Indian J Pediat 51: 313-316, 1984

Spectrum of poisonings among children in Afghanistan

Meharban Singh, M.D.H.Y. Hessam, M.D., S. Azamy, M.D. and L.S. Arya, M.D.

Two hundred and ten cases of poisoning were seen during a 2-year study period accounting 1,2 per cent of all children hospitallsed for medical disorders. About 80 per cent of children were under 5 year of age. Poisoning due to oarious therapeutic agents was commonest (67.1%)followed by chemical agents (10%), hydrocarbons (8.6%), plants (6. 7%), food (5.7%) and carbon monoxide gas (2.4%). Ooerdosage due to wrong adoice of the Physician or ignorance of mother was responsible for drug poisoning in 46.8 per cent of all poisonings due to medicaments. Chlorpromazlne alone accounted for 33.3 percent cases of drug polsonings. The mortality rate was 3.3 percent and all deaths were apparently due to home made or proprietary drug formulations.

Poisoning among children is one of the common medical emergencies encountered in pediatric practice. Accidents including poisonings are orie of the leading causes of morbidity and mortality among children in the West where ravages of infectious dis- eases and nutritional deprivation have been controlled. The prevalence and pattern of poisonings depends upon the education, ecology, socio-economic status and social beliefs and customs of a community. Due to increasing technological advances, newer bazards in the form of various chemicals for domestic, farm and industrial use are increasingly disseminated in our environ- ment. Poisonings are preventable but in order to evolve any preventive strategy it is essential to identify the prevalence, pattern and predisposing factors. There is no infor- mation on this subject from this country. The present study was undertaken to iden-

Institute of Child Health. Kabul, Afghanistan.

Reprint requests: Dr. Meharban Singh, Associate Pro- fessor. Department of Pediatrics, All India Institute of Medical Sciences, New Delhi I l0 029.

tify the incidence and pattern of poisonings among hospitalised children in Afghanistan.

Mater ia l a n d M e t h o d s

All the children with poisonings admitted to the Institute of Child Health, Kabul dur- ing the Afghan years 1358-1359" comprise the subject of this study. Children with toxic reactions to various therapeutic agents, whether prescribed or unprescribed by the Physician, were included in this study. The demographic pattern, nature and clinical profile of the patients have been analysed. The data has been compared with studies from India in order to highlight the differen- ces in the pattern of poisoning so that appropriate preventive measures can be adopted.

Results

During the two-year study period, 17,603 children with medical disorders were admit- ted to the hospital. Of these, 210 children reported with v a r i o u s poisonings thus

314 THE INDIAN JOURNAL OF PEDIATRICS Vol. 51, No. 410

account ing for 1.2 percent o f total medical admissions. One hundred and th i r ty eight patients belonged to Kabul city while seventy two came from adjoining rural areas.

Age and sex distribution : One hundred and sixty seven (79.5%) chi ldren were under 5 year of age. Almost one-third of chi ldren were unde r the age of one year. The overall male to female ratio was 1.3, which conforms to the overall sex-wise pattern o f admissions in the hospital.

Time interval between ingestion of poison and hospitalization : Fifty percent of patients reached the hospital within 4 hours of inges- t ion o f poison. One hundred and seventy five (83.3%) chi ldren were brought to the

Table I. Distribution of various types of poisons

Toxic agent Number of Deaths cases (%)

Medicaments 141 (67.1) 7 Chemical agents 21 (10.0) --

lnsectisides 13 Potassium 3 permengnate Acetic acid 1 Arsenic 1 Hydrogen peroxide I Sulphur 1 Sulfuric acid I

Hydrocarbons 18 (8.6) -- Kerosene i 5 Diesel oil 3

Plants 13 (6.2) Dathura 9 Bhang 2 Unknown 2

Food poisoning 12 (5.7) -- lfective 7 Toxic 5

Gas poisoning 5 (2.4)

hospital within 12 hour o f ingestion, Ten patients belonging to the rural area reported to the hospital after a lapse o f over 24 hours after ingestion of the toxic substance. Nature of poisoning:The spectrum of various poisons is detailed in Tables I and II. The

c o m m o n e s t poisoning was due to over- dosage or accidental ingestion of various medicaments which accounted for 67.1 per- cent of all poisonings. This was followed by poisoning due to chemical agents (10%), hydrocarbons (8.6%), po i sonous seeds or leaves (6.2%), food (5.7%) and carbon mon- oxide gas (2.4%).

Overdosage o f medications for therapeutic purposes, ei ther due to fault of the physician or parents, accounted for 46.8 percent of all poisonings due to medicaments. Accidental overdosage o f ch lo rp romaz ine alone, due to wrong prescription or inadver tant over administrat ion, accounted for forty seven

Table II. Distribution of various medicaments

Name of the drug Number Deaths of cases

Chlorpromazine Opium Diazepam Piperazine Phenobarbitone Salicylates Diphenhydramine Antistine Atropine Belladona Belladona Tr. Bellargol Butazolidine Haloperidol Etaphyllin Meilerii P.A.S. Tofranil Unknown

4 7 m

17 2

1

44 4

Total 210 (100.0) 7 Total 141 7 (3.3%)

M E H A R B A N S I N G H ET AL : S P E C T R U M O F P O I S O N I N G S C H I L D R E N IN A F G H A N I S T A N 315

(22,4%) cases. About one-half of these children were under one-year of age. Chlor- promazine was prescribed for the treatment of vomiting for patients with acute gastroen- teritis which is rather frequent under the age of one year. Administration of opium for treatment of diarrhoea, cough and excessive crying is common in Afghanistan. Of seven- teen patients with opium poisoning, twelve (70.6%) were under one year of age. Kerosene poisoning was seen in fifteen (7.1%) children which is strikingly low as comPared to reports from India. Organo-phosphorous poisoning :!oc to various insectisides was seen in thirteen (6.2%) instances.

