W. Steven Pray, PhD, DPh; Joshua J. Pray, PharmD candidate

Disclosures

US Pharmacist. 2004;29(3) 

Among the phone calls that pharmacists field are those related to accidental childhood poisoning episodes. The interchange is often fraught with tension as distraught parents and/or caregivers attempt to discover the best course of action to limit danger to the child.

Statistics on poisoning deaths vary greatly. The Poison Prevention Week Council (PPWC) estimates that adults place one million phone calls yearly for help with childhood poisonings and that 30 children die from accidental poisonings each year.[1,2] The CDC provides this data for all age groups:

  • Poison control centers reported 2.2 million poison exposures in 2000 (one every 15 seconds). Of these, 52.7% occurred in children younger than 6.[3]

  • In 1999, national vital statistics databases recorded 19,741 poisoning deaths in adults and children; poison control centers reported 920 deaths in 2000.

Although the figures given above are startling, they would undoubtedly be far worse if it were not for the efforts of the PPWC. This body has its beginnings in a law, the origin of which is seldom reported in the public media. Homer A. George was a Missouri pharmacist who was troubled by the paucity of information regarding antidotes for pharmaceutical products.[4] He also noticed that existing references presented conflicting information on treatment. However, he gradually realized that rather than focusing on treating the problem once it had occurred, the most rational approach would be a massive public health effort to prevent childhood poisonings. To implement his plan, he approached the mayor of Cape Girardeau in 1958, eventually convincing him to proclaim a Poison Prevention Week.[5] George then persuaded the governor of Missouri to designate a statewide Poison Prevention Week. Buoyed by these successes, George ultimately convinced his congressional representative to introduce legislation in the 86th US Congress. It gained the support of the Public Health Service (PHS), the American College of Apothecaries, and the American Pharmaceutical Association (APhA). As a result, President John F. Kennedy signed a bill on September 16, 1961, that authorized the president to designate the third week in March as National Poison Prevention Week.[6] To organize this, APhA and PHS held an initial meeting in which 21 professional, industrial, and service organizations and federal agencies agreed to spearhead the effort. The number of cooperating organizations has now reached 37, all having an interest in and commitment to preventing poisonings.

This year's National Poison Prevention Week is March 21 to 27 and will focus on poisonings in children younger than 5.[6] The overlying theme of this year's Poison Prevention Week is "Children Act Fast … So Do Poisons!"[1,3]

Pharmacists who practiced in the 1970s may vividly remember attempting to find the number of a poison control center to assist a frantic caller. Each poison control center had its own number, greatly complicating matters. For instance, a pharmacist who had recently moved to a new area would be unfamiliar with the telephone number of the local poison control center. Similarly, parents who were traveling would not know the number of the poison control center located where they were staying. This issue was simplified on January 30, 2002, with the launch of a national toll-free poison control phone number: (800) 222-1222.[7] The number automatically connects the caller to his or her local poison control center, 24 hours a day, seven days a week. The hotline received 44,000 calls the first month and now logs one million calls yearly.[7,8]

Concerned parents who attempt to purchase nonprescription poison control products discover that the range of possibilities is quite restricted. Syrup of ipecac was once recommended for every household with young children but recently has fallen under a cloud of suspicion. Activated charcoal is an effective nonprescription poison adsorbent, but it typically is not displayed prominently in retail pharmacies.

Ipecac was a well-accepted poison treatment until several months ago. At that time, two unrelated problems began to dovetail. One was a continuing question regarding the usefulness of ipecac. The other was burgeoning evidence of widespread abuse of ipecac by people with anorexia and bulimia.

The ability of ipecac to induce vomiting in the poisoned patient has been thought to limit the extent of toxin absorption. An FDA advisory panel recommended its approval for this use in 1982; FDA concurred in a 1985 publication. A final ruling has not yet appeared.

However, a serious challenge to ipecac appeared in the journal Pediatrics in November 2003 in a paper entitled, "Home syrup of ipecac use does not reduce emergency department use or improve outcome."[9] The author researched poisonings in children younger than 6 in 2000 and 2001 as reported to the American Association of Poison Control Centers‚ Toxic Exposures Surveillance System Database. Specifically, he examined blinded data from 64 centers, including whether ipecac was used at home, the rate of referral to emergency departments, the actual rate of emergency department usage, and the eventual outcome of the case. He discovered that 1.8% of patients were administered syrup of ipecac at home. The mean rate of referral to an emergency department was 9% of ingestions (9.59% in centers with a higher rate of ipecac use versus 9.02% in centers with a lower rate of ipecac use); only 0.58% of patients had an adverse outcome (the figure was identical in centers with high and low rates of ipecac use). In comparing those who ingested ipecac to those who did not, it became clear that administration of ipecac did not affect referral to an emergency department, nor did it affect the rate of adverse outcomes.

In the same issue of Pediatrics, the American Academy of Pediatrics (AAP) Committee on Injury, Violence, and Poison Prevention issued a policy statement on poison treatment in the home.[2] It discussed AAP's past recommendation that households with young children keep a 1-oz bottle of syrup of ipecac in the home to be used only on the advice of a physician or poison control center. In light of the study cited above, however, AAP updated its policy, recommending against keeping ipecac in the home, further recommending that ipecac presently in the home be disposed of safely. It cited several additional reasons for this change in policy:

  • Ipecac does not completely remove a toxin from the stomach. Further, tablets often remain in the stomach after a bout of ipecac-induced vomiting.[10]

  • Adverse effects of ipecac include persistent vomiting, lethargy, and diarrhea, occurring in 13% to 17%, 12% to 21%, and 8% to 13% of patients, respectively. Lethargy can complicate assessment of patients who ingest sedative medications.

  • Ipecac is mistakenly given to 61% of children who ingest nontoxic substances because their parents or caregivers fail to call a health care professional prior to administration.

  • Persistent ipecac-induced vomiting may cause patients to expel needed interventions, such as activated charcoal, N-acetylcysteine, or whole-bowel irrigations.

  • Ipecac is abused by people with eating disorders and by child caregivers with Munchausen syndrome by proxy who administer ipecac to those in their care. (One can find on the Internet the death certificate of singer Karen Carpenter. The primary cause of death, thought for years to be anorexia nervosa, is prominently listed as emetine cardiotoxicity, sustained as a result of longstanding ingestion of ipecac.[11])

FDA has approved activated charcoal in treatment of poisoning as an adsorbent agent. However, this may be problematic for pharmacists in making recommendations for its routine use at home. Manufacturers seldom advertise activated charcoal products to pharmacies. When contacted, they seem ambivalent about retail pharmacies stocking their products. The AAP stopped short of recommending its routine use in the home for these reasons:[2]

  • It is poorly accepted by pediatric patients because of its black color and unpleasant, gritty taste (in emergency departments, it is most often given via nasogastric tube).

  • As a result of long-term storage, particles settle into dense cakes that fail to resuspend with normal efforts at shaking the bottle. Parents may unknowingly give a dose that is mostly vehicle, assuming that it will be effective.

  • It is often vomited and stains linens and surfaces.

  • Routinely stocking activated charcoal at home may lead to overuse and inappropriate use.

The growing controversy over ipecac and the limited availability of activated charcoal severely restricts the choices available to the community pharmacist. At this time, pharmacists should refer all callers to the National Poison Control Hotline for expert assistance.

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