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Michael Smith, MD (Host): Welcome to this is Pediatrics in Practices, a CME Podcast. I'm Dr. Mike, and joining me today is Dr. Michelle DePhillips from Children's Mercy Pediatrics in Practice. And in this episode, we're going to be discussing the critical issue of pediatric poisonings and antidotes, Dr. DePhillips, welcome to the show.

Michelle DePhillips, MD, FAAP: Thank you. Thanks for having me.

Host: So what are the most common substances that lead to pediatric poisonings today and has it changed over time?

Michelle DePhillips, MD, FAAP: So things that we think about most commonly and what we see most commonly are things that are commonly in the home. So over the counter products, Tylenol, ibuprofen, Benadryl, cough and cold medicine, those are going to be your parents' medication, the patient's medication, if they're an adolescent.

Those are by far and away the things that we're going to see the most commonly. Has it changed? I would say overall that's been pretty consistent. I think the thing that we have seen change the most, especially, well probably in, both adolescents, but also in more of your toddler or young school aged children, we've seen a lot more cannabinoid or marijuana ingestions just with it becoming legal in the state of Missouri.

So I'd say we've definitely seen more of that in the last couple of years.

Host: So can you walk us through a typical case of a child presenting with poisoning in the emergency department? You know, what are the red flags the doctor should look for and kind of what's the whole process for that child to be worked up?

Michelle DePhillips, MD, FAAP: So some of that is going to depend on what they ingested, how much potentially they ingested, and correct how symptomatic they are. So if we have a child or an adolescent that's come in and has taken something and they are, red flags symptoms, or signs that we look for would be are they altered in any way?

So not behaving, not acting at baseline. Do they have changes in their vital signs? Are they really tachycardic meaning really high blood pressure, low blood pressure, high heart rate, low heart rate, is it affecting their breathing? Those are going to be really the big red flag things that we look for. And obviously we see the whole gamut from kids who come in and we monitor them for four to six hours and they never have any symptoms from their ingestion all the way to kids again who have these red flag symptoms.

So, a lot of the times if we can trust what someone has taken, which I'll be honest with you sometimes in our teens and adolescents, we can't always trust what they tell us. And so a lot of times in these ingestions we will do lab work to screen for various things. So things that drug ingestions can affect are your kidneys, your liver, it can affect your blood counts at times.

And then looking for other co-ingestion. So you take cough and cold medicine while that a lot of times has Tylenol or it has aspirin in it. And those are two big over the counter things that really we worry about more than a lot of other things that kids could get into just because they can have big effects and need different treatment than some other substances.

So, it can be coming in, evaluating them, if we're concerns, giving them things to support their breathing, giving them things to support their blood pressure if they're that symptomatic. But a lot of times, luckily, kids are fairly unaffected and so it can be a period of observation for four to six hours.

And if they're doing well at that point, then they can potentially be discharged home.

Host: So when a child presents to the emergency room, how often do you know they ingested something?

Michelle DePhillips, MD, FAAP: That can be the tricky thing. So a lot of times, I would say the majority of the time, especially in a toddler, right, because this is all bimodal. You're going to have your toddlers, your young school age kids who are going to unintentionally ingest or take something. And then you're going to have your older kids, your adolescents, your teens who may take them for other reasons, whether that's recreational, whether that's self-harm.

And so a lot of times if it's a toddler, a parent will know because they've seen them or whatever it may be. They may see an empty bottle of pills or know that they've gotten into something. It's those teens that sometimes are harder. So a lot of times they have endorsed that they have taken something and that's when family will bring them in.

But sometimes we don't know. And that's really when their symptoms become important because, we talk about toxidromes and what toxidrome is a certain medication can give a constellation of symptoms. And so if a patient is presenting that way, then we can say, oh, this is really consistent with X, maybe a Benadryl in ingestion or a fentanyl ingestion or whatever that may be. So some of it depends on how the patient is presenting in terms of can we put it together? Do we need to wait on a drug screen to figure that out, is how we address it.

Host: So in the emergency room and maybe even in pediatric offices, do they have certain antidotes ready to go that will help with some of those top ones? Is that how that works?

Michelle DePhillips, MD, FAAP: It can be how that works. I can speak for me in the emergency department. I would assume that most pediatric offices at this point, at least carrying naloxone or Narcan, which would be the big antidote, I think that is available more in the community, in schools, and pediatric offices. So that's probably going to be the big go-to for most providers. Now for us in the ER, we clearly have more things. So naloxone for an opioid overdose. The other big, when we talk about antidotes, right? So a lot of these things that are ingested don't really have quote unquote antidotes. A lot of it is supportive care. So again, we support their blood pressure, if they're agitated, those sorts of things.

