Frequency and Management of Drug and Chemical Poisoning among Children Attending an Emergency Department in a Single Hospital in Saudi Arabia

Background: Accidental poisoning is one of the common medical emergencies in children that leads to morbidity and mortality. Medications and chemical agents play a major role in these adverse events resulting in social, economic, and health consequences. Aims of the study: The study aimed to evaluate the frequency and management of poisoning among children attending the emergency room at East Jeddah Hospital, Jeddah city, Saudi Arabia. Methods: This study was a retrospective chart review of all acute pediatric poisoning incidences in children (0-16 years of age) from October-21-2016 to March-03-2020 who were admitted to the emergency department of East Jeddah Hospital, Jeddah city, Saudi Arabia. Data was analyzed via SPSS software. Results: A total of 69 incidences of acute poisoning were admitted to the emergency room at East Jeddah Hospital; males were 55.1 %. Most children were under 5 years of age (59.4%). Unintentional poisoning occurred among 56.5% of observed cases of which 52.2% occurred in children younger than 5 years; 7.20% (5) patients were 12 to 16 years of age and had deliberate self-poisoning. The association between type of poisoning and age groups was statistically significant (Chi-square=28.5057, p=0.0001). Most incidences occurred at home (92.8%). Medicines were the most common cause of poisoning (73.9%). An excessive dose of prescribed medicine poisoning accidents was reported in 10.1% cases. Analgesics such as paracetamol were the most documented medication associated with poisoning (39.1%) followed by anticonvulsants and other central nervous system active medicines (18.8 %). The most common route of poisoning was oral administration (81.2%). One mortality case was documented due to poisoning. Conclusion: A total of 69 incidences of acute poisoning in children occurred in a single hospital over 3 years. Most incidents were accidental and occurred in children younger than 5 years of age. Medicines were the most common cause of poisoning. Analgesics such as paracetamol were the most common documented medicine associated with poisoning.


Introduction
Acute pediatric poisoning remains a worldwide health issue that requires medical attention at hospital emergency department with consequences of morbidity and mortality (1). It has social, economic, and health implications especially in children under the age of five who accounted for the largest percentage of poisonings globally (2).
The outcomes of poisoning ranged from mild incidences to severe complication or death, and most pediatric poisoning occurred accidentally by ingestion (3,4).
According to the World Health Organization (WHO) report (2002), an estimated 193,460 fatalities were linked to unintentional or accidental poisoning (5). In 2015, the American Association of Poison Control Center (AAPCC) reported that more than 1.3 million children were exposed to poisoning substances, and 40% of whom were children less than 3 years (6).
In Saudi Arabia, a review of seven years of case notes of children admitted to a single military hospital in Eastern province identified 168 accidental pediatric poisoning out of 9951 pediatric admissions (1.7%). This was most common in children between 1 to 3 years (63%). Most poisoning cases were related to medicines and accounted for 108 cases (64.3%) and household materials (n= 60, 35.7%) (7).
Another retrospective study of all pediatric poisoning cases reported to the drug and poison information center in Saudi Arabia identified 735 children presented to Pediatric Emergency department with poisoning from January 2010 to December 2016. Children younger than two years of age (n=459, 62%) were significantly affected by poisoning. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted September 10, 2020. . https://doi.org/10.1101/2020.09.08.20190868 doi: medRxiv preprint Drug overdose (n=119, 92.2%) was the major reason for poisoning and analgesics were the most common (n=26, 20.4%) (8).
The most frequent source of poisoning varied from country to country depending on social, economic, cultural, and educational background (1,9). In developed countries, the most toxic substances are medicines and household products such as cleaning agents; developing countries frequently see kerosene and pesticides (1,9). The current literature about poisoning among children in Saudi Arabia is limited in terms of examination of poisoning agent and the medications used for management and clinical outcomes.

Aims
This study aimed to determine the frequency and management of acute pediatric poisoning in East Jeddah Hospital in Jeddah city, Saudi Arabia. The objectives of the study were: • To identify the type of ingested poison.
• To describe the outcomes of poisoning.
• The name of antidote given.
• To describe the outcome of treatment.

Methods
This study is a retrospective medical chart review of all acute pediatric poisoning cases  is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted September 10, 2020. . https://doi.org/10.1101/2020.09.08.20190868 doi: medRxiv preprint

Data collection and statistical analysis
The data was collected from patients' electronic medical reports at the hospital using data collection sheet by two pediatric physicians and two pharmacists who work at the emergency department. The data collection sheet was comprised of the patient's demographic profile such as age, gender, weight, nationality, patient medical history, vital signs, the place when poisoning occurred, the type of poisoning, the type of medicine, route of intoxication, symptoms of intoxication, the medical treatment, antidote given, and the outcome of medical management. Data analysis used SPSS (SPSS Inc., Cary, NC version 20.0) and comprised descriptive statistics.

Ethical Approval
Management authorization was gained from the Saudi Arabia Ministry of Health

Results
There were 69 incidences of acute poisoning.

Patterns of poisoning
Nearly half of the documented poisoning cases occurred unintentionally (n=39, 56.5%), and were for children younger than 5 years of age (n=36, 52.2%). The vast majority of these incidents occurred at home (n=64, 92.8%). Intentional poisoning occurred in five cases (7.2%) for children over 5 years of age. Acute poisoning due to excessive dose of is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted September 10, 2020. . https://doi.org/10.1101/2020.09.08.20190868 doi: medRxiv preprint a prescribed medicines was reported in (n=7, 10.1%) of the incidents, and (n=18, 26.1%) were reported as unclassified ( Table 2). The association between the pattern of poisoning and age groups was statistically significant (Chi-square=28.5057, p=0.0001) at 5% level of significance (Table 2, Figure 1)

Sources and routs of poisoning
The main source of acute poisoning were medicines that were associated with the majority of incidents (n=51, 73.9%) followed by intoxication by chemical substances (n=9, 13%); nine cases (13%) were unknown toxic materials. Oral route of ingestion was found to be the most common route of intoxication in (n=56, 81.2%) of all incidents as shown (Table 3; Figure 2).

