Pediatric Poisoning: Diagnosis and Management

Initial Stabilization and Assessment

Immediately assess and stabilize airway, breathing, and circulation (ABCs) before any diagnostic workup or decontamination attempts. 1, 2 Most pediatric poisonings are accidental in children under 5 years and fortunately result in minimal morbidity, but rapid deterioration can occur even in initially stable-appearing children. 2, 3

Primary Survey Priorities

Airway management: Establish patent airway and provide bag-mask ventilation if respiratory depression present; proceed to endotracheal intubation for patients unable to protect airway reflexes. 4
Breathing support: Correct hypoxia immediately as it drives most toxin-related morbidity and mortality. 4, 2
Circulation: Address hypotension and dysrhythmias; correct acidosis as it potentiates many toxic effects. 2
Dextrose and naloxone: Administer empirically for altered mental status—check bedside glucose and give naloxone 0.1 mg/kg IV/IO/IM for suspected opioid involvement. 4

Critical Pitfall

Children can experience profound effects from small medication amounts and may appear compensated initially before rapid hemodynamic or mental status collapse. 2, 3 Never assume stability based on initial presentation.

Toxidrome Recognition

Identifying the toxidrome—the constellation of signs and symptoms characteristic of specific poison classes—is essential when the ingested substance is unknown. 1, 5, 6

Major Toxidromes to Recognize

Anticholinergic syndrome:

Dilated pupils, dry flushed skin, hyperthermia, urinary retention, decreased bowel sounds, agitation, delirium. 2, 5
Common sources: antihistamines, tricyclic antidepressants, atropine-containing plants. 5

Cholinergic syndrome:

Miosis, salivation, lacrimation, urination, defecation, bronchorrhea, bronchospasm, bradycardia. 2, 5
Sources: organophosphate/carbamate pesticides, nerve agents. 4, 5
Treatment: Atropine 0.02 mg/kg doubled every 5 minutes until drying of secretions; pralidoxime 20-50 mg/kg for organophosphates. 4

Opioid toxidrome:

Miosis, respiratory depression, decreased level of consciousness, bradycardia, hypotension. 2, 5
Treatment: Naloxone 0.1 mg/kg IV/IO/IM or 2-4 mg intranasal; titrate to restore respiratory drive and protective reflexes, not full consciousness. 4

Sympathomimetic syndrome:

Mydriasis, diaphoresis, hyperthermia, tachycardia, hypertension, agitation, seizures. 2, 5
Sources: cocaine, amphetamines, decongestants. 5

Sedative-hypnotic toxidrome:

CNS depression, respiratory depression, hypotension, hypothermia. 4, 5
Benzodiazepines cause this through GABA-A receptor agonism. 4

Diagnostic Evaluation

History Taking Essentials

Obtain the "5 Ws" of poisoning: What substance, When ingested, Where it occurred, Why it happened (accidental vs intentional), and hoW much was taken. 6, 3

Medication access: Identify all medications in household, including visitors' medications and grandparents' pillboxes. 6, 3
Timing: Exact time of ingestion determines peak toxicity window and decontamination window. 6
Coingestants: Assume polypharmacy ingestion until proven otherwise, especially in adolescents. 4, 2
Pica behavior: Ask about mouthing objects or eating non-food items—critical for lead poisoning and foreign body ingestions. 4, 7

Physical Examination Focus

Vital signs: Temperature, heart rate, blood pressure, respiratory rate, oxygen saturation—abnormalities guide toxidrome identification. 2, 6
Pupil size and reactivity: Miosis vs mydriasis narrows differential significantly. 5, 6
Skin findings: Diaphoresis, flushing, cyanosis, needle tracks. 5, 6
Neurologic status: Glasgow Coma Scale, focal deficits, seizure activity. 6, 3
Cardiac monitoring: Continuous ECG for QRS widening (sodium channel blockers), QT prolongation (multiple agents), dysrhythmias. 4, 2

Laboratory Studies

Order basic metabolic panel, liver function tests, and renal function tests for all symptomatic poisonings to identify electrolyte derangements and end-organ dysfunction. 2, 6

