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WI CAN Educational Series

Hillary W. Petska, MD, MPHChild Advocacy and Protection Services

Children’s Hospital of Wisconsin

Matthew Torbenson, JDDeputy District Attorney

Milwaukee County

3/20/20

• Review the epidemiology of pediatric poisonings.

• Recognize that ingestions in children are not always accidental.

• Describe the importance of investigation in cases of suspected poisoning.

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• Exposures in the US• >300 kids/d treated in

ED

• 2 kids/d die

• Accidental >> intentional poisoning

• 610 “malicious” exposures/yr

CDC 2019, Gummin 2019, Yin 2010, 2011

• Top 5 Therapeutic Errors

1. Given med twice

2. Incorrect dose

3. Wrong med given

4. Meds given too close together

5. Confused units of measure

Gummin 2019

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• N = 928 children

• 94% witnessed or suspected ingestion

• 13% evaluated by CPT

• 4% referred to CPS

W ood 2012

• Unintentional ingestion

• Momentary lapse of supervision

• Drug exposure during breastfeeding

• Neglect

• Supervisory neglect

• Dangerous environment

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• Intentional ingestion• Self-inflicted

• Recreational use

• Suicide attempt

• Inflicted by another• Caregiver under

influence gives wrong med

• Drug given to decrease

responsiveness

• Inflict harm or gain

attention (medical child abuse)

Reece 2009, Gummin 2019

• Peak age group = 1-2 yo

• Substances 1. Cosmetics/personal

care products

2. Household cleaning substances

3. Analgesics

4. Foreign bodies/toys

5. Topical preparations

• Medical attention < 2 hrs

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Reece 2009, I llingworth 1994

• Age < 1 yo• <5 mos

• Extrusor ref lex

• 9 mos:• Crawling

• Pincer grasp

• Self-feeding

• 12-18 mos:• Walking

• Substance• Low dose if noxious

• Illicit

All Exposures1 Malicious Exposures2

1. Analgesics 1. Analgesics

2. Topical preparations 2. Stimulants/street drugs

3. Antihistamines 3. Sedatives/hypnotics/antipsychotics

4. Vitamins 4. Cold/cough preparations

5. Dietary supplements/ herbals/homeopathic

5. Unknown drug

6. GI preparations 6. Ethanol

7. Antimicrobials 7. Topical preparations

8. Cardiovascular drugs 8. GI preparations

9. Cold/cough preparations 9. Antihistamines

10. Electrolytes and minerals 10. Antidepressants1Gummin 2019 2Yin 2010

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Reece 2009

• Presentation• Unexplained seizures or

life-threatening events

• Death w/o obvious cause

• Chronic unexplained symptoms (~MCA)

• Other evidence of maltreatment

• History• No or changing• Not c/w child’s

development

• Delay in seeking care

• Chief Complaint• Witnessed/suspected

ingestion

• Unexplained symptoms/ altered mental status

• Recurrent unexplained illness or symptoms (overlap with MCA)

• Child fatality

• Incidental finding on drug screening

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• Complete medical history

• All drugs/meds in the home

• Symptoms

• Development

• Discipline

• Interview child if possible

Symptoms Possible causative agents

Hallucinations Atropine-like agents

Bizarre movements Phenothiazines, metoclopramide, antihistamines

Diarrhea Laxatives, salt, ipecac, furosemide, caffeine, iron

Vomit Arsenic, ipecac, furosemide, cooking oil, ethylene glycol, caffeine, iron

Bloody vomit Iron, salicylates

Extreme thirst Salt +/- water deprivation

Bizarre lab results Insulin, salt, salicylates, sodium bicarbonate

Mouth burns/ulcers Lye, muriatic acid, tabasco sauce, peppers

Sweating Cocaine, nicotine, amphetamines

Fever Amphetamines, salicylates, phenothiazines, tricyclic antidepressants, cocaine, vitamin A overdose

Failure to thrive Water deprivation or intoxication, laxatives, phenytoin, ipecac, salt

Seizures/apnea Salt, phenothiazines, tricyclic antidepressants, hydrocarbons, barbiturates, ethanol, codeine

Drowsiness/sedation Benzodiazepines, opioids/opiates, hypnotics, insulin, anticonvulsants, methadone, marijuana

M eadow 1989, Paschall 2005

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• Sympathomimetic (meth, amphetamines, cocaine, opiate withdrawal, PCP)

• Hyperthermia (increased body temperature), tachycardia (increased heart rate), hypertension (increased blood pressure), mydriasis (dilation of the pupil), warm/moist skin, agitation

• Cholinergic (organophosphates, betel nut, VX, Soman, Sarin) • SLUDGE (Salivation, Lacrimation, Urinary incontinence,

Diarrhea/Diaphoresis, GI upset/hyperactive bowel, Emesis)

• Anticholinergic (antihistamines, atropine, phenothiazines, TCA)

• Hyperthermia, tachycardia, hypertension, hot/red/dry skin, mydriasis or unreactive pupils, urinary retention, absent bowel sounds

• Opioids (codeine, dextromethorphan, heroin) • Miosis (constriction of the pupil), respiratory depression, sedation

Toce 2017

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• Labs

• Glucose

• Electrolytes

• Drug test

• Imaging

• KUB

• Consults• Toxicology

• Child Advocacy

• Substrate• Blood

• Urine

• Test method• ER drug screen

• Comprehensive drug panel

• Limitations

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Moeller 2008

ER Drug Screen Urine Drug Investigation

Substances Detected 6 >140

Threshold Workplace (high) <<Workplace (low)

Amount of Urine 1 – 5 ml 1 – 6 ml

Time to Result <2 hours 3-5 days

Confirmation No Yes

Methodology Immunoassay GC-MS or LC-tandem MS

Sensitivity and Specificity Low High

Charge $900 $361

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Substances on standard drug

screens

Cross-reacting substances

Amphetamines Amantadine, buproprion, chloroquine, chlorpromazine, desipramine, dextroamphetamine, ephedrine, labetolol,

methylphenidate, phentermine, procainamide, promethazine, pseudoephedrine, ranitidine, selegiline, trazodone

Cannabinoids Dronabinol, efavirenz, NSAIDs, proton pump inhibitors

Cocaine Salicylates, topical anesthetics with cocaine

Opiates Dextromethorphan, diphenhydramine, quinolones, poppy seeds, rifampin

PCP Chlorpromazine, dextromethorphan, diphenhydramine, ibuprofen, imipramine, ketamine, meperidine, thioridazine,

tramadol, venlafaxine

Farst 2012

• DDx:• Unintentional exposure

• Supervisory neglect

• Sepsis• Meningitