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Epidemiological study of acute poisoning in children: a 5-year retrospective study in the Paediatric University Hospital in Białystok, Poland
  1. Urszula Pawłowicz1,
  2. Anna Wasilewska2,
  3. Witold Olański1,
  4. Marta Stefanowicz2
  1. 1Hospital Emergency Department (HED), Paediatric University Hospital (PUH), Białystok, Poland
  2. 2Department of Pediatrics and Nephrology, Medical University of Białystok, Białystok, Poland
  1. Correspondence to Professor Anna Wasilewska, Department of Paediatrics and Nephrology, Medical University of Białystok, Waszyngtona 17, 15-274 Białystok, Poland, annwasil{at}interia.pl

Abstract

Background Poisoning among children and youths in the northeastern part of Poland accounted for 25% of the total number of patients admitted to the Hospital Emergency Department of the Paediatric University Hospital of Bialystok.

We hypothesise that the epidemiology of poisoned paediatric patients admitted is related to increase in ‘designer drugs’ (mainly amphetamine- and ecstasy-like psychostimulants, hallucinogens and synthetic cannabinoids (‘spice’) intake, which became popular 5 years ago in our country.

Methods A retrospective chart review of medical records of 489 patients admitted due to poisoning in the 5-year period (2006–2010). The data included: age, sex, place of residence, nature of the substance, causes of poisoning, former use of psychoactive stimulants, accompanying self-mutilation and injuries and length of hospitalisation. Categorical variables were expressed as percentages, and continuous variables as mean and SD. The data were collected in a Microsoft Excel database. Statistical analysis was performed using the Statistical Programme for Social Sciences.

Results Out of 2176 hospitalised children, 489 were admitted because of poisoning. Out of these, 244 (49.9%) were hospitalised due to intoxication by alcohol. Only eight children used designer drugs. The mean age of all patients in our group was 12.86±5.04 years, of which 52.4% were male. Poisoning was intentional in 75.5%, and accidental in 24.5% of cases. Appearance of ‘designer drugs’ had no significant impact on the number and epidemiology of poisonings in our group.

  • poisoning
  • alcohol abuse
  • drug abuse
  • paediatric emergency med
  • toxicology

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Introduction

Poisoning is considered one of the significant causes of morbidity and mortality in children.1 ,2 It accounts for about 3% of hospital referrals. Poisoning occurs when any substance interferes with normal body functions after it is swallowed, inhaled, injected or absorbed. The incidence of poisoning has been increasing,1 and cases of poisoning continue to be a major problem in emergency medicine practices.3 According to 1998 American Toxic Exposure Surveillance System data, it has been shown that 2.2 million cases of poisoning are reported annually in the USA and 1.5 million of these cases are children4 and adolescents.1 ,5 ,6 The most frequently taken drugs include benzodiazepines, acetaminophen, alcohol, antidepressants, antipsychotics, anticonvulsants and non-therapeutic substances.4 Since the 1990s, a growing number of cases of abusing various psychoactive substances by children and adolescents have also been observed in Poland. Causes of poisonings and types of factors show variability in different countries and even different regions of the same country. Therefore, a toxicity profile of each region should be identified individually.

The aim of this study was to observe the epidemiological trends in paediatric intoxications in our region. We assessed the number of children hospitalised due to intoxication in the 5-year period, from 1 January 2006 to 31 December 2010 at the Hospital Emergency Department (HED) of the Paediatric University Hospital (PUH) in Bialystok. We hypothesise that the epidemiology of poisoned paediatric patients admitted is related to increase in designer drugs intake, which became popular 5 years ago in our country. ‘Designer drug’ is defined as a drug with properties and effects similar to a known hallucinogen or narcotic but having a slightly altered chemical structure, especially such a drug created in order to evade restrictions against illegal substances. Based on the spectrum of their actions on the cognitive processes, mood and behaviour, ‘legal highs’ can be classified into three basic categories: amphetamine- and ecstasy-like psychostimulants, hallucinogens and synthetic cannabinoids (‘spice’).

Methods

The study was conducted on poisoned children and adolescents in the northeastern part of Poland admitted to the HED of the PUH of Bialystok.

The study protocol was approved by the ethics committee, Medical University of Bialystok, and was conducted in accordance with the Declaration of Helsinki.

A retrospective chart review of medical records of 489 patients admitted due to poisoning in the 5-year period (2006–2010). The data included: age, sex, place of residence, nature of the substance and causes of poisoning, former use of psychoactive stimulants, previous suicidal attempts and admissions caused by these, condition of the patient after admission, accompanying self-mutilation and injuries, length of hospitalisation and information on where the patient was discharged to. Epidemiology characteristics were studied in six age groups: <1, 1–3, 4–7, 8–12, 13–15, 16–18 years of age. Poisonings were categorised as intentional or accidental. The existence of a connection between the poisonous substance and trauma, suicidal attempts and the condition of the patient after admission were also analysed. Poisonings were divided into four categories, depending on the kind of the poisonous substance: alcohol, medications and narcotics—including designer drugs, and others—mainly substances found at home.

