Poisoning and ingestions in children

• Most childhood poisonings are exploratory accidents in toddlers aged 1 to 5 years. Cosmetics and personal care products are the commonest exposures (about 13.4 percent), cleaning products about 10 percent, and medicines about 7.9 percent, while true poisoning is uncommon and fatalities are rare. ^[5]
• The first steps are always the same: check airway, breathing and circulation, remove the child from the source, and call the national poison centre (in the UK, NHS 111 routes the public to the National Poisons Information Service; in the USA, the Poison Help Line is 800 222 1222). ^[5][6]
• Only a minority of ingested agents needs stomach-emptying. The American Academy of Clinical Toxicology and the European Association of Poisons Centres and Clinical Toxicologists discourage routine activated charcoal, gastric lavage and cathartics; they are reserved for selected, severe cases with poison-centre advice. ^[5]
• Syrup of ipecac is no longer recommended for home or routine hospital use. ^[5]
• The agents that most often kill children are those that act in tiny doses: iron, button and coin-cell batteries, caustics, hydrocarbons, tricyclic antidepressants, opioids, oral hypoglycaemics, cardiovascular drugs and a few others; patients with exposure to these need a lower threshold for referral. ^[5]
• Two antidotes in particular are time-critical: N-acetylcysteine (paracetamol) within the first 8 hours, and deferoxamine for moderate-to-severe iron poisoning. Button batteries lodged in the oesophagus must be removed urgently because an aorto-oesophageal fistula can form. ^[1][2][4]

By the end of this page you should be able to:

1. Set out the immediate ABCDE approach to a child with a suspected poisoning and know when to call a poison centre.
2. Take a focused exposure history and recognise the main toxidromes.
3. Decide when decontamination (activated charcoal, gastric lavage, whole-bowel irrigation) is justified and when it is contraindicated.
4. Manage paracetamol (acetaminophen), iron, button battery, caustic and common household-product ingestions.
5. Recognise antitoxin-specific treatment (N-acetylcysteine, deferoxamine) and stopping criteria.
6. Arrange safe disposition, observation and prevention counselling.

Poisoning in children is almost always unintentional. A mobile toddler who climbs, opens bottles and puts things in the mouth meets household and medicinal products that were never designed to be swallowed. The distribution matters clinically: cosmetics and personal care products, cleaning agents, analgesics, medicines and foreign bodies together dominate poison-centre call logs, although most turn out to be nontoxic or minimally toxic in the small amounts a child swallows. ^[5] The task of the clinician is therefore triage: recognise the small minority of children who have taken a high-risk agent or a toxic dose, treat them promptly, and avoid invasive decontamination in the rest. ^{[5] [7]}

Poison centres exist for exactly this reason. In the United Kingdom the National Poisons Information Service provides 24-hour expert advice to NHS staff and runs TOXBASE, a web-based toxicology database for healthcare professionals. Members of the public in England, Scotland and Wales reach the service through NHS 111; in Northern Ireland they contact their GP, and in the Republic of Ireland the National Poisons Information Centre is reached on 01 809 2166. ^[6] In the United States the Poison Help Line (800 222 1222) serves both families and professionals, and poison centres answered over 2.4 million exposure reports in 2003 alone, of which 76 percent involved oral ingestion, 93 percent occurred in the home and more than 80 percent were unintentional. Children under 6 years accounted for 51 percent of those exposures. ^{[5] [3]}

The home is the site of most childhood poisonings. Infants and non-ambulatory toddlers cannot reach high or locked objects, so a serious ingestion in that age group should prompt careful reassessment of access, storage and, where appropriate, safeguarding. ^[5] Medications that visitors bring into the home (a purse, pillbox or overnight bag) are a recurring hidden source. ^[5] Secondary sources include grandparents' houses, and more recently liquid nicotine, cannabis edibles, gummy vitamins and laundry detergent capsules, which are attractive to young children and can be toxic in small volumes. ^[7]

Globally, the burden is uneven. The World Health Organization notes thousands of accidental childhood deaths from poisoning each year, concentrated in low- and middle-income countries, where pesticides, kerosene and other domestic chemicals are common. ^[7] In high-income countries the same agents (medicines, household cleaners, foreign bodies) predominate, but mortality is much lower because of child-resistant packaging, product reformulation, poison centres and better critical care. Iron poisoning in children in the United States, for example, fell after education and child-safety packaging were introduced. ^[5]