But the other two when I think of antidotes, I really think of are gonna be NAC or N-Acetyl cysteine in a Tylenol overdose. So Tylenol can be pretty deadly and scary or bad and affect children. And then we think about things like bicarbonate drips for an aspirin overdose.

So when we think of antidotes, those are the big things that come to mind along with naloxone.

Host: We focused a lot on medications though. How often do you see kids coming into the ER, maybe they ingested some bleach or some laundry deter. Like how often do you see that?

Michelle DePhillips, MD, FAAP: I would say we see that not infrequently, we see exactly drugs, medications more frequently, but we do, yeah, it's going to be your little Tide pods, your dish pods, dish washing pods, they get into something underneath the counter. So household bleach, rat poisoning is another big one. So yeah, we see that not infrequently.

And again, it depends on what the substance is. Luckily, most of the quote unquote, household things, even household bleach usually are non-toxic to children, but some of them, if they're very acidic, very alkali, they can cause damage to the esophagus if it gets in the airway, and so it depends on the substance, depends on their symptoms.

Sometimes they can be observed and for four to six hours, if they're doing fine, eating and drinking can go home. If we feel that it's damaged their esophagus in any way, then sometimes we do have to admit them. They have to go and get a scope to look, but for the most part, most things that kids get into in that vein they do fairly well, luckily.

Host: What about, when it comes to the antidotes are there any underutilized ones or misunderstood ones?

Michelle DePhillips, MD, FAAP: Oh man, this is always my shameless plug for naloxone. I think that unfortunately we all know that the Fentanyl crisis is real, opioids real. That peds are not out of that realm either. So we see a lot of that. And so, you know, I think my big plug in answering that question would really just say there's no stigma in prescribing naloxone for your patients and for families and for educating families, because you never know if it's going to be your child, if it's intentional, unintentional, if you're going to come across somebody while you're at a sporting event. I think that naloxone is just probably under talked about and under prescribed, whether that's stigma, whether that's knowledge, I don't know.

But, I think everyone should have it in their car or their purse or have it in their home because it's just, it's so, so prevalent these days.

Host: You know, in the emergency room, are most pediatric emergency physicians kind of trained to look at a child who it looks like they've ingested something and they can quickly maybe categorize this as, okay, this looks over the counter. This looks like some of the chemicals you talked about. This might be an illicit substance. Can you guys quickly categorize that or is that just hard too?

Michelle DePhillips, MD, FAAP: It depends. It depends on the situation. As part of our fellowship training to become a pediatric emergency medicine physician, we do a lot of toxicology. It's a big part of the boards we take. It's a big part of our three years of training. So I will say we all do feel pretty comfortable with recognizing, especially those ingestions, again, that present and the kid is very sick.

We know how to manage those. But again, if we know what substance we're dealing with, or even if we don't, we know some of the signs and symptoms and how to treat. So yes, I would say by far and away that we're all pretty comfortable and then we have our friendly toxicologists and poison control that can always help us if we're feeling that we're not, confident or not sure.

Host: So when do you call Poison Control Center? How do they play a role?

Michelle DePhillips, MD, FAAP: Yeah, so we're a little bit interesting at Children's Mercy. We actually have toxicologists that are on call 24 hours a day that are all fellowship trained. So our method is actually if we need something that we call them and discuss it with them. And they give recommendations because they actually see our kids in the hospital that are admitted with these ingestions or overdoses.

Now, poison control, however, is someone that anyone can call any time of day 24/7. They are staffed and I think they're probably honestly a little underutilized too. So, poison control is great. I mean, I have used them before. I've had pediatrics offices use them before. Families used them before, and so my recommendations for families would be if you have a kid that's taken something, whether it's a household product, a medication, whatever it may be, poison control, as long as your kid is stable, poison control is should be really your first call because they can provide pretty good guidance of, oh hey, yeah, you need to go to the ER now. Or, Hey, these would be the common things you can watch your child. They should be okay. And a lot of times they can actually prevent an office visit or an ER visit if they're called and talked to the family about it.

So yeah, we recommend families call.

