Hospital Based Study of Poisoning Among Children , 1 to 18 Years of Age in Eastern Nepal Affiliation

Introduc on The poisoning among children had been a major cause of hospital admission and also a significant global health problem throughout the world including Nepal. There are various studies sugges ve of incidence rate of poisoning in children ranging from 0.74% to 3%. In older children, poisoning is usually inten onal where as in infants and younger children it is . accidental in nature There are few studies done in Nepal and they are mainly from Kathmandu valley, this study will add more informa on from eastern region of Nepal. Objec ve This study aimed to find out the type of poisoning among children and adolescents, manner of poisoning and its outcomes. Methodology This was a retrospec ve study carried out at Nobel Medical College Teaching Hospital over a period of one year star ng from st st 1 August 2014 to 31 July 2015. This study included all the children and adolescents of 1 to 18 years of age admi ed to pediatric ward and ICU for the management of poisoning. The informa on including name of poisons, manner of poisoning, socio-economic and demographic factors related to poisoning, geographical distribu on of sample popula on, dura ons of hospital stay and outcome of treatment were retrieved from the records. The data was analyzed using SPSS. Results A total of 64 cases were studied. It included almost the same number of males (n=31) and females (n=33). The age group of 13-18 years had the largest prevalence of poisoning (n=22). Organo-phosphorus (n=25) was the commonest poison. As the study was conducted in a ter ary care center of eastern Nepal located at Biratnagar, Morang district, a majority of the cases (39) were from Morang. A total of 41% children required hospital stay for more than 7 days where as 37% of them required 5-7 days of hospital stay and only 22% children stayed for 1-4 days in the hospital. No mortality was noted. Conclusion The pediatric poisoning in eastern Nepal is a significant public health issue and nature of poisoning was accidental followed by suicidal. The commonest age group involved is adolescence, which highlights the need for educa on and implementa on of suicidal preven on programin this region. The higher prevalence of accidental poisoning in first two year of life necessitates the need of child safety and injury preven on program in the community.

1 August 2014 to 31 July 2015.This study included all the children and adolescents of 1 to 18 years of age admi ed to pediatric ward and ICU for the management of poisoning.The informa on including name of poisons, manner of poisoning, socio-economic and demographic factors related to poisoning, geographical distribu on of sample popula on, dura ons of hospital stay and outcome of treatment were retrieved from the records.The data was analyzed using SPSS.

Results
A total of 64 cases were studied.It included almost the same number of males (n=31) and females (n=33).The age group of 13-18 years had the largest prevalence of poisoning (n=22).Organo-phosphorus (n=25) was the commonest poison.As the study was conducted in a ter ary care center of eastern Nepal located at Biratnagar, Morang district, a majority of the cases (39) were from Morang.A total of 41% children required hospital stay for more than 7 days where as 37% of them required 5-7 days of hospital stay and only 22% children stayed for 1-4 days in the hospital.No mortality was noted.

Conclusion
The pediatric poisoning in eastern Nepal is a significant public health issue and nature of poisoning was accidental followed by suicidal.The commonest age group involved is adolescence, which highlights the need for educa on and implementa on of suicidal preven on programin this region.The higher prevalence of accidental poisoning in first two year of life necessitates the need of child safety and injury preven on program in the community.

INTRODUCTION
Poisoning among children had been a major cause of hospital admission and a significant global health problem 1,2 throughout the world including Nepal.There are various studies sugges ve of incidence rate of poisoning in children [3][4][5][6][7][8][9] ranging from 0.74% to 3%.In older children poisoning is usually inten onal whereas in infants and younger children it 10,11,12 is accidental in nature.
According to World Health Organisa on (WHO), in the year 2004 an es mated 346,000 people died worldwide from uninten onal poisoning.Of these deaths, 91% occurred in low and middle income countries.Most of the poisonings take place in rural areas of developing countries, where safeguards typically are inadequate or lacking altogether.There is a growing concern regarding the unregulated use of pes cides in the field of agriculture.Although the developing countries use 25% of the world's produc on of pes cides, they experience 99% of the deaths due to pes cide 13 poisoning.
According to WHO, the suicidal rate is increasing and more children and adolescents are having increasing number of stressors on daily life that could lead to more self-harm using poisons available.The pa ern of poisoning is dynamic and differs a lot according to me and from country to country as 11 well.Hence, epidemiological surveillance of each country and also the different regions within the country is an important public health ac vity to bring up preven ve programs in the country which is possible a er having adequate and reliable data from the representa ve popula on.This study has been designed to generate this data.Poisoning in children is one of the common cause of hospital admission in Nepal.There are few studies done in Nepal and they are mainly from Kathmandu valley, this study will add more informa on from eastern region of Nepal, which is quite different socio culturally and demographically from central and other part of Nepal.This study will be helpful to make strategic planning for the preven on of poisoning among children.

