March 18, 2010— -- Allison Muller understands the dangers of pills that find their way into a toddler's hands. As director of the Poison Control Center at the Children's Hospital of Philadelphia, she knows that one to two tablets of certain medications can be lethal to a toddler.
So when her 1-year-old son had nearly swallowed a potentially dangerous pill, she said she "panicked."
Upon arriving home from work, Muller learned from her husband that her infant son had found a pill on the floor and put it in his mouth.
"You can't turn your back for a second, or he's putting something in his mouth," she said.
The pill turned out to be Tramadol, a medication known to increase the risk of seizure. She later learned that the pill had fallen out of the pocket of one of her friends who had visited her home recently.
Muller said that the episode showed her that even though she keeps the family's medications in a locked tackle box, the threat of accidental ingestion remains.
Indeed, such cases are all too common, statistics suggest. According to the American Association of Poison Control Centers, in 2002 there were 2.4 million toxic ingestions, and more than half of these occurred in children younger than 6. Children aged 18 to 36 months seemed to be at the highest risk, and in these little bodies, just one pill can be deadly.
Even more worrisome is the fact that, after taking some of these pills, a child can appear perfectly fine until it is too late.
"They may look OK for now, but they're not," said Dr. Henry Spiller, director of the Kentucky Regional Poison Center in Louisville. "Within two hours, we have seen patients go from ingestion to death -- even after taking only one to two pills."
A review paper published earlier this month in the journal Pediatric Emergency Medicine Practice outlined the risks of more than three dozen medicines that, the authors noted, could kill kids in a single swallow.
"People don't know that just one of these pills can cause such bad problems in a child, but it's true," said Dr. Erica Liebelt, president of the American College of Medical Toxicology and a pediatric emergency physician at the University of Alabama in Birmingham.
Even parents who keep medicines out of their children's reach are at risk of such an emergency; the Emergency Medicine Clinics of North America notes that in 50 percent of all childhood accidental poisonings, the medication bottle was only "out" for a short amount of time as it was being used.
Also, as in Muller's case, a visitor might drop a pill. Or, as Dr. Carl Baum, a pediatric emergency physician and toxicologist at Yale University noted, "Kids find pills off the floor in a hotel room all the time. Parents bring them in having no idea what they took".
For these reason, emergency medicine specialists urge, parents should recognize the high risk of accidental ingestions and be prepared to act. Call 911 immediately, experts say, or call the Poison Control Center at 1-800-222-1222. Parents should also be prepared to take their child to the hospital immediately, and they should bring the bottle of whatever the child took in the ambulance and to the ER. Importantly, new guidelines from the American Association of Pediatrics urge against the use of Ipecac or any other mechanism to induce vomiting.
Fortunately, once children are in the emergency room, doctors can rapidly respond, as some medications have antidotes, reversal agents or supportive therapy.
On the following pages are seven of some of the more common medicines that, while useful or even life-saving for the patients who take them, can lead to emergencies when accidentally ingested by kids.
Category: Calcium channel blockers
Scientific names: Diltiazem, Verapamil, Amlodipine, Nifedipine
Brand names: Cardizem, Cartia, Norvasc
Indications: High blood pressure (hypertension), angina, atrial fibrillation
Symptoms in children: Dangerously low blood pressure and heart rate, seizures
For patients with heart issues, medications in this family are very commonly prescribed. They are used to treat a number of cardiac conditions, from high blood pressure to fast heart rates. However, in children, they can cause dangerously low blood pressure and heart rate, and even lead to shock.
Symptoms in children who ingest these medications usually show up one to five hours after they take the pill, but in the extended release pills, they may be delayed up to 14 hours -- a fact that may make it even more difficult for the parent to figure out why the child is ill.
Spiller, of the Kentucky Regional Poison Center, said that he once treated a 2-year-old girl who, while being babysat by her grandmother, took between two and four of the woman's Amlodipine (Norvasc) pills. Initially the toddler showed no symptoms, so it was 45 minutes before the family brought her to the hospital. When the girl became drowsy, they rushed her in – but to no avail. Spiller said her blood pressure was already dangerously low, and within 45 minutes her heart rate plummeted. Eventually, her heart stopped.
"No matter what we did, we were not able to get back a blood pressure or any sort of rhythm," Spiller said.
"All [calcium channel blockers] in kids are frightening to me," Spiller said. "If they take them, and take enough, then you're fighting against a hurricane. They are difficult to rescue."
Category: Camphor-containing rubs
Scientific name: Camphor
Brand names: Vicks VapoRub, Ben-Gay, Tiger Balm, Save the Baby
Indications: Relieves muscle aches, itching, coughing, and fever blisters
Symptoms in children: Rapid development of seizures, delirium, coma, and death
Camphor is a very common product in over-the-counter products. It also has a very pungent odor and taste, which may make it seem like the last thing a toddler would try to eat.
But according to the AAPCC, in 2001 there were almost 8,000 cases of camphor ingestion in children younger than 6 years old. Camphor is especially dangerous because ingesting it works so quickly; symptoms occur within 10-20 minutes, and often children can go into seizures without any warning. Shortly after ingesting these rubs, children may become hyperactive and restless. The skin around their lips may become blue. In the worst cases, these symptoms can progress to seizures and, eventually, to coma and respiratory depression, in which they may stop breathing altogether. Unfortunately, the amount that it takes to send a child into this downward spiral is very small; toddlers have been known to have seizures within 10 minutes after eating only one to two teaspoonfuls, and even one teaspoon can be lethal.
Emergency medicine experts say that if you think your child has eaten one of these rubs or if you smell camphor on your child's breath, do not wait for them to develop symptoms. The quicker you call 911, the better their chances of survival.
