (range 10 minutes to 2 days) a er inges on of which 38% of pa ents presented within one hour of poisoning, 46% presented within period of 1 to 6 hours and 16% of pa ents presented a er six hours.Overall, drugs were the most common cause of poisoning which was followed by kerosene as shown in table 1.The type of poisoning also varied according to age with drugs and kerosene being common in age group below 5 years while organophosphorus compounds was common above 10 year of age and dhatura poisoning in children between 5 to 10 years (Table 2).

Discussions
Poisoning is a common pediatric problem and is one of the important causes of hospital admission worldwide 4,5 .The incidence of poisoning varies in diff erent regions of world and one of the studies from Finland which analyzed acute poisoning below the age of six years over two decades found the incidence to be 5.2 per 10 000 per year 4 .Although the incidence of poisoning is exactly not known in Nepal, a hospital based study showed that 3.4% of hospital admissions below the age of 15 years were due to acute poisoning 6 .
Overall, drugs were the most common cause of poisoning in this study followed by kerosene oil, organophosphorus and corrosives which is similar to previous studies done in South East Asian region 5 .However previous studies from Nepal showed organophosphorus followed by kerosene as the most common cause of poisoning 2,6 .Kerosene followed by drugs was an important cause of poisoning below the age of 10 years and organophosphorus poisoning followed by drugs was more common in adolescent age group in this study.The vulnerability for uninten onal poisoning in young children can be explained with developmental stage of explora on and autonomy.Easy reach of poison storage loca on, psychological stress in parents and lack of close supervision by parents and caregiver, lack of caregiver educa on and easy reach of drugs are other risk factors found for uninten onal poisoning in children 7 .Nepal also does not have strict drug regula on policy, even if such regula ons are there, it is not in prac ce, regarding where and how to store drugs and also provision of child lock container for drugs, which is also contribu ng for poisoning in young children.Adolescents are vulnerable to poisoning due to their immaturity to cope the stress and confl icts which arise during adolescence, depression, diff erent problems at school, family problems, psychiatric illness, academic failures and poor communica on between adolescent and family 3,8,9 .There should be increased awareness regarding various aspects poisoning at individual level, community level and policy level using diff erent forms of media 1 , organizing symposium among stakeholders and establishment of "Na onal poison centre" among diff erent parts of country will help to decrease incidence and improve outcome of poisoning 1 .
Most of these acute poisoning in this study occurred at home while almost similar results were found from a previous study undertaken in a referral hospital in Nepal 2 .This refl ects that most of the hazardous substance may be present in households and these poisoning could be poten ally preventable with simple measures such as proper storage and labeling of poten ally dangerous substance in the households, an cipatory guidance to parents as well as proper management of stress in the adolescents.
The outcome of acute poisoning depends upon severity of illness which is determined by presenta on me to hospital, amount, potency and nature of these chemical substances.Each of these factors independently and in combina on infl uences the plan of management and outcome 10 .Severity of poisoning may also determine the dura on of hospital stay independently and interac ng with various factors men oned above.One important factor which determines outcome is presenta on me to hospital and in this study, 38% of pa ents presented within 1 hour of poisoning, 46% presented within period of 1 to 6 hours while 16% of pa ents presented a er 6 hours of poisoning which is almost similar to another study from South East Asia 5 .Although it depends upon type of poisoning, majority (68%) of the pa ent were symptoma c at presenta on in our study.The probable reason of such early presenta on in this study may Mean age of acute poisoning in this study was high (7.8 years) as compared to similar studies (5.84 year) done in Nepal 6 .The maximum number of pa ents (50%) were below the age of fi ve years which is similar to most of studies done in similar se ng where 60 2 to 64.89% 1 of acute poisoning occurred in the same age.The second largest propor on of pa ents (38%) in this study was the 10 to 18 years of age which is in accordance with study from a referral hospital in Nepal 2 .One of the studies from Pakistan, however, showed 5 to 10 years of age group to be second commonest age group rather than 10 to 18 years age group 5 .There was male preponderance in all age groups of children with acute poisoning in this study which is also similar to other studies from Nepal 1, 2, 6 and South East Asia 5 .

Conclusion
Children below fi ve years of age are most vulnerable for acute poisoning.Drugs and hydrocarbons like kerosene were most common causes of poisoning in young children while organophosphorus poisoning was more common in adolescent.Parents should be counseled and educated about poten al poisoning and preventa ve measures at home and school in the par cular locality (rural vs. urban).Adolescent issues and problems leading to poisoning should be addressed mely to prevent any undesired mishaps.It is highly recommended that the government should develop policies to regulate over the counter (OTC) availability of drugs, insec cides and pes cides and strict implementa on of safe drug packaging, drug storage and provision of a child lock containers for drugs to save those precious lives.

Table 1 :
Causes of Poisoning

Table 2 :
Distribu on of Type of Poisoning by Age Group