PUBLIC HEALTH
A NEW
ASPECT
OF
“ACCIDENTAL”
POISONING
IN CHILDHOOD
An
Approach
to
Prevention
Alfred J. R. Koumans, M.D.
Norwalk Ilospital, Norwalk, Connecticut
CONTRIBUTORS’
SECTION
IflE
IGNITING spark for this study wasPrvi(le1 by observation of a 4-year-old
girl who was admitted to the Norwalk Hos-pital ill cOma after taking all overdose of
her mothers i)arbiturates. Tilere was a strik-ing resemblance to the motilem noted in the polish Oil tile finger- and toenails, in the permanent wave and in the make-up on the
face. Tile idea of deliberate or
subcon-scious imitation of tile parent in other ways, such as taking of pills, was vividly sug-gested.
The oniy reference to this factor found in
tile literature studied was a general
state-ment by Camp, “Children wilo see the
parents take something from the medicine cabinet aie ipt to imitate with sometimes disastrous results.”
It seemed desirable to study the matter further fronl this “epidemiologic” aspect, particularly because poisoning is so
com-OO and dangerous in young children.111
PATIENT MATERIAL AND PROCEDURES
All children conling to the Norwalk Hospital Emergency Roonl with the diagnosis of
inges-tion of llle(lication not prescribed were seen and
the par’iits (1U5ti1lCl. Only tilose cases were
investigated in WiliCil 1)iilS or sui)stances
resem-l)iing them were taken. Excluded as bCVoIl(l
the sxj,e of the studs’ was poisoning by gases,
li(1uids and household I)OisOn5.
While the child received emergency
treat-ment or soon thereafter, tile acCompanying
adult was questiolled according to a standard
(Dlestiollllaire (Table I). Cases were
subse-(fuently tabulated in two groups: Group A
in-eluded children swallowing pills or similar
p0-tential poisons; Group B, those taking baby
aspirin, resembling candy in aspect and taste.
Group B serves as a limited control for Group
A.
RESULTS
In Table II are tabulated tile distribution
as to age, sex, and wiletiler tile cilild
watched the parent take pills or not. In 19
cases only tile mother took medicine
regu-larly (daily or weekly); in 1 case the father,
and in 1 case both parents took medicine
regularly. In four other rnstallces tile parents
took aspirin occasionally. In the five
remain-ing cases neither parent took pills; in tilree of these, other factors could have beell of
importance, as follows: 1) one cilild wilo
liked baby aspirin took pink pills of similar appearance; 2) one child who was accus-tomed to taking Empinin#{174} wilen ill took
some on her own; and 3) one child who was neceivillg a maintenance dose of bar-hitumates overdosed herself.
In this group of 30 patients there were 2 repeaters, 1 of whom watched both pareilts
take pills.
Among tile 24 patients in Group B (Table
III), in one instance only the motiler took pills regularly, in two the father, and in one
both I1rents took pills regularly. Ill t\V()
other instances tile 1)1rellts took as)inii oc-casionally, 1)0th being Oi)served wilile doing
so. In this group there were two repeaters, neither of \vilose parents took pills.
Two Otilen possible factors were studied and are tabulated below (Table IV). One of these was tile “accessibility” of the
Age (yr) Male Female lVateher.s
1-’2 .5 7 5 .5 0
‘2-3 11 7 19 13 12 1
3-4 1 1 1 1 ()
4-5 0 2 2 2 0
Non-watchers
1068 “ACCIDENTAL” POISONINC
‘Fot.al 18 12 30 21
TABLE I
Intoxication Statistics
No. ____ Date ___________
1. Name
Age
Sex
2. I)id the child take pills (poison or medicine) before?
3. Nature of plus (poison) (brand name or name of medicine)
Color:
‘Faste:
4. I)oes the miother or father take me(licLIle regularly? (State wlli(h one)
What kind:
What frequency:
For what length of time?
‘Xas there an interval betveen taking pills by parent an(l the acci(lent? 5. Did the child watch the parents taking their pills?
6. Was there difficulty involved for the child in getting the pills?
7. Were the pills locked away?
8. I)id the parents ever forbid the child to take pills?
9. Is the child a type that puts everything in its mouth?
10. Form filled in by:
the child was an “oral explorer,” that is,
whether he commonly put foreign objects in his mouth.
