Approach to household substance exposure (pediatrics): Clinical sciences

Inhalation or ingestion of various household substances can cause serious morbidity and mortality in the pediatric population.

Increased mobility and frequent hand-to-mouth activity during the toddler and preschool years create the potential for unintentional or exploratory ingestions.

While exposure to some substances like lead cause vague, subacute, or chronic symptoms; ingestion or inhalation of caustic substances, carbon monoxide, organophosphates, or toxic alcohols can cause acute, life-threatening symptoms.

Now, if a pediatric patient presents with a chief concern suggesting a household substance exposure, you should first perform an ABCDE assessment to determine if the patient is unstable or stable.

If unstable, stabilize the airway, breathing, and circulation; and consider intubation if they demonstrate shallow, ineffective, or absent respirations. Next, obtain IV access and administer IV fluids. Then, put your patient on continuous vital sign monitoring, including blood pressure, heart rate, and pulse oximetry. If needed, provide supplemental oxygen, obtain a point-of-care blood glucose level, and order a 12-lead ECG. Finally, if indicated, consider a surgical consultation or endoscopy.

Here’s your first clinical pearl! Depending on the substance and timing of ingestion, you can consider using a decontamination method to minimize absorption. While ipecac syrup and gastric lavage are no longer recommended, activated charcoal can be effective if given within one hour of ingestion. Keep in mind that charcoal does not bind well to liquids or charged molecules like iron; and you should avoid using it for caustic ingestions, since it can obscure visualization during endoscopy. Always make sure your patient can protect their airway before you give activated charcoal, since it can induce vomiting!

Now that we have discussed unstable patients, let’s return to the ABCDE assessment and look at stable ones.

First, obtain a focused history and physical examination. If your patient is preverbal, or if they present with altered mental status, caregivers or family members can provide details.

For unwitnessed exposures, ask about circumstances surrounding the event, such as the child’s location when they were discovered, and potential hazards in the home or surroundings. History will reveal either a known or suspected exposure.

The patient or their caregiver may report symptoms like headache, nausea, and vomiting;

while the exam might reveal vital sign abnormalities, such as bradycardia or tachypnea, as well as altered mental status.

At this point, you should consider a household substance exposure and assess the onset of your patient’s symptoms.

Let’s discuss patients with a subacute or chronic onset of vague symptoms. Here, consider lead poisoning. While many patients are asymptomatic and identified by routine screening, some experience anorexia, abdominal pain, constipation, and developmental delay. History may reveal risk factors for lead exposure; for example, your patient’s home might have been painted before 1978; or its pipes might have been installed before 1986. Physical exam findings are often unremarkable, but because chronic lead poisoning can cause anemia, you might notice pallor. At this point, you should order blood lead levels, and if they’re elevated, diagnose lead poisoning.

Here’s a clinical pearl! While the prevalence of lead exposure has decreased due to government regulations, lead-related morbidity remains a concern among certain populations; like pre-school children, those living in an urban setting, and those from a lower socioeconomic background; so remember to screen for lead exposure during well-child visits.

Alright, let’s switch gears and take a look at patients with acute symptom onset.

Here, assess for signs of caustic substance ingestion. History may reveal a witnessed ingestion of a caustic agent, such as bleach or dishwasher detergent; or the patient may have been found near a spilled bottle of household cleaner. Affected children frequently present with dysphagia or refusal to swallow; and, if the injury involves the airway, they might also have dyspnea. The physical exam typically reveals drooling, and you may see oral mucosal burns. Some patients may also have audible stridor or a rash where the agent contacted the skin. With these findings, consider caustic substance ingestion, and urgently order an endoscopy.

If it demonstrates oropharyngeal or esophageal erythema and possibly ulcers, diagnose caustic substance ingestion.

Now, let’s discuss patients without signs of caustic substance ingestion. Here, assess for historical features suggesting carbon monoxide poisoning. Affected patients typically present with headache, drowsiness, and nausea. However, when it comes to infants, they might act colicky, fussy, or have feeding difficulties.

Symptoms often occur during the winter months, when caregivers are more likely to use wood-burning stoves, kerosene heaters, an old furnace, or indoor fireplaces. History often reveals multiple individuals in a shared living space with similar symptoms. Keep in mind that because younger children need more oxygen than adults, they might develop symptoms more quickly than adults, too. If any of these features are present, consider carbon monoxide poisoning, and order a carboxyhemoglobin level. If it’s elevated, diagnose carbon monoxide poisoning.

On the flip side, if you identify no features suggesting carbon monoxide poisoning, assess for signs and symptoms of the cholinergic toxidrome.