Anion gap metabolic acidosis: Calculate anion gap; if elevated, consider toxic alcohols, salicylates, metformin, iron. 2, 6
Osmolar gap: If elevated with anion gap acidosis, suspect methanol or ethylene glycol. 2
Specific drug levels: Acetaminophen and salicylate levels should be obtained universally in intentional ingestions; other levels (digoxin, theophylline, valproate, lithium, iron) based on history. 2, 6
Pregnancy test: Mandatory in all females of childbearing age. 6
Abdominal radiography: Consider for children with pica or suspected ingestion of radiopaque substances (iron, lead, heavy metals). 4, 7

Gastrointestinal Decontamination

Activated charcoal is the decontamination method of choice, but should NOT be used universally—only when benefit clearly outweighs risk. 1, 2, 6

Activated Charcoal Administration

Dosing: 1 g/kg (maximum 50 g) orally or via nasogastric tube. 4
Timing window: Most effective within 1 hour of ingestion; limited benefit after 2 hours for most substances. 2, 6
Indications: Potentially toxic ingestion of substance known to bind to charcoal, patient has intact or protected airway. 2, 6

Contraindications to Activated Charcoal

Unprotected airway: Risk of aspiration pneumonitis exceeds any benefit. 4, 6
Substances not adsorbed: Alcohols, hydrocarbons, caustics, heavy metals (iron, lithium, lead), potassium. 1, 6
Gastrointestinal pathology: Bowel obstruction, perforation, recent surgery. 6

Alternative Decontamination Methods

Whole bowel irrigation: Polyethylene glycol solution 25 mL/kg/hour (up to 2 L/hour in adolescents) until rectal effluent is clear. 1

Indications: Sustained-release preparations, iron overdose, body packers, substances not bound by charcoal. 1, 6

Gastric lavage: No longer recommended routinely; only consider within 1 hour of life-threatening ingestion when charcoal cannot be used. 6

Syrup of ipecac: Contraindicated—no role in modern poisoning management. 6

Specific Antidote Therapy

Opioid Poisoning

Naloxone is the antidote of choice; administer immediately for respiratory depression regardless of other suspected coingestants. 4

Pediatric dosing: 0.1 mg/kg IV/IO/IM; intranasal 2-4 mg repeated every 2-3 minutes as needed. 4
Titration goal: Restore adequate respiratory drive and protective airway reflexes, NOT full consciousness. 4
Maintenance infusion: Two-thirds of waking dose per hour if repeated boluses needed. 4
Critical point: In suspected combined opioid-benzodiazepine poisoning, administer naloxone FIRST before considering flumazenil. 4

Benzodiazepine Poisoning

Flumazenil can reverse benzodiazepine-induced respiratory depression in SELECT low-risk patients, but has significant contraindications. 4

Pediatric dosing: 0.01 mg/kg titrated up to 1 mg. 4
Safe scenarios: Pediatric exploratory ingestions, iatrogenic procedural sedation overdoses when high-risk conditions excluded. 4
Absolute contraindications: Chronic benzodiazepine use (risk of withdrawal seizures), coingestion of proconvulsant drugs (tricyclic antidepressants), preexisting seizure disorder, cardiac arrest. 4
Adverse effects: Seizures, ventricular dysrhythmias, asystole—particularly dangerous with coingestants. 4

Organophosphate/Carbamate Poisoning

Atropine is the cornerstone of treatment; titrate aggressively to dry secretions and reverse bronchospasm. 4

Pediatric dosing: 0.02 mg/kg doubled every 5 minutes until atropinization achieved (dry secretions, improved oxygenation). 4
Maintenance infusion: 10-20% of total loading dose per hour (up to 2 mg/hour in adults). 4
Pralidoxime: Add for organophosphates (NOT carbamates): 20-50 mg/kg loading dose, then 10-20 mg/kg/hour infusion. 4
Endpoint: Clinical improvement in muscarinic symptoms, not cholinesterase levels. 4

Calcium Channel Blocker/Beta-Blocker Toxicity

High-dose insulin euglycemia therapy is first-line for severe calcium channel blocker or beta-blocker poisoning with shock. 4

Insulin dosing: 1 unit/kg IV bolus, then 1-10 units/kg/hour infusion titrated to hemodynamic response. 4
Dextrose coadministration: Give 0.5 g/kg dextrose with insulin bolus; prepare continuous dextrose infusion to maintain euglycemia. 4
Monitoring: Check glucose every 15-30 minutes initially, potassium hourly (anticipate hypokalemia requiring aggressive repletion). 4