The clinical follow-up and severity of each case is graded using the AVPU scale (A-Alert—conscious, oriented; V-Verbal—responds to verbal instructions; P-Pain—responds to painful stimuli; U-Unresponsive—unconscious, responds to no stimuli).

The data were collected in a Microsoft Excel database. Statistical analysis was performed using the Statistical Programme for Social Sciences. Categorical variables were expressed as percentages, and continuous variables as mean and SD.

Results

During the study period, out of 2176 children hospitalised at the hospital emergency unit, 489 were admitted because of poisoning, which accounted for 25% of the total number of patients. A thorough analysis showed that in the years 2006 and 2007 the number of children admitted to the HED due to poisoning remained the same (15.3% in 2006 and 15.1% in 2007). The largest percentage of poisonings was recorded in 2008 (28.8%), and since that year the percentage of hospitalisations due to poisoning have remained the same. During that time, the overall number of children admitted to the HED increased despite the population staying at the same level. It might be the result of reorganisations in healthcare and patients being taken over from other hospitals in the area. (Source: Central Statistical Office of Poland).Table 1 shows the characteristics of patients analysed.

Table 1

Characteristics of patients analysed

The average age of children in the whole study group was 12.86±5.04 years. The most numerous group consisted of youths 16–18 years of age, while postprimary school adolescents and children constituted as many as 77% of the study group. Another frequently hospitalised group was the group of young children (under 3 years.), which included 13.5% of all the poisoned patients. Poisonings were slightly more frequent in boys compared with girls. We found 75.5% of poisonings to be intentional, while only 24.5% were accidental. Worth noting is the fact that single intentional poisonings occurred in the third age group, although they were usually experimental in nature. In the 8–12 age groups, intentional poisonings were still a minority. However, in older groups: 13–15 and 16–18 yrs. they were more likely, and accounted for 155/168 and 201/208, respectively. Notably, suicide attempts occurred from the age of 13 onwards. Accidental poisonings occurred mainly in the first four age groups.

Poisonings in urban children were more likely than in rural children, at 18% and 82%, respectively. Two-thirds of urban children resided in Białystok. Patients admitted to the HED due to a first-time poisoning were a vast majority. Successive hospitalisations due to the same reason constituted only 6.3%. A total of 208 individuals provided information on previous use of psychoactive substances, out of which 25% responses were positive. Previous suicide attempts were confirmed by seven individuals.

A further analysis was conducted with a view to assessing whether the time (month and day of the week) has the influence on the number of patients hospitalised at the HED due to poisoning. The number of poisonings, monthwise, is presented in figure 1.

Figure 1

The number of poisonings (percentage in the whole patients hospitalised in each month) monthwise.

When analysing the overall number of poisonings split monthwise, the most evident phenomenon was a significant drop in the frequency of poisonings in the summer holiday months (July, August). The frequency of poisonings, mainly with alcohol, increased in the school period on non-school days. With respect to days of the week, it was found that the most HED admissions occurred on Fridays (70/489). Intentional poisonings were most frequently hospitalised on Saturdays (52/369) and Sundays (58/369), and the frequency of accidental poisonings increased considerably on weekdays. Poisoning percentages by the substance in the whole study group are presented in figure 2. The most frequently used drugs included: Ibuprofen, acetaminophen, antiepileptic drugs, antidepressants, sedatives and soporifics, neuroleptics, cough drugs, contraceptives, hypotension drugs and vitamins. Designer drugs were classified as narcotics. The ‘other’ category includes mainly household chemicals and carbon monoxide.

Figure 2

The number of poisonings in the whole study group by the substance.

As can be seen in the above figure, poisonings in the group of children studied were most often caused by alcohol (244/489) and drugs (156/489). Intentional poisonings usually involved the consumption of alcohol or narcotics, also including designer drugs, while accidental poisonings were most often caused by drugs (2/3 of drug poisonings are accidental) or substances classified as ‘other’.

Alcohol poisonings occurred for the first time at age 6 years, and accounted for 5.6% of cases among 8–12-year-olds. Their frequency grows considerably in the 13–15 age group (up to 41%), with as many as 54% of all alcohol poisonings falling in the 16–18 age group. Among all those poisoned by alcohol, boys were a majority (148/244).

Among drug poisonings, two increased frequency periods were noted. In younger children, between 1 and 3 years of age—27.5% (43/156 cases)—those were mainly accidental poisonings. In older children, 13–15  and 16–18 years of age, it was 28.2% (44/156) and 37.8% (59/156), respectively. A majority of poisonings in these age groups were intentional. In the whole group of drug-poisoned children, girls were a majority (97/156).

