Dr. Schor of the National Institutes of Health and Deputy Director of the National Institute of Neurological Disorders and Stroke has no relevant financial relationships to disclose.)
Childhood poisoning frequently presents with delirium, seizures, and decreased level of consciousness. Neurologists are often called upon to evaluate children with these presentations. As children age, distinct patterns of poisoning emerge. Ingestions in children under the age of 5 are almost always unintentional, the result of toddler exploratory behavior. As children enter adolescence, there is an increase in attempts at self-harm, as well as in the use of recreational drugs.
Many types of ingestion can be deceptively dangerous. It is, therefore, important to be aware of the signs of common and serious ingestions and to be able to treat dangerous ingestions appropriately. This article will focus on the common syndromes of poisoning and those toxins that may present with injury to, or symptoms referable to, the nervous system.
• Childhood poisoning is a common medical problem.
• Neurologic manifestations are a common result of toxic exposures.
• Important in diagnosis is the recognition of common toxidromes.
• Most laboratory investigation, including toxicologic screening, is of little value in diagnosing acute toxicity.
Historical note and terminology
Although medical attention on poisoning in the 20th century has focused on childhood poisoning, with the development of the Poison Information Center system, the new millennium has presented new challenges to toxicologists, pediatricians, and neurologists. Illicit drug availability, environmental exposures to well-known toxins like lead, and newer complex organic industrial compounds have made trauma from toxins a commonplace and urgent clinical dilemma.
The rise of the environmental movement in the 1960s, following publication of Rachael Carson's Silent Spring, continued as the Consumer Product Safety Commission took on responsibility, and since then, a number of legislative acts have mandated compensation for exposure to various environmental toxins. Medical toxicologists became essential figures in the clinical management of both adults and children. The list of potential hazards has grown to include not only accidental and intentional self-exposures, but medical errors, chemical terrorism, gas disasters, warfare, occupational chemical mass exposures, radiation disasters, and mass food poisonings, as well. In addition, 2 new disciplines – toxicogenomics and nanotoxicology – have been developed. Toxicogenomics refers to the genetic susceptibilities that pertain to toxic substances (such as idiosyncratic drug reactions). Nanotoxicology is the toxicology of tiny particles usually smaller than 100 nanomillimeters. This refers particularly to the translocation of these tiny particles to new sensitive target sites such as the central nervous system and the bone marrow (Wax 2015).
The impact of toxins of multiple origins has made the potential for neurologic dysfunction and disruption more commonplace and an important part of the differential diagnosis of most clinical neurologic symptoms in both children and adults.
Chemical and drug poisoning in children results in significant morbidity, mortality, and health care expenditure. Exposures in children represent more than half of the 2.4 million calls made to U.S. poison control centers annually (Mowry et al 2015). Children suffer more than 20 million nonfatal injuries annually at a cost of 7 million to the health care system (Schnitzer 2006).
The Annual Report of the American Association of Poison Control Centers reveals 2,890,909 calls made to the 56 certified Poison Centers in the country which, in turn, made over 2 million follow-up calls for the human exposures. Sedatives/hypnotics/antipsychotic exposures have increased 12% in recent years and tend to have increasingly serious outcomes. Antidepressant exposures have also increased. Combined, these 2 groups are the second most common exposures in children and young adults (American Association of Poison Control Centers 2014; Mowry et al 2015).
Exposure-related fatalities in 2014 were 1408, with an additional 427 cases thought to be possibly related to an exposure. Fifty-eight of these were individuals younger than 20 years of age. There were 16 exposure-related deaths (1.4%) in children under 5 years of age. Sixty-one adolescent fatalities (13-19 years) were reported, most of them intentional (American Association of Poison Control Centers 2014; Mowry et al 2015).
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