Martha K. Swartz, MS, RNC, PNP Yale University School of Nursing

New Haven, Connecticut

. Poison Prevention .

M uch progress has been made over the past two decades to reduce the incidence of pediatric poisonings. Among the factors that have contributed to this decline are the use of child-resistant containers, the formulation of products with less relative toxicity, the increased vig- ilance of child care providers, more sophisticated steps in prevention and intervention by health care providers, and poison control centers. Nevertheless, toxic expo- sures remain a major pediatric problem, with more than 1.5 million poisonings reported to poison control cen- ters annually (Woolf & Lovejoy, 1990). A review of early efforts at poison prevention and a discussion of current thinking regarding steps that are most likely to be effective may assist pediatric health care providers in targeting their efforts.

n BACKGROUND

The first Poison Control Center was established in 1953 to serve as a center for information regarding product toxicity, ingredients, and recommended treatment after exposure. In 1957, the Surgeon General established a National Clearinghouse for Poison Control Centers to coordinate the activities of smaller local centers. The annual National Poison Prevention Week, which takes place in March, was instituted. In 1966, the House of Representatives began hearings on a bill that required the use of child-resistant packaging that ultimately led to the Poison Prevention Packaging Act of 1970 (Wal- ton, 1982). This law, which is administered by the Con- sumer Product Safety Commission, requires that sub- stances that are toxic, corrosive, irritant, or sensitizer be contained in packaging that is significantly difficult for a child younger than 5 years of age to open yet not difficult for adults to use properly. A follow-up 5-year (1973 to 1978) evaluative study, which reviewed rates of ingestion and death associated with these regulated substances, indicated a decline in ingestion rates of 45% and a decrease in the number of deaths associated with

j PEDIATR HEALTH CARE. (1993). 7, 143-144.

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accidental ingestions to 0.5 of 100,000 children (Wal- ton, 1982).

The federal regulation of poisonous products and the mandated standards of safe packaging have done much to lower the incidence of accidental pediatric poisoning. Nevertheless, education about poison prevention and safety promotion must remain a high priority for health care providers if further success is to be achieved.

w HEALTH EDUCATION STRATEGIES

Several common approaches to health education re- garding poison prevention have been identified (Lito- vitz & Manoguerra, 1992). One method is to focus educational materials on those substances that are most frequently the source of accidental exposures. This tac- tic, however, may generate confusion in that the fre- quency of exposure is not related to the toxic potential of any one product. Rather, frequency of exposure is related to the commercial availability and market share of the product and accessibility to the child. According to data collected by the American Association of Poison Control Centers (AAPCC), the substance categories most frequently implicated in pediatric exposures are cosmetics and personal care products, cleaning sub- stances, and plants, all of which account for 30.4% of reported exposures; yet the toxic hazards associated with these substances is relatively low (Litovitz & Mano- guerra, 1992).

A second strategy in poison prevention efforts is to focus on the current trends in poisoning or the products that may be receiving undue attention in the press be- cause they happen to be of interest to toxicologists or poison control centers. Although these efforts may reach a potentially large audience, the actual risk related to the product in question may be obscured.

A third strategy of educational poison prevention efforts has been recommended by the AAPCC in a re- cent report (Litovitz & Manoguerra, 1992). Because it is often difficult to convey more than three messages within the content of educational material, the AAPCC recommends that current prevention efforts be redi- rected to address those products that are most likely to cause pediatric poisoning fatalities. To determine the

JOURNAL OF PEDIATRIC HEALTH CARE 143

144 Product Alert

relative risk of various products, the AAPCC conducted a study in which a hazard factor was devised to assess more objectively the relative risk posed by various phar- maceutical and nonpharmaceutical products that have been implicated in toxic exposures.