Calcium supplementation: Calcium chloride 20 mg/kg (0.2 mL/kg of 10% solution) IV push for cardiac arrest; infuse over 30-60 minutes for other indications. 4

Maintenance infusion: 20-40 mg/kg/hour; titrate to blood pressure without exceeding ionized calcium 1.5-2 times upper limit of normal. 4
Preferred route: Central venous access, especially in children (peripheral extravasation causes severe tissue injury). 4

Glucagon: 0.05-0.15 mg/kg (maximum 2-10 mg) IV bolus, then 1-15 mg/hour infusion; anticipate vomiting. 4

Atropine: 0.02 mg/kg for symptomatic bradycardia unresponsive to other measures. 4

Sodium Channel Blocker Toxicity (Tricyclic Antidepressants, Cocaine)

Sodium bicarbonate is the specific antidote; administer for QRS widening >100 msec or ventricular dysrhythmias. 4

Pediatric dosing: 1-3 mEq/kg IV bolus given slowly. 4
Target pH: 7.45-7.55 (alkalemia narrows sodium channels and reverses cardiotoxicity). 4
Maintenance infusion: Prepare 150 mEq/L solution (3 ampules in 1 L D5W), infuse at 1-3 mL/kg/hour. 4
Monitoring: Arterial blood gas every 30-60 minutes; watch for hypernatremia, hypokalemia, alkalemia. 4
Note: Use 0.5 mEq/mL concentration for neonates; different formulations exist for adults (1 mEq/mL) vs children. 4

Digoxin Toxicity

Digoxin-specific antibody fragments (Fab) are indicated for life-threatening dysrhythmias or hyperkalemia from digoxin. 4

Acute overdose: 1 vial per 0.5 mg digoxin ingested (1 vial = 40 mg Fab). 4
Chronic toxicity: Dose (vials) = [serum digoxin (ng/mL) × weight (kg)] / 100. 4
Empiric dosing: 10-20 vials for critically ill patient with unknown ingested dose. 4

Cyanide Poisoning

Hydroxocobalamin is first-line antidote for suspected cyanide poisoning (smoke inhalation, industrial exposure). 4

Pediatric dosing: 70 mg/kg IV (adult dose 5 g). 4
Alternative: Sodium nitrite 6 mg/kg IV (watch for hypotension) plus sodium thiosulfate 250 mg/kg IV. 4

Methemoglobinemia

Methylene blue is indicated for symptomatic methemoglobinemia or methemoglobin level >20%. 4

Dosing: 1-2 mg/kg IV over 5 minutes; repeat every hour if needed (maximum cumulative dose 5-7 mg/kg). 4
Contraindication: G6PD deficiency (causes hemolysis). 4

Lead Poisoning: Special Considerations

Lead poisoning requires a distinct diagnostic and management approach focused on environmental remediation and chelation for severe cases. 4, 7, 8, 9

Blood Lead Level Interpretation

≥5 μg/dL (≥50 ppb): Elevated—requires intervention and environmental investigation. 4, 7, 8
15-44 μg/dL: Confirm with repeat venous sample within 1-4 weeks; consider abdominal radiography if pica history present. 4
>44 μg/dL: Urgent confirmation within 48 hours; contact Pediatric Environmental Health Specialty Unit (888-347-2632) or Poison Control (800-222-1222) for chelation guidance. 4, 7

Management by Blood Lead Level

5-14 μg/dL:

Retest venous lead within 1-3 months to verify trend. 4, 8
Report to local health department; request home inspection. 4, 8
Screen for iron deficiency (increases lead absorption); start multivitamin with iron. 4, 8
Nutritional counseling emphasizing iron-enriched foods and adequate calcium. 4, 8
Structured developmental screening at all visits. 4, 8

15-44 μg/dL:

All interventions above PLUS abdominal radiography if pica behavior present. 4
Gut decontamination if leaded foreign bodies visualized. 4
Consult toxicology or PEHSU before any chelation. 4

>44 μg/dL:

Confirm within 48 hours with repeat venous sample. 4, 7
Strongly consider chelation therapy, particularly if symptomatic or unsafe home environment. 7, 9
Critical: Child must be removed from contaminated environment BEFORE chelation or lead source eliminated—ongoing exposure during chelation paradoxically increases lead absorption. 7
Hospitalization may be necessary depending on home safety, social situation, chronicity. 4, 7