Host: So just to make sure, a parent who might be listening to this podcast is following all this. So we have emergency room specialists like you, then you have poison control. Great first call, especially if they don't seem that bad. But you mentioned the toxicologist. Can you explain that role a little bit more?

Michelle DePhillips, MD, FAAP: So a toxicologist, they can go various routes. A lot of them honestly do emergency medicine and then they do fellowship, so special training within toxicology. So they function in different ways. Ours, like I said, they're a consultant service for us. So if we ever have a child in the emergency department that has ingested something, we're looking for management options, those sorts of things; then they are first call personally, and they also, like I said, will come, if your child has to be admitted to the hospital for an ingestion of some sort, then they will come and see your child at the bedside, either that day or the following day, whatever it may be, to provide those recommendations.

So they're just an additional source of expertise essentially in all things drugs and ingestions.

Host: Are there any recent innovations or updates in the management of poisonings that frontline providers should know about?

Michelle DePhillips, MD, FAAP: No, not really. I would say that everything is fairly consistent and frontline providers, again, the big thing is really gonna be naloxone for an opioid overdose because they're not going to carry, you know, n-acetylcysteine, they're not going to carry some of these other things. And so out in the field, frontline providers, I would say naloxone is going to be the biggest one that you're going to have on hand outside of an emergency department,obviously.

Host: Why not carry n-acetylcysteine? Isn't that pretty easy to get?

Michelle DePhillips, MD, FAAP: Are you talking about in a general pediatrics office or a general provider's office?

Host: Like general pediatrics, and n-acetylcysteine is over the counter supplement, right? So are you using more like, a different format of the NAC.

Michelle DePhillips, MD, FAAP: I cannot tell you that I'm an expert in that. I actually did not even realize you could buy over the counter. To be completely honest with you, I don't know. You know, we give a loading dose and then we give a maintenance dose. And I think the big thing about it is that there's a lot that's factored into that.

And we don't give n-acetylcysteine to every child who's ingested Tylenol. There's an algorithm, it's a time thing. You try to get their first level at four hours after they ingest it, and you only treat certain kids because kids with levels so high, they're the ones that are going to go on to have liver issues, is what we worry about.

And so it's pretty detailed and pretty outlined what kids get it and what kids don't. Because by far and away, most kids who come in and have ingested Tylenol do not end up meeting criteria to need treatment with a n-acetylcysteine. But it is a little bit of a waiting game because the most accurate is a four hour level and then on out past that.

So it would probably be hard for a general pediatrics or a general provider's office to do.

Host: Yeah. It's best to send them to the specialists like you in the ER.

Michelle DePhillips, MD, FAAP: Correct. Yes. Tylenol is definitely one of those things that I would send somewhere that they could get those levels and be monitored. Yes.

Host: What preventative strategies can pediatricians share with families to reduce the risk of all of this? Wouldn't prevention just be the best thing, right?

Michelle DePhillips, MD, FAAP: No. So many, so many things. Yes. So, I would say important things is lock your medication up. Keep them up and away. You know, kids, they're not dumb. They know how to get into things. Sometimes you go, where did you find that? So making sure you're locking things up, either lock boxes, safes, keeping them up and out of reach.

Same thing when you're adolescents, even if you think you can trust your adolescent or your teen, they show us that you can't always do that. And so making sure you have a general idea of pills, maybe even in a prescription that they normally take to make sure they're not overusing. Pills that you're not taking anymore.

So you've been prescribed pain pills or opioids for a surgery. Well, when your pain's better get rid of them, get them out of the house. I know people like to keep things just in case, but I would say get rid of the things that you don't need. And then drug takebacks are a great things too. A lot of pharmacies have them, hospitals have them.

So if you have a bunch of stuff that you're not using anymore, get rid of it. There's different resources online with how you can dispose of medications. And then I would just say the other thing too, with your teens is just being very open with them from a, I would say school age point in their lives about drugs and the danger of drugs.

And we never take medicines that aren't prescribed to us would be my advice for parents.

Host: You know, a lot of communities now you can get rid of your prescriptions, they have like a Saturday or something where you can drop off prescription drugs and stuff like that. So that's helpful, I'm sure.

Yeah. This has been great. What great information. Thank you so much for coming on today.

Michelle DePhillips, MD, FAAP: Absolutely.

Host: For more information, you can go to cmkc.link/cmepodcast. If you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics of interest to you. This is Pediatrics in Practice, a CME podcast. I'm Dr. Mike. Thanks for listening.