Prescription Pain Medications
Category: Narcotic pain medications
Scientific names: Oxycodone, hydrocodone, methadone
Brand names: Oxycontin, Percocet, Vicodin and others
Indications: Alleviates pain
Symptoms in children: Sleepiness, which proceeds to lethargy. Can eventually stop breathing, which leads to death
Opiates, which are derived from opium, are ubiquitous in prescription pain medications today -- a testament to their effectiveness. However, infants and children may be more susceptible to their effects than adults, putting them even more at risk. In fact, opiates and other pain medications, including acetaminophen, were the number one cause of medication-induced fatality from accidental ingestion in children younger than 6 in 2004, with the AAPCC counting 139 such deaths in that year alone.
"You have to be very careful about these medications," the American College of Medical Toxicology's Liebelt said. In her emergency room alone, she said, two toddlers have died from these pills in the past two years.
According to one study, 50 percent of toddlers who took two 5 mg tablets became rapidly ill within an hour. For an infant, even half of a tablet of hydrocodone can be lethal.
Sustained-release versions of these pills can be especially lethal, Spiller said, as they contain "such giant doses ... which can be lethal for a child with no tolerance." Spiller said that one 2-year old girl who was brought to his ER had taken two tablets of Oxycontin while her mom was answering the door. For four hours she had no symptoms -- and then she suddenly went into cardiac arrest.
Fortunately, paramedics often carry Naloxone, an antidote to these medications. When parents call 911, it is important that they tell the paramedics that your child took one of these pills, as they may be able to administer this treatment in the ambulance on the way to the hospital.
Aspirin and Oil of Wintergreen
Scientific names: Acetylsalicylic acid, methyl salicylate
Brand names: Bayer, Ecotrin and others
Indications: Alleviates muscle pain, prevents heart attacks, Oil of Wintergreen used for flavoring
Symptoms in children: Nausea, vomiting, agitation, seizures, lethargy, coma and death
This class of medication is very toxic to children in large doses, specifically in the high doses found in oil of wintergreen. Oil of wintergreen is particularly hazardous because its pleasant smell tempts toddlers to ingest it, but one teaspoon of oil of wintergreen is the equivalent of nearly 90 baby aspirins -- a life-threatening dose for a toddler or child.
Additionally, because aspirin is such a commonly used drug, most families are almost certain to have it in the home.
Children who have overdosed on these drugs may initially experience nausea, vomiting, and sweating. These symptoms can soon progress to swelling in the brain, coma and even death. Liquid formulations that contain salicylates are considered by emergency medicine experts to be even more dangerous, as their often concentrated form can lead to severe, rapid-onset toxicity. In many cases, as little as 4 ml in a child can be fatal.
Scientific names: Amitriptyline, imipramine, buproprion
Brand names: Elavil, Tofranil, Wellbutrin, Zyban
Indications: Treats depression, chronic pain and migraines, smoking cessation
Symptoms in children: Seizures, unresponsiveness and heart arrhythmias
After pain medications, antidepressants are the second highest cause of accidental death from poisoning in children younger than 6, according to the 2004 report by the AAPCC.
Symptoms can be delayed for up to six hours, after which children can develop anything from seizures to coma and life-threatening heart rhythms. Liebelt, of the American College of Medical Toxicology, pointed to one toddler who ingested her mother's migraine medicine as the woman was preparing to take it. The child was later brought into the emergency department with lethargy and a dangerously low blood pressure after taking only one or two pills.
Topical Blood Pressure Patches, Eye Drops, and Nasal Sprays
Category: Topical Eye Drops, Nasal Sprays, and Blood Pressure Patches
Scientific names: Clonidine, oxymetazoline
Brand name: Afrin, Clear Eyes, Clonidine patch
Uses: Eye redness/itchiness, nasal congestion, glaucoma
Symptoms in children: Lethargy, low blood pressure, coma
These medications, designed to be absorbed over time through the skin, can lead to serious consequences when ingested by a toddler. Ever the explorers, children have been known to drink these sprays and eye drops, and they will even lick discarded medication patches. Symptoms from these ingestions can be delayed for four hours, but as little as 6 ml can lead to lethargy or coma, although death from this small of an amount is unlikely.
These dangers have been known for some time. In a case report published in the journal Clinical Toxicology in 1979, a 21-month old girl that developed a dangerously low heart rate and blood pressure and became comatose after taking a single 0.3 mg tablet. In another case report published in the journal Annals of Emergency Medicine in 1988, a 9-month-old boy sucked on a discarded Clonidine patch that had been worn for five days and thrown out. He became lethargic and developed a life-threateningly low blood pressure that required a stay in the intensive care unit.
Category: Diabetes Medications
Scientific Name: Sulfonylureas
Brand name: Glyburide, Glipizide
Uses: Diabetes management (non-insulin dependent, or Type 2)
Symptoms in children: Dangerously low blood sugar, coma, seizures
As these medications are more commonly prescribed, the incidence of pediatric poisonings has also increased, with over 2,500 occurrences in the United States in 2001. Children may not display signs of this until one to six hours later, but symptoms may last for 24 hours, so these children are often hospitalized for observation.
Not only are these medications dangerous for a child that is not diabetic, children have less energy stores in their livers than adults do, making them more susceptible to the effects. They may develop sleepiness, confusion, headache and seizures -- and some children have developed permanent brain damage and even died.
Spiller said he once took care of a young boy who began having seizures after taking one of these pills. Upon arriving in the emergency department, the child was paralyzed on one side. He improved after treatment, but the paralysis lasted for over 18 hours. Fortunately, sulfonylurea poisoning has a "rescue;" giving these children glucose can save their lives.
Dan Childs contributed to this report.