The overall flow is a single decision chain: stabilise, identify, assess, decontaminate only if justified, treat specifically, observe, refer. ^[5]

History. Record age and weight, the agent, amount and formulation, the time of ingestion, whether it was witnessed, co-ingestants, all prescription and over-the-counter medicines in the house (including those brought in by visitors), and whether there has been a similar episode in the family (which may point to abuse or neglect). ^[5]

Toxidromes. The examination looks for patterns: anticholinergic (tachycardia, dry flushed skin, mydriasis, ileus), cholinergic (salivation, lacrimation, urination, diarrhoea, bronchorrhoea, bradycardia), opioid (hypoventilation, miosis, hypothermia), sympathomimetic (tachycardia, hypertension, mydriasis, agitation), salicylate (tinnitus, tachypnoea, fever) and others. The ambient temperature, blood glucose, bedside ECG and pulse oximetry are part of the look. ^[5]

Exposure thresholds. Age guides triage. Most exposures involve toddlers and preschool children between 1 and 6 years. Infants and immobile toddlers rarely ingest agents placed out of reach, so significant toxicity in that group deserves careful safeguarding review. ^[5] Adolescents with ingestions are more often intentional and should be assessed for suicide and substance use, with consultation and admission. ^[5]

A thorough history and examination are usually enough. Routine "drug screens" rarely help in paediatrics and false-positive and false-negative results mislead. ^[5] For agents that can kill in tiny doses, order targeted quantitative levels instead. ^[5]

For paracetamol, obtain a serum paracetamol concentration: at 4 hours after ingestion for immediate-release products (or immediately if later), plotted on the Rumack-Matthew nomogram. ^[1][5] For iron, serum iron at 4 to 6 hours, plus full blood count, urea and electrolytes, glucose, liver and clotting tests; abdominal radiograph may show radiopaque tablets in the first few hours but a normal film does not exclude poisoning. ^[2] For an unknown ingestion, the basic chemistry panel, blood gas (anion and osmolar gaps), paracetamol and salicylate levels are the sensible first tests; a targeted ECG is needed for cardiotoxic drugs (tricyclics, calcium-channel and beta blockers, digoxin, antiarrhythmics). ^[5]

Gastrointestinal decontamination used to be routine. It is not anymore. The AACT and EAPCCT position papers and current paediatric reviews agree that most children need supportive care only, and that the decision depends on the agent, dose, elapsed time, and symptoms, always with poison-centre advice. ^[5]

Key points from the consensus guidance: activated charcoal works best when given early and evidence of improved outcome later is limited; gastric lavage is discouraged routinely and is performed only by practiced clinicians with poison-centre advice; ipecac syrup is abandoned and neither the AACT/EAPCCT nor the American Academy of Pediatrics recommend it for home use, so existing household ipecac should be discarded. ^[5] Activated charcoal does not adsorb iron and is not used in iron poisoning. ^[2] Hemodialysis is reserved for specific toxins and situations (salicylates, theophylline, lithium, methanol, severe iron) after toxicology and nephrology discussion. ^[5]

Antidotes are given once the patient is stable, usually within the first few hours, and many need repeated dosing because of short half-lives. ^[5] Decisions should follow poison-centre advice.

Paracetamol (acetaminophen). Paracetamol is the leading cause of acute liver failure in the United States and the most common over-the-counter poisoning worldwide. Toxicity develops at doses above about 12 g in 24 hours, single doses of 7.5 to 10 g, or above 150 mg/kg in adults; in children a single dose of 150 to 200 mg/kg in otherwise healthy children aged 1 to 6 is associated with toxicity. About 30,000 paediatric paracetamol poisonings go to the US National Poison Data System each year. ^[1] The mechanism is accumulation of N-acetyl-p-benzoquinoneimine as glutathione stores are exhausted; the result is zone 3 centrilobular necrosis, with multisystem failure in severe cases. ^[1]

Diagnosis rests on the serum paracetamol level. Take it 4 hours after ingestion for immediate-release products, immediately if presentation is later. Compare it with the treatment line on the Revised Rumack-Matthew nomogram: 150 micrograms per mL (990 micromol per L) at 4 hours, falling to 4.69 micrograms per mL (31.3 micromol per L) at 24 hours. A level above the line calls for treatment. For extended-release formulations or co-ingestion with anticholinergics or opioids, repeat the level. a level above 10 micrograms per mL with unknown timing also needs treatment. Repeated supratherapeutic ingestions (over 24 hours) cannot be plotted on the nomogram, so decisions rely on clinical assessment, the paracetamol level and transaminases. ^{[1] [5]}