DISCUSSION
The difference between the results shown
in Tables II and III regarding the
pen-centage of parents taking pills could point to another factor than those already cited:
that of availability of the pills. This would
become probable if the children in Group A ingested the same pills as their parents.
Seven children were reported to have done so, five took other pills, and in the remain-ing patients it was not known. Thus the
availability of pills probably plays a role. Other factors, however, seem to be needed
for explanation of tile childs behavior.
The generally accepted etiologic factors
of “accidental” poisoning in childhood can be grouped as follows:
I. Objective Causes:
1. Easy accessibility of “
2. Attractiveness of agent’4
II. Subjective Causes:
1. Oral exploration of environ-ment’2’ 16, 17
2. “Accident proneness”hl 11
It should be stated that, regarding the
data presented in Table IV, there is no ade-quate control group which might justify some tentative statements. The data are sug-gestive, but conclusive evidence for or
against is lacking.
TABLE II
l)ATA ON PATIENTM IN Gioup A: THOSE Wuo SWALLOWED PILis OTHER THAN BABY ASPIRIN
Parents Takmnq
Total .
Age Stale Female JJ’atchers
1-’2 0 0 0 2
2-3 8 7 15 2 ‘2 13
3-4 3 l 5 ‘2 1 4
4-5 ‘2 0 ‘2 0 0
.V071-ratrhers
‘Fotal 15 9 t4 4
PUBLIC HEALTH 1069
* Exact percentage unknown.
TABLE III
1)ATA ON PATIENTS IN Game B: ThosE Wiio SwArj,owEn BABY ASI’IHIN
Parents Taking Total
Pills
Accessibility
The predominance of difficult access in
both groups might indicate that there was
a definite purpose behind the child’s
pill-swallowing, not merely a chance discovery.
Almost invaniably* the story told was “the child climbed on the table (sometimes even put a chain on the table) and must have
reached for the top shelf to get the bottle.” On one occasion he even opened a locked cabinet!
Oral Exploration
From these data the relative importance
of this factor seems less than usually pre-sented.
Attractiveness
This factor is suggested as fan as baby aspirin is concerned. In Group A previous
administration of baby aspirin had occurred in 5 cases; in 13 others some other medica-tion (pills) was given at an earlier time. Of
tile pills taken by the patients in Group A
TABLE IV
FArrolls OF AccKSsIBIuTY AND “ORAL
EXPLORA-TION” AMONG TilE Two GROUPS
Group A Group B
Accessil)ility
Easy 9 5
Difficult 18 20 “Oral explorer”
Admitted I 1 8
I)enied 18 16
0 Exact percentage unknown.
76% were white on of another “unattractive”
color, according to the classification of Jolly and Forrest.14 In Group B there was a history of previous intake of baby aspirin in 20 of
the 24 cases. The parents frequently
mdi-cated that the child mistook it for candy, or that he had been asking for the “candy” he received when ill.#{176}
Another possible contributory factor, hitherto unmnvestigated, may be deduced
from Tables II and III. The relative propon-tion of “watchers,” 67% in Group A versus
only 13% in the companion Group B, is
striking. The factor responsible for this difference may well be imitation of the par-ents by the children, a familiar phenomenon in the psychology of small children.
If this mechanism, briefly and
supemfi-cially investigated in this study, could be confirmed on a wider scale, it would be of great importance to incorporate proper
par-ent education into our preventive efforts, by advising them to take their pills out of sight
of their children.
SUMMARY AND CONCLUSIONS
Certain etiologic factors relating to
ac-cidental ingestion of medication (pills) in children under 5 years of age were studied. There seemed to be a purposeful behavior behind the “accident.” Availability, easy ac-cessibility and oral exploration are
1070 “ACCIDENTAL” POISONING
less attractive form of this medication would
seem indicated.
Of the children poisoned by medication other than baby aspirin, 67% frequently ob-served their parents taking pills. This was found in only 13% of a comparison group of children who ingested baby aspirin. This
factor is suggested as playing an additional role, and could be minimized by proper parent education.
Acknowledgment
I am deeply grateful to Dr. Roy N. Bamett,
Director of Laboratories, Norwalk Hospital, for his continuous interest and invaluable assist-ance.
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