In the narcotics category, although it only ranked third as a cause of poisoning leading to hospitalisations (23/489), particular attention must be paid to designer drugs, besides marihuana and amphetamine. Eight children were admitted because of the use of designer drugs. Poisonings by substances classified as ‘other’ occurred mainly between 1 and 12 years of age, and by psychoactive substances—between 13 and 18 years of age. The gender distribution was balanced in both the age groups. Poisoning by two substances was confirmed in 23 patients, 50% (12/23) of those being alcohol and drugs.

Upon admission to the HED, and after initial stabilisation of vital signs, the patient's condition was evaluated, taking into consideration the degree of unconsciousness, any accompanying self-harm, injuries, and his or her behaviour during hospitalisation, including any need to use coercion, unauthorised departure from the department, lack of cooperation with the medical stuff or aggressive behaviour without the need to apply any additional means of control. The detailed characteristics of the condition of the patients at the time of admission and during hospitalisation are presented in table 2. Abbreviations AVPU scale: A (Alert)—conscious, oriented; V (Verbal)—responds to verbal instructions; P (Pain)—responds to painful stimuli; U (Unresponsive)—unconscious, responds to no stimuli).

Table 2

The detailed characteristics of the condition of the patients at the time of admission and during hospitalisation

In the study group, 56 children were unconscious on admission. In 80% of cases, this was caused by alcohol poisoning. Among 30 patients classified as P, as many as 77% were poisoned by alcohol, against the corresponding rate of 48% in the V group %.

Self-harm related to 11.5% of the hospitalised children, a majority of whom were 13–15-year-olds, diagnosed with and treated for intentional drug poisoning. Girls with a history of previous use of psychoactive substances prevailed.

Twelve percent of the children treated at the HED due to poisoning were diagnosed with injuries, which were most frequent in the 16–18 age groups. Injuries occurred mostly in alcohol-poisoned boys (49/59 injuries), with head injuries mainly accompanying unconscious patients (U in AVPU scale), and other injuries—patients classified as V.

During their stay at the HED, patients hospitalised due to intentional poisoning posed behavioural problems considerably more often, unlike accidentally poisoned children, who seldom caused problems and whose behaviour was classified as normal.

In the years 2006–2010, the average hospitalisation time in the group of poisoned patients at the HED was 1.64±0.5 days, and specifically: 1 day—182 patients (37.2%), 2 days—302 patients (61.8%), 3 days—5 patients (1%). A total of 70.4% of patients were discharged home in a good general condition; 17.7% were transferred to another PUH department—mainly those who required further diagnostics, observation and/or treatment; 4.7% of the hospitalised children were transferred directly to the psychiatric department; 7% of the study group were transferred to a correctional care facility following initial diagnostics and stabilisation of vital signs. In the span of 5 years, there was one incident (0.2%) where a child was transferred to a sobering-up station.

Discussion

The results of our analysis demonstrate that the emergence of legal ‘designer drugs’ on the Polish market in 2007 had no significant impact on the number, epidemiology or characteristics of poisonings among children and youths admitted to the HED for that reason in our region. Alcohol poisoning remains the leading cause of HED hospitalisations in the group of children studied, similar to certain other European countries, such as Croatia7 or other parts of the world, such as China,8 Australia9 or Iran.10 Just as in other countries, alcohol consumption was an issue with male adolescents.7 ,8 ,10–14 A decrease was also noted in the age of children admitted to the HED due to alcohol intoxication (in our paper, the youngest child poisoned by alcohol was 8–years old), which is also confirmed by the observations conducted in China in the years 2004–2009.8

Alcohol use and abuse are common problems in the teenage years. According to the European School Survey Project on Alcohol and Other Drugs (ESPAD), surveys conducted among 15–16-year-olds in 35 European countries, showed that Poland ranks below average.13 However, the frequency of occasional consumption of large quantities of alcohol increased considerably: a slight, yet constant, increase in the number of cases of sporadic intensive alcohol consumption can be seen.13

The second most frequent reason of HED hospitalisation in the studied population of children involved drug poisoning. These data are difficult to compare with studies conducted by other authors, as the poisonous substances were classified differently in each case. Worth noting is the fact, however, that drug poisonings were considerably less frequent in our region than in such countries—for example, Spain,6 ,11 Israel,15 Turkey,16 or Pakistan,5 where they represented 50% of all poisonings, with alcohol occupying a more distant position.6 ,11 ,16 One of the reasons may be related to religion, namely Islam, and the resulting alcohol prohibition, although in Iran,10 where drinking alcohol is illegal, it is the leading cause of poisoning hospitalisations. Comparing with European countries, Poland is a clear leader in the frequency of at least one-off use of non-prescribed sedatives,13 with girls taking drugs much more often than boys.8 ,10 ,13 ,16 Thus, the results of our analysis for our region are in line with those data. The age distribution of drug-poisoned children in our study clearly identifies two age groups. The first large group is young children with accidental poisonings, the other, adolescents mainly with intentional poisonings. Similar results were obtained by the authors in Spain in their analysis conducted in the years 2008–2009.11