Environmental Investigation

Housing built before 1960 (especially pre-1940) has 68% lead hazard prevalence—this is the highest-yield history element. 8

Recent renovations or repairs in past 6 months. 8
Deteriorating paint, visible paint chips on interior/exterior surfaces. 8
Soil contamination near roadways or industrial sites. 8
Imported spices, cosmetics, folk remedies, pottery, cookware. 8
Parental occupational exposures causing take-home contamination. 8

Developmental Considerations

No safe threshold exists for lead exposure—even levels <5 μg/dL associated with decreased IQ and neurodevelopmental problems. 8, 9

Greatest IQ decrements occur at lower blood lead concentrations (nonlinear relationship). 8
Immediate referral to early intervention programs (Part C services for children <3 years). 8
Enriched, nurturing environments help counteract negative effects. 8
Lead exposure peaks at 18-36 months, making intervention time-sensitive. 8

Supportive Care Principles

Most pediatric poisonings require only supportive care as specific antidotes exist for limited toxins. 1, 5, 3

Seizure Management

Benzodiazepines first-line: Diazepam 0.1-0.3 mg/kg IV/IO or lorazepam 0.05-0.1 mg/kg. 4
Correct hypoglycemia, hypoxia, hyperthermia—common precipitants in poisoning. 2, 3
Avoid phenytoin in drug-induced seizures (often ineffective). 3

Dysrhythmia Management

Sodium bicarbonate: For wide-complex tachycardia from sodium channel blockers. 4
Magnesium sulfate: 25-50 mg/kg IV for torsades de pointes. 4
Avoid: Class Ia and Ic antiarrhythmics in poisoning-related dysrhythmias. 4

Hypotension Management

Crystalloid resuscitation: 20 mL/kg boluses up to 60 mL/kg total. 3
Vasopressors: Norepinephrine preferred for distributive shock; avoid pure beta-agonists in beta-blocker/CCB toxicity. 4
Specific antidotes: Prioritize insulin, calcium, glucagon for CCB/beta-blocker toxicity over pressors. 4

Hyperthermia Management

Aggressive cooling: Evaporative cooling, ice packs to groin/axilla, cooled IV fluids. 5, 3
Benzodiazepines: For agitation-induced hyperthermia (sympathomimetics, serotonin syndrome). 5
Avoid antipyretics: Acetaminophen and NSAIDs ineffective for drug-induced hyperthermia. 5

Disposition and Monitoring

All symptomatic children require hospital admission for continuous monitoring until symptom resolution. 2, 6

Admission Criteria

Any abnormal vital signs or altered mental status. 2, 6
Ingestion of substance with delayed toxicity (acetaminophen, sustained-release preparations, toxic alcohols). 2, 6
Intentional ingestion in adolescents (psychiatric evaluation required). 6
Inadequate home supervision or concern for non-accidental ingestion. 6, 3

Observation Period

Minimum 4-6 hours: For most immediate-release medications if asymptomatic. 2, 6
24 hours: Sustained-release preparations, substances with delayed toxicity. 2, 6
Serial monitoring: Vital signs every 15-30 minutes initially, then hourly once stable. 6

Discharge Criteria

Asymptomatic for appropriate observation period. 2, 6
Normal vital signs and mental status. 6
Reliable caregiver and safe home environment. 6
Poison control follow-up arranged. 6

Prevention and Poison Control Resources

Contact Poison Control Center (800-222-1222) for ALL poisoning cases—expert guidance available 24/7. 6, 3

Pediatric Environmental Health Specialty Units: www.pehsu.net or 888-347-2632 for lead and environmental toxin guidance. 4, 7
CDC Lead Poisoning Resources: www.cdc.gov/nceh/lead or 800-CDC-INFO (800-232-4636). 4

Prevention Counseling

Store all medications and household products in locked cabinets out of children's reach. 6, 3
Use child-resistant packaging (not child-proof—delays but doesn't prevent access). 3
Never refer to medications as "candy." 3
Dispose of unused medications properly through take-back programs. 6
Post Poison Control number (800-222-1222) prominently in home. 6

Provide a comprehensive overview of the diagnosis and management of pediatric poisoning.

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