Acetylcysteine is the antidote and is highly effective if started within 8 hours of ingestion, with equal benefit whether given at 0 to 4 hours or 4 to 8 hours. It may still help later, and remains indicated when liver injury is present. It is given intravenously or orally. Standard intravenous regimens follow the usual loading-dose and infusion structure used for acetylcysteine; a poison centre or medical toxicologist should advise on the exact regimen and duration for the case. Oral loading is 140 mg/kg followed by 70 mg/kg every 4 hours (72 hours total, 18 doses); patients over 100 kg receive a maximum loading dose of 100 mg/kg. Treatment continues until the patient is clinically well, with cleared paracetamol levels, a normalising INR and falling transaminases. High-risk ingestions may need airway protection, fluids or vasopressors, and, in severe cases, haemodialysis, on poison-centre and toxicology advice. ^{[1] [4]}

Activated charcoal is controversial but can be considered in the first 2 to 4 hours, especially for large or extended-release ingestions; once acetylcysteine is indicated and the patient is within the early window, antidote matters more. ^[1] Consultation with a medical toxicologist or poison centre is recommended for all paracetamol poisonings. ^[1]

Iron poisonings remain one of the most dangerous ingestions in children under 6 years: 4,072 single iron or iron-salts exposures were reported to the US National Poison Data System in 2015, of which 3,211 were unintentional and 2,036 involved children aged 5 or under; 1,161 needed treatment and 1 death was recorded. ^[2] Children usually reach iron through maternal prenatal tablets or children's supplements. ^[5] The toxicity is dose-dependent and expressed as elemental iron (a 325 mg ferrous sulphate tablet contains about 65 mg, or 20 percent; ferrous gluconate 300 mg contains about 36 mg, or 12 percent; ferrous fumarate 100 mg contains about 33 mg, or 33 percent; prenatal vitamins contain 60 to 90 mg per tablet; children's multivitamins 5 to 19 mg). Ingestion under 20 mg/kg is generally nontoxic, 20 to 60 mg/kg can produce moderate symptoms, and over 60 mg/kg is associated with severe, potentially fatal toxicity. As few as 5 to 10 adult ferrous fumarate tablets (55 mg elemental iron each) can kill or seriously harm a child. ^{[2][5] [1]}

The clinical course has five stages, not all of which occur: ^[2]

• Stage 1 (0.5 to 6 hours): vomiting, abdominal pain, haematemesis, diarrhoea, sometimes bleeding. ^[2]
• Stage 2 (6 to 24 hours): a deceptive symptom-free latent phase while absorption continues.
• Stage 3 (6 to 72 hours): shock, metabolic acidosis, hepatocellular injury, coagulopathy, renal failure. ^[2]
• Stage 4 (12 to 96 hours): hepatic failure. ^[2]
• Stage 5 (2 to 8 weeks): gastric outlet obstruction and bowel strictures from scarring. ^[2]

Serum iron is the key test and is ideally taken 4 to 6 hours after ingestion (later with sustained-release preparations, so repeat the level). Levels under 350 micrograms per dL suggest mild risk, 350 to 500 micrograms per dL moderate toxicity, and over 500 micrograms per dL severe systemic toxicity. Plain abdominal radiographs may show radiopaque tablets in the first 6 hours, but absence does not exclude poisoning and the count does not predict severity. ^[2]

Management depends on severity. ^[2] Asymptomatic children with subtoxic exposures 4 to 6 hours after ingestion need observation only; mild gastrointestinal symptoms in the latent period can also be observed with supportive care. Systemic toxicity, persistent symptoms or haemodynamic instability need intensive care: intravenous crystalloids, correction of coagulopathy with vitamin K and fresh frozen plasma if needed, and deferoxamine chelation for serum iron above 500 micrograms per dL, metabolic acidosis, shock or organ dysfunction. Deferoxamine runs as a continuous intravenous infusion of 15 mg/kg per hour (maximum 35 mg/kg per hour, maximum 6 g per day), usually for 24 hours. Whole-bowel irrigation with polyethylene glycol via nasogastric tube speeds removal of unabsorbed tablets; activated charcoal does not bind iron and is not used. Admission is needed for persistent symptoms, dehydration or any need for deferoxamine; intensive care for shock, coma, acidosis or serum iron over 1000 micrograms per dL. Discharge is reasonable after 6 to 12 hours of observation with normal laboratory results and serum iron under 350 micrograms per dL. ^[2][5] Toxicology consultation is advised in moderate-to-severe cases, and psychiatric assessment is essential after intentional overdose. ^{[2] [4] [1]}