n DEVELOPMENT OF THE HAZARD FACTOR

Of the approximately 3.8 million exposures involving children younger than the age of 6 years reported to poison control centers in 1985 through 1989, 2,117 children experienced a major outcome (life-threatening effects or residual disability), and 111 deaths occurred (Litovitz & Manoguerra, 1992). For most of the toxic substances implicated, a hazard factor was devised that represents a composite of variables beyond the acute toxicity of ingredients. These additional factors encom- pass the effects of availability, access, formulation, pack- aging, and the use of child-resistant closures. A sub- stance with a relatively low hazard factor does not mean that it is not poisonous but rather that, given the effects of packaging, closure type, market availability, and home storage practices, the toxicity resulting from ac- cidental exposure is likely to be relatively low. Some of the pharmaceutical and nonpharmaceutical substances that have been assigned relatively high hazard factors and that account for the greater percentages of pediatric fatalities are summarized in the Box. Iron supplements were the most common cause of pediatric unintentional ingestion deaths, followed by antidepressants and car- diovascular medications in pediatric pharmaceutical-re- lated deaths. Hydrocarbons (including five lamp oil deaths) and pesticides were most commonly implicated in nonpharmaceutical pediatric ingestion deaths. Of note, the substance categories most frequently reported to poison control centers (cosmetics, cleaning sub- stances, plants) have relatively low hazard factors (Litovitz & Manoguerra, 1992).

The development of the hazard factor concept by the AAPCC has numerous implications for pediatric health care providers. The results of the AAPCC study do not imply that we may relax our efforts in poison prevention but rather inform us by identifying areas where inten- sified efforts at prevention may significantly lower pe- diatric mortality and morbidity rates. Specifically, ed- ucational interventions aimed at the prevention of ac- cidental iron supplement ingestions are clearly warranted. In this regard, the AAPCC calls for a mul- tifaceted approach that involves the regulatory re- striction of iron to prescription status, repackaging of iron supplements, and conspicuous labeling that con- tains a clear warning of the unintentional ingestion haz- ard of iron. Pharmaceutical products that also warrant priority in poison prevention efforts are narcotic anal- gesics, anticonvulsants, antidepressants, cardiovascular drugs, methyl salicylates, and antimalarials (chloro-

Journal of Pediatric Health Care Volume 7, Number 3

a BOX SUBSTANCES MC%T FREQUENTLY IMPWATED IN

UNlNTlfNTtONAL PEDtATRK INGESTtON FATALlTtES

(1983 TO 1990)

Pharmaceuticals

Iron supplements Antidepressants Cardiovascular medi-

cations Salicylates

Percentage of pharma- ceutical-related fatalities

30.2 18.9 13.2

11.3

Nonpharmaceuticals Percentage of mmphar- mace&id-related fatalities

Pesticides 27.3 Hydrocarbons 27.3 Alcohols & ethylene 15.9

glycol Gun bluing 9.1 Cleaning substances 6.8 Data from “Comparison of Pediatric Poisoning Hazards” by T. Li-

tovitz and A. Manoguerra, 1992, Pediatrics, 89, p. 1001.

quine), which are often taken by international travelers. This last category of drugs can be extemely toxic to the cardiovascular system, and death may occur in a small child with the ingestion of one or two tablets. Non- pharmaceutical agents with high hazard values are bev- erage ethanol, ethylene glycol, methanol, acids, alkalis, drain cleaners, oven cleaners, hydrocarbons (kerosene, lighter fluid, naphtha, lamp oil), insecticides, and gun bluing compounds.

It is interesting that the list of substances with high hazard values largely parallels the list of products that are required by the Poison Prevention Packaging Act to have child-resistant closures (Litovitz & Manoguerra, 1992). To the extent that deaths and disabilities still result from the accidental ingestion of these products, further efforts in the research and development of ef- fective therapeutic approaches in poison prevention are crucial.

REFERENCES Litovitz, T., & Manoguerra, A. (1992). Comparison of pediatric

poisoning hazards: an analysis of 3.8 million exposure incidents. A report from the American Association of Poison Control Cen- ters. Pediutriq 89, 999-1006.

Walton, W. (1982). An evaluation of the Poison Prevention Pack- aging Act. Pediahia, 69, 363-370.

Woolf, A.D., & Lovejoy, F.H. (1990). Poisoning. In M. Green & R. J. Haggerty (Eds.), Ambuhtoy Pediatrics (pp. 221-231). Phil- adelphia: W B Saunders Company.