The third largest groups of children in our study were patients hospitalised due to poisoning by narcotics, also including designer drugs. The presence of designer drugs in the body is very difficult to confirm by laboratory testing.17 Therefore, even if the patient denies their use, intoxication cannot be precluded. Furthermore, no studies are available on the effect of designer drugs on humans.18 Most often, it can only be supposed that those were involved by observing the patient's clinical condition.19–21 Acute designer drug poisoning symptoms may include mainly: symptoms related to the central nervous system (mental confusion, hallucinations, agitation, anxiety, phobias, logorrhea, weakness, dizziness and somnolence) and the circulatory system (hypertension, tachycardia, chest pain), and dilated pupils. The statistics concerning the prevalence of psychoactive substances among school youths (including the latest ESPAD survey results) show that the phenomenon is not as widespread in Poland as in western European countries, with a growing trend in its development in recent years.22 ESPAD also reports that the tendency to use narcotics, which had been growing in Poland in the years 1995–2003, has now slowed down.13 Another essential fact is that designer drug toxicity increases in combination with alcohol and/or other psychoactive substances (drugs, narcotics, other designer drugs). Narcotic poisonings occurred more frequently in children with a history of previous use of psychoactive substances and/or designer drugs.

The average age of children and youths in our study group was 12.86 years±5.04 years. Unfortunately, due to significant differences in the age groups in other published data, it is not possible to compare the results.

We observed a significant increase in frequency of poisonings in urban children. Both our data and data from Pakistan showed similar results, indicating that almost 80% of poisoned children and adolescents come from urban areas.5 A vast majority were children admitted to the HED due to a first-time poisoning, which was also confirmed in a German study.23

With respect to the cause of poisoning, 75% had been intentional and the rest accidental. A similar distribution was described by Saglam et al16 in an analysis conducted in Turkey in 2007. In our study, the number of intentional poisonings increased with age.15 It was also noted that the injured patients were most often boys under the influence of alcohol. In the USA, an increased number of injuries were recorded in alcohol-poisoned adolescent patients.14 In Austria, as many as 34% of children hospitalised due to alcohol poisoning had been injured.9 In the group of children studied who were hospitalised at the HED, it was also found that self-harm occurred most frequently in 13–15-year-old girls hospitalised due to intentional drug poisoning. Similar tendencies were observed in children hospitalised in Spain11 and in Turkey, in adult women poisoned by drugs.16

Our paper also includes an analysis of the dependency between the number of children presenting at the HED due to poisoning and the month as well as the day of the week. The most evident phenomenon involved a considerable decrease in admissions in the summer holiday months, which was a new finding in the context of previously published studies from Croatia.7 This could have been related to children going away on holiday and fewer children staying in the city and county of Białystok. The lack of school stress could have been another contributing factor. During the school period, the number of alcohol poisonings increases on non-school days, mainly Saturdays and Sundays, which is the same in several European countries—for example, Croatia, Spain or Bulgaria.7 ,11 ,12 ,24 The frequency of accidental poisonings increased considerably on weekdays, which could have been related to weaker parental supervision.

The average hospitalisation time in the group of poisoned patients at the HED was 1.64±0.5 days. This time is fairly short, considering the fact that in a Warsaw hospital, 80% of alcohol-poisoned children were discharged home on the fourth day.25 A majority of our patients, as in China, were discharged home8 and these were mainly alcohol-poisoned youths. Another large group was children referred for further diagnostics and observation in other departments. These were most often drug-poisoned children.8

In conclusion, our study found, that ‘designer drugs’ had no significant impact on the number, epidemiology or characteristics of poisonings among children and youths admitted to the HED in our region. Alcohol is still the leading cause of HED hospitalisations due to poisoning. The age of alcohol intoxication is decreasing. Fluctuation in numbers of patients hospitalised at the HED due to poisoning depends on time (month and day of the week).

References

Footnotes

  • Contributors Each author of this article, UP, AW, WO and MS, had individual, significant, substantial contribution to conception and design, acquisition of data and analysis, and interpretation of data. Every author drafted the article or revised it critically for important intellectual content in different periods. Every author also gave final approval of the version to be published.

  • Competing interests None.

  • Limitations Some limitations of our study include the quite small sample size, coming from the northeast part of Poland, the heterogeneous population (different doses of drugs, different time from poisoning to clinical assessment) and the retrospective nature of this study.

  • Provenance and peer review Not commissioned; externally peer reviewed.