What’s new in critical illness and injury science? Pediatric poison prevention – No more “accidents”

A mother brings her child to the pediatric emergency department (ED) with a chief complaint of “bleach ingestion”. The triage note reads: “Mom had stored bleach in an empty bottle of ginger ale. Her child found the bottle on the kitchen countertop and took a few sips thinking that it was soda. Upon realizing what had happened, the mother made him vomit and immediately presented to the ED for evaluation of this accidental ingestion.” Several questions immediately come to mind after reading the triage note. Why was bleach disguised in a bottle of ginger ale? Why was it left out on the kitchen counter? Finally, why did the mother induce emesis in her child? While this is just one example of the many types of pediatric exposures that can occur in the household, it highlights a critical theme: there is still much work to be done in terms of pediatric poison prevention. In 2023, the National Poison Data System reported approximately one million potential toxic exposures to children < 6 years of age.[1] These patients have the highest rate of ED visits for medication-related toxic exposures and account for nearly half of all total reported exposures.[1] Unsurprisingly, 99% of these pediatric exposures are reported as unintentional.[1] Pediatric exposures are directly related to their changing cognitive and motor development, putting those aged 5 years and under at the highest risk for exploratory ingestions, as children in this age group tend to explore their environments by touching, licking, and ingesting anything and everything they can find. The home, generally regarded as a “safe space,” is in reality a breeding ground for exploratory ingestions, but it is unfair to assume that a caregiver inherently knows how to keep the home safe and what to do in the event of an emergency. Along with many other aspects of health-related care, caregivers are not expected to shoulder this responsibility alone, and for pediatricians and all clinicians working in pediatrics, this is where primary prevention plays a crucial role. Since the Poison Prevention Packaging Act in 1970, there has been a considerable reduction in pediatric mortality from medication-related overdose.[2] However, this reduction has since plateaued and, in fact, has increased over the last several years.[1] With polypharmacy and the prevalence of edible cannabis products on the rise in and around the household, pediatric ingestions continue to rise exponentially.[3,4] Medications, when compared to nonpharmaceutical products, were responsible for 70% of all ED visits for exposures, 81% of which were in patients younger than 5 years of age.[3] Recent trends indicate that increasing adult drug prescriptions (e.g. opioids, beta-blockers, antihypertensives, and hypoglycemic agents) are associated with rising rates of pediatric exposures and poisonings.[5] Unfortunately, safe storage practices are lacking, particularly in households with prescription opioids, which have now become the leading cause of pediatric poison-related mortality.[6,7] New trends continue to emerge, and the changing landscape of policy and regulation has most recently led to increasing access to tetrahydrocannabinol (THC) products and a subsequent 1375% increase in exploratory pediatric THC ingestions in the form of edible preparations.[4] Similar to pharmaceuticals, caregivers may not recognize the risk imposed by simply having edible THC products present, and as these substances become more commonplace, their risks inherently increase too. Accordingly, we are witnessing a steep rise in THC exposures and a corresponding increase in hospital admission to both the general and critical care units.[4] Despite the growing data on unintentional exposures, it seems as though we have taken a passive approach to prevention. Caregivers may only receive poison prevention education for the first time in the ED after an exploratory ingestion, but what if by then, it is too late? For change to occur, we must reframe our perspective and understanding of pediatric poison prevention to bring this growing problem to the forefront of routine preventative care. It starts by recognizing that regardless of where we work or what specialty we practice, by virtue of working in pediatrics, we all have the power to influence the environment in which our patients live. However, these patient encounters are unfortunately limited by time and competing responsibilities. In order to be effective, we must incorporate standardized routine anticipatory guidance and medication screening tools for patients in the ambulatory, emergency, and inpatient settings to circumvent these barriers and help facilitate screening in a more consistent and efficient manner. We must be creative in taking advantage of any available time, starting with “waiting” time. One such method includes using pediatric poison prevention and medication safety campaigns that can be read, watched, or listened to in waiting areas, patient rooms, and at pharmacies at the time of medication dispense or purchase. Distributing these easy-to-use resources (e.g. pamphlets, videos, fliers, and posters) in a variety of settings will emphasize the importance of this rising problem and offer opportunities for families to learn more as they “wait.” Integrating screening questions at the time of discharge from the ED or routinely during clinic well-visits that inquire about recreational substance use at home (i.e. cannabis) by any household member should be considered. Moreover, asking caretakers how they store their pharmaceuticals is essential in starting the discussion about safe storage and offering a practical solution by distributing lock boxes to high-risk households. While the Poison Prevention Packaging Act in 1970 was a tremendous step forward in medication safety, perhaps federal legislation is now needed to tackle the risk of pediatric THC exposure, given that cannabis products are often packaged in a manner that entices pediatric patients with the use of cartoons, bright colors, and fruit or candy flavors.[8] In today’s technology-driven world, social media can serve as a viable platform to deliver public health messaging.[9] To date, social media has been used to promote safe practices regarding smoking cessation, exercise, and diet.[10–12] In fact, some evidence suggests that social media is further reaching than traditional media due to the interactive nature between content creators and users.[13,14] Social media campaigns driven by public health institutions such as regional poison control centers offer a unique avenue to reaching a mass audience to raise awareness on the subject matter. Finally, we must be mindful and intentional during encounters to foster a psychologically safe environment for families to speak free of judgment and condemnation when we inquire about substance use in or around the home. Concepts such as safe storage and “up and away” are paramount and need to be addressed methodically and periodically to raise awareness and motivate action. Normalizing these discussions in all three settings (inpatient, emergency, and ambulatory care), especially early on, will ultimately facilitate opportunities for intervention by distributing both educational and practical resources for medication safety practices. After an exposure, there is a dangerous tendency for both caregivers and clinicians to refer to the sentinel event as an “accident.” Perhaps this is one of our biggest faults. But why? To some, the term “accident” implies an act of deity – an event that could not have been prevented. When referring to such events as “accidental,” it absolves all those involved – both caregivers and healthcare providers. We believe calling such events “unintentional” or “exploratory” (as opposed to “accidental”) sets a standard for our patients and the healthcare community at large, that we can prevent anything if we strive to do so. As healthcare providers, we must believe that we live and practice in a world where we can prevent anything and everything; otherwise, we have lost purpose in what we do. This is the spirit of preventative medicine, and specifically, pediatrics. Recognizing this and the barriers that we currently face, we must work together in a variety of settings to actively normalize discussions about medication safety, raise awareness, and disseminate practical resources to the community, and hopefully together, we can change these preventable statistics.