METHODOLOGY
This study was carried out at Nobel Medical College Teaching Hospital (NMCTH), Biratnagar, Nepal during a dura on of one year, i.e. from 1st August 2014 to 31st July 2015.The study popula on was composed of cases admi ed to the pediatric ward, PICU and emergency department, all of which were from the age group of 1-18 years of age.The study was conducted by doing a retrospec ve view of the records of the cases of pediatric poisoning of (1-18years) cases, admi ed at NMCTH, Biratnagar at the specified me period of the study.Pa ents with a mild s ng, which didn't require admission, were excluded from the study.The sample size of the study was dependent on the number of total admissions but it was expected to be at least 60 cases.Pre tes ng was done by looking at the discharge record from the pediatric ward and data was retrieved and discussed among the co-authors.The data was entered in MS Excell and later transferred into SPSS for further analysis.The details about the poison including name of poisons, manner of poisoning, socio-economic and demographic factors related to poisoning, geographical distribu on of popula on, dura ons of hospital stay, outcome of treatment and preven ve aspect of poisoning were retrieved from the records.
The analyzed data were presented in the table and figures in an appropriate manner.All quan ta ve variables were expressed as the median and standard devia on, while qualita ve variables were expressed as frequencies and percentages.The associa on among variables with type of poisoning and outcome was measured.Ethical clearance was obtained from the Ins tu onal Review Commi ee of the Nobel Medical College Teaching Hospital, Biratnagar, an accredited body of Nepal Health Research Council.

RESULTS
Table 1 shows the socio-demographic profile of the study popula on (n=64) that included 52% female and rest were male.The maximum number of cases were in the age of 13-18 years ( 34%) and the lowest (13%) were in 6-12 years age group.Major ethnicity was Madhesi (41%).
The majority of cases were from Morang district (61%) that is followed by Sunsari (16%), Saptari (9%), Siraha (6%) and also from India (8%).Majority of cases were from Morang district as the hospital is located in Biratnagar which is the headquarter of Morang district.As in figure 1, the majority of children (78%) were from low socio-economic status family.

Number of cases Percentage
Age group (Years)  While looking at the trend of pediatric poisoning, we noted that the poisoning was accidental in nature in 58% and suicidal in 42% of children.This finding is different from the finding of UD Chhetri et al in Patan Hospital where 76% were accidental and only 18% were suicidal.This study really highlights the need of more suicidal preven on program in this region.The organophosphorus poisoning was the most common poison involved, followed by kerosene poisoning and the commonest route of administra on was oral.A study 17 done by Ram P et al in South India found kerosene poisoning and organophosphorus poisoning to be the two most 18 common poisons involved, similarly Chaudhary FR et al in Bangladesh also noted organophosphorus poisoning to be the commonest poison used, both of which share stark similari es with our findings.The third most prevalent poison was Dhatura (n=6).There were significant number of children (n=9) where we could not accurately iden fy the poison.The others category of poison included one case each of Ayurvedic medica on, de ol, olanzepine, phenol, rat poison, oleander, zalim lo on and wasp bite.These are quite a variety of drugs and poisons.
The dura on of hospital stay in poisoning varies depending upon the type of poisons used, health condi on of the pa ents at the me of hospital admission and the necessity of intensive care support.In our study, 41% of children stayed for more than seven days while 37% stayed for 5-7 days and only 22% stayed for 1-4 days.In terms of outcome of management, 81% were discharged, 11% went home on leave against medical advice(LAMA) and 8% were taken home on discharge on parents request (DOPR).There was no mortality in the hospital.Since we couldn't follow up DOPR

Table 2
shows that the most common type of poisoning was organo-phosphorous poisoning (39%) which was followed by kerosene poisoning (23%) and 12 % had others poisoning which ayurvedic medica on, de ol, olanzepine, rat poison, oleander, zalim lo on and wasp bite.The commonest manner of poisoning was accidental (58%) in nature.