Management of poisoning
Treatment of poisoning incidents varied from one case to another depending on patient condition, type of poisoning and time of exposure. In this study, treatment intervention was reported in most cases as shown in (Table 5) is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted September 10, 2020. . https://doi.org/10.1101/2020.09.08.20190868 doi: medRxiv preprint 51.6%) were given activated charcoal, N-acetylcysteine (n=9, 29%), antihistamines (n=3, 9.7%). One patient received naloxone, atropine and fomepizole ( Table 6).

Outcome of poisoning
A total of 25 (36.2%) children were admitted to the pediatric ward, while 35 (50.7%) were discharged from the emergency room after receiving treatment and eight (11.6%) were admitted to the Pediatric Intensive Care Unit (PICU). One case of mortality was documented (n=1, 1.4%) (Table 7; Figure 3).

Discussion
There were 69 incidences of acute poisoning admitted to the emergency room at a single is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted September 10, 2020. . https://doi.org/10.1101/2020.09.08.20190868 doi: medRxiv preprint potential risk (14,15). Intentional poisoning usually affected adolescent, in a study of 148 cases of poisoning, 86% were accidental; of the intentional cases, 33% were suicidal in subjects 12 years or older (14,15).
In this study, ingested medicines were found to be the main cause of acute poisoning (73.9%) consistent with a previous study (16) followed by chemical poisoning that occurred in 13% of the incidents. According to the Annual Report of AAPCC (2018) National Poison Data System (NPDS) (6), the top five most common exposures in children age 5 years or less were cosmetics and personal care products (12.1%) followed by household cleaning substances (10.7%) and analgesics (9.04).
Analgesics-specifically non-steroidal anti-inflammatory drugs-as well as household cleaning substances are the most common poisons in children in recent studies. (17,18).
In these studies, analgesics like paracetamol were the most documented cause of poisoning in children (39.1%) in addition to pharmaceutical products such as syrups that attract children due to colors and flavors (19) followed by anticonvulsants (18.8%) and antipsychotics (13%). Other studies reported that neurologic medicines were the most common drugs causing poisoning in children followed by analgesics (1) .
The management of poisoning cases in pediatric cases depends on several factors such as the type of poison, the dose, clinical manifestation, age, presence of other diseases or injury, and the time of poisoning exposure (20).
Most poisoning cases were managed in the hospital through decontamination with active charcoal (51.6%), and N-acetylcysteine (antidote of paracetamol) was given to (29%) of the cases. Previous studies have shown that active charcoal alone is a better treatment for poisoning cases presenting in the hospital within one hour (21). Activated charcoal can decrease the absorption in stomach and intestine for a wide variety of is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted September 10, 2020. . https://doi.org/10.1101/2020.09.08.20190868 doi: medRxiv preprint toxins and medicines such as carbamazepine, phenobarbital, theophylline, salicylates, and valproic acid (20), In this study, 25 patients (36.2%) were admitted to the pediatric ward while (n=8, 11.6%) cases were admitted to the PICU; one mortality was documented. The clinical severity of poisoning incidents in this study is higher than what is reported in similar research where most cases where mild, and 101 (17.2%) cases were admitted to the hospital and only 21 (3.6%) were admitted to the PICU (1). Most childhood poisoning incidences occurred due to the easy availability of medicines and chemicals at home in several forms and a lack of parental supervision to keep these materials in a safe place and out of reach to children. A World Health Organization report revealed that an estimated 193,460 deaths were caused annually because of unintentional poisoning worldwide of which 84% occurred in low-and middle-income countries. Educating the community and particularly parents about the risks of drugs and chemicals poisoning in children may reduce the occurrence of such harmful adverse events (16,22,23).
One limitation of this study is its retrospective nature and single setting. Incomplete and missing data may also limit the generalizability of the study's findings. The results highlight the importance of community education and developing guidelines for monitoring and managing poisoning incidents in Saudi Arabia.

Conclusions
There were 69 incidences of acute poisoning in children in a single hospital within approximately three years. Most incidents were unintentional and occurred in children younger than 5 years of age. Most poisonings were due to medicines. Analgesics such as paracetamol was the most common documented medicine associated with poisoning. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted September 10, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted September 10, 2020. . https://doi.org/10.1101/2020.09.08.20190868 doi: medRxiv preprint . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.
is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted September 10, 2020. . https://doi.org/10.1101/2020.09.08.20190868 doi: medRxiv preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted September 10, 2020. . https://doi.org/10.1101/2020.09.08.20190868 doi: medRxiv preprint  is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted September 10, 2020. . https://doi.org/10.1101/2020.09.08.20190868 doi: medRxiv preprint at hospital followed by only 1 at school.
• 81.16% (56) patients had Oral route of Intoxication followed by local, IV, and inhalation.
. CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.
is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted September 10, 2020. . https://doi.org/10.1101/2020.09.08.20190868 doi: medRxiv preprint  is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted September 10, 2020. . https://doi.org/10.1101/2020.09.08.20190868 doi: medRxiv preprint  is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted September 10, 2020. . https://doi.org/10.1101/2020.09.08.20190868 doi: medRxiv preprint  is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted September 10, 2020. . https://doi.org/10.1101/2020.09.08.20190868 doi: medRxiv preprint