Children frequently swallow objects, and over 50,000 foreign-body ingestions in children under 5 years were reported to the US National Poison Data System in 2022. Most foreign bodies pass spontaneously. Coins remain the commonest medicinally attended foreign body in the US, but buttons, button batteries, magnets and small toys are the dangerous ones. ^[4]

Button (disc) batteries deserve their own protocol. They can lodge in the oesophagus, nose, ear or other orifices and produce corrosive injury within a few hours. Lithium cell batteries carry the highest tissue-damage risk. The mechanism is formation of a local circuit with adjacent tissue, causing burns, coagulative necrosis, perforation, mediastinitis, peritonitis and strictures; a rare but potentially fatal complication of an oesophageal button battery is an aorto-oesophageal fistula with arterial bleeding into the oesophagus. ^[4]

Management is as follows. Any button battery in the oesophagus needs urgent removal. When endoscopy cannot be done immediately, oral honey has been proposed to limit local tissue damage. Oesophageal batteries in symptomatic children need immediate gastroenterology or surgical involvement. Asymptomatic patients who present more than 12 hours after ingestion, or in whom the battery has passed into the bowel, can sometimes be monitored for spontaneous passage, with imaging repeated after 7 to 14 days; any new symptoms warrant emergency reassessment and likely surgery. Children who have swallowed unknown batteries need a radiograph promptly, because batteries and coins differ radiographically: batteries show a double-contour (halo) appearance and a two-layer profile on lateral views, while coins are single dense discs. ^[4]

Magnets (especially rare-earth magnets) are dangerous when more than one is swallowed, or when one is swallowed with another metal object, because they attract across tissue planes and cause pressure necrosis, perforation, peritonitis and obstruction. Such cases need specialist input; asymptomatic patients who swallow multiple magnets may be observed with serial imaging, with timing guided by the case, and surgery is considered when there is no progression or symptoms develop. ^[4]

General rules apply to all foreign bodies: emetics, muscle relaxants and meat tenderisers are ineffective and can be harmful; laxatives are unproven and should only be used with specialist advice; expectant management is reasonable for small inert objects (such as a coin) in the stomach or bowel in a healthy, asymptomatic child, with clear return precautions. ^[4]

Caustic ingestions cause severe morbidity and mortality in all ages. About 80 percent of caustic ingestion cases in the United States occur in children and most are unintentional, exploratory ingestions of household cleaners such as bleach and ammonia in small amounts. ^[3] About 180,000 caustic exposures were reported in the US in 2019, mostly paediatric and mostly accidental, with lye the commonest alkaline agent. ^[3] The oesophagus is most vulnerable to alkalis and the stomach to acids, and extremes of pH (below 3.0 or above 11.0) are of greatest concern, although strong acids and strong alkalis can both cause severe full-thickness injury. ^[3] Alkalis classically cause liquefactive necrosis with deep penetration; acids cause coagulative necrosis with more superficial eschar, although in practice both can be equally destructive. ^[3]

The approach is: ^[3]

• Secure the airway first (drooling, stridor, respiratory distress, hypoxia), give fluids and vasopressors if in shock, and stabilise before any invasive tests.
• Do not induce vomiting and do not neutralise the pH (weak acid or base titration risks exothermic injury and has no human outcome evidence); dilution with milk or water is also not recommended in current practice.
• Only activated charcoal for specific metal caustics such as zinc or mercuric chloride.
• No blind nasogastric tube placement in the emergency department (risk of infection and perforation); place only under direct endoscopic vision.
• Upper endoscopy (EGD) is the gold standard and should be done within 24 hours, especially for symptomatic patients (posterior pharyngeal burns, stridor, chest/abdominal pain, inability to tolerate liquids) and for any intentional ingestion; asymptomatic patients without mucosal burns may not need endoscopy. ^[3]
• CECT can add information but does not replace endoscopy.