Clinical features : The clinical picture was characterized by the well known specific features peculiar to various poisonings. In about one-third of patients with poisoning due to various drugs, the nature of the medicament was unidentified because parents did not bring the prescription or empty container. The common general symptoms of poisonings included varying degrees of alterations in consciousness (62.8%), vomiting (14.3%), irritability (3.3%), seizures (2.8) and shock (1.9%).

Mortality : There were seven deaths in our series giving a mortality rate of 3.3 percent (Table II). Unfortunately two children died due to overzealous administration of opium by the mother for the treatment of acute diarrhoea.

Discussion

The incidence of poisoning among hos- pitalized children in the present series was 1.2 percent. This is comparable to the incidence of 0.6-7.6 percent for childhood poisonings reported by various authors 1-8 from India. Most children (79.5%) with

poisoning were less than fiVe year of age. The male preponderance of 1.3:1 was in confor- mity ~with overall sex-wise distribution of hospital admissions. Some workers 3. 5 have reported significantly higher incidence of poisoning among male children and ascribed it to their boisterous and naughty behaviour.

Poisoning due to inadvertant overdosage or accidental ingestion of household tern- dies and medicaments was most common. Chlorpromazine alone accounted for 33.3 percent cases of all drug poisonings. Almost one-half of patients with poisoning due to medicaments was because of overdosage either as a result of wrong advice by the physician or ignorance and overzealous concern of the parents. Overdosage was most common in children under the age of one year while accidental ingestion was seen mostly among older children. The availa- bility of some formulations in rather unac- ceptalbe concentrations in the local market and lack of education and awareness among the parents and doctors accounted for these therapeutic misadventures. For example, chlorpromazine drops are available in con- centrations of 1, 2 and 4 percent and pipera- zinc syrup is available in a concentration of 1000 mg per 5 ml. It is desirable that the drug companies should evolve a uniform policy for formulation of various drops and syrups which should be universally followed to avoid confusion. The increasing number of various medicaments and their easy availa- bility on the counter without doctors' pres- cription has led to increased incidence of poisoning due to drugs. Unlike reports from the West, the poisoning with salicylate~ was rare and no case of iron poisoning was encountered. Due to ready availability of opium in the home and paucity of health care facilities, opium poisoning was rather common as observed in other developing

316 THE INDIAN JOURNAL OF PEDIATRICS VoL 51, No. 410

countries. Prompt parenteral administra- tion of nalorphine can save these children and it is essential that a chart showing specific antidotes with their dosages should be displayed in the emergency and intensive care rooms of Pediatric services.

Kerosene poisoning was seen in 7.1 per- cent of children as compared to its incidence of 20.0-59.7 percent in Inda. I-8. Wood and electricity are more commonly used as a fuel for cooking purposes in this country as com- pared to kerosene. The poisoning due to various pesticides and insectisides are assuming greater importance and they accounted for 6.2 per cent cases. Gaind et al 6

and Singh et a l 7 reported the incidence of poisoning with organo-phosphorous com- pounds as 4.5 percent and 7.0 percent respec- tively. During winter months carbon monoxide gas poisoning is common due to the necessity of burning coals indoors for heating purposes. The mortality of 3.3 per- cent is comparable to other hospital based reports. 1-8

There is a need to undertake community surveys to identify potential poisons in environment of Various child populations. The medical and paramedical staff must strive to minimise iatrogenic poisoning by ensuring that drugs are prescribed in appropriate dosage, prescriptions are writ- ten legibly with name and strength of the

drug and clear instructions for its adminis- tration are given in the locally understood language. Poisonings can be prevented by vigilance, health education and awareness o fall concerned with the welfare of children. It is desirable that indiscriminate use of phenothiazines for symptomatic treatment of vomiting should be avoided and parents should be cautioned against self medi- cations. The children are at the mercy of adults in these matters and we pediatricians must safeguard their health interests.

References

I. Pohowalla JN, Ghai OP : Common accidental poisonings in children in Indore. I n d ~ n J Child HeaRh 8: 208, 1959.

2. Manchanda SS, Sood SC : Accidental poisoning in children with a case report of naphthalene poison- ing. Indian J Chi ld Heal th 9: 113, 1960

3. Sharma U, Saxena S : Accidental poisoning in children in Jaipur. Indian J Pedla t r 41: 174, 1974

4. Aggarwal U, Gupta A : Accidental poisoning in children. Indldan Pedla t r 11: 617, 1974

5. Buhariwalla RJ, Sanjanwalla : Poisoning in children; A study of 303 cases. Indian Pedlatr 6: 141, 1969

6. Gaind BN, Man Mohan, Ghosh S : Changing pat- tern of Poisoning in children. Indian Pedlatr 14: 295, 1977

7. Singh S, Narang A, Walia BNS, Mehta S, Kumar L : Accidental poisoning in children : 10 years experience. Indian Pedla t r 18: 163, 1981

8. Chauerjee B, Banerjee DP: Accidental poisoning in children. Indian Pedlatr 18: 157, 1981