Zargar grading on endoscopy ranges from 0 (normal) to 3b (extensive necrosis); grade 2b and above carry a meaningful stricture risk. Steroids remain controversial: pooled evidence does not support their routine use for preventing stricture, although high-dose methylprednisolone has been used for grade 2b injuries in some series. Emergent surgical consultation is needed for mediastinitis, peritonitis, haemodynamic instability or high-grade injury, with removal of necrotic tissue and, where necessary, resection or bypass for established strictures. ^[3]

Non-pharmaceutical household products are the most common substances in exploratory ingestions in young children. Most household products cause little harm in the small volumes a child swallows, but a short list carries serious or fatal toxicity: alcohols, button batteries, corrosive cleaners, laundry detergent pods, hydrocarbons and magnets. ^[7] Liquid detergent pods in particular combine an attractive colour with a concentrated irritant surfactant dose, and hydrocarbons (kerosene, furniture polish, lamp oil, lighter fluid) are dangerous both for aspiration pneumonitis and for systemic toxicity. ^[5][7] Prevention is storage: child-resistant containers, out of sight and reach, locked cupboards, and keeping agents in original containers (never in drinks bottles), together with anticipatory guidance from the 6-month well-child visit onward. ^[5][7]

A child who has taken one agent has often taken others, and the poison-centre rule is to ask about co-ingestants and to check for paracetamol and salicylate in every significant ingestion because both are commonly present and dangerous. ^[5] In adolescents, intentional ingestions and substance use need psychiatric assessment and admission. ^[5] In toddlers, a mediating cause such as an unwell child, a visitor's medicine bag or a change in household routine often explains the event; repeated unintentional poisonings in one family merit preventive discussion and a closer look at the caregiver situation and the possibility of abuse or neglect. ^[5]

Mimics of poisoning matter too. A poisoned child can look like sepsis, meningitis, epilepsy, trauma or a metabolic disorder, and trauma should be considered whenever there is altered mental status. ^[5] Conversely, an asymptomatic child who has swallowed a delayed-acting agent needs observation for longer than the initial exposure window. ^[5]

Prevention is the most useful clinical action. Poisoning prevention is an integral part of anticipatory guidance from the 6-month well-child visit, and the message is simple and repeated: store medicines and chemicals up high and out of sight, in locked cupboards, in original child-resistant packaging; never transfer them into food or drink containers; keep handbags and visitor medicines out of reach; dispose of old medicines safely. ^[5][7] Carers of children who have had an ingestion benefit from a calm explanation of what happened, clear return precautions and, where appropriate, a review of home storage with a pharmacist or health visitor. ^[5][7]

• Most childhood poisonings are accidents in toddlers; the job is triage, not routine decontamination. ^[5]
• Stabilise airway, breathing and circulation first, remove from the source, then call the national poison centre (NHS 111 in the UK, 800 222 1222 in the US). ^[5][6]
• Cosmetics and personal care products (about 13.4 percent), cleaning products (about 10 percent) and analgesics (about 7.9 percent) are the exposures poison centres see most; most are nontoxic in the dose a child takes. ^[5]
• Gastric lavage, activated charcoal, cathartics, syrup of ipecac and dilution are not routine; they are reserved for selected cases with poison-centre advice. ^[5]
• Activated charcoal 1 to 2 g/kg (max 50 to 60 g) only when presentation is early; covered agents include carbamazepine, phenytoin, theophylline, salicylates and valproate. ^[5]
• Ipecac is obsolete and should be discarded from homes. ^[5]
• Paracetamol: toxic at over 12 g in 24 hours, 7.5 to 10 g in a single dose, or over 150 mg/kg in adults; 150 to 200 mg/kg in young children; level at 4 hours on the Rumack-Matthew nomogram; antidote N-acetylcysteine, most effective within 8 hours. ^[1]
• Iron: under 20 mg/kg nontoxic, 20 to 60 mg/kg moderate, over 60 mg/kg severe; deferoxamine for serum iron over 500 micrograms per dL or systemic toxicity. ^[2]
• Button batteries in the oesophagus need urgent removal; honey if endoscopy is delayed; beware aorto-oesophageal fistula. ^[4]
• Caustics: no vomiting, no neutralisation, no blind tube; EGD within 24 hours; high-grade injuries need surgical care. ^[3]
• High-toxicity household products (alcohols, batteries, caustics, detergent pods, hydrocarbons, magnets) need early referral and clear return precautions. ^[5][7]
• Infants under 1 year and non-ambulatory toddlers with a serious ingestion, and any adolescent ingestion, need careful safeguarding review. ^[5]

No individual MedGrasp topic is linked from this page yet. Practical follow-ons are supportive care of the critically ill child, analgesia and antipyretics, dehydration and paediatric fluids, acute gastrointestinal bleeding and safeguarding, which can be linked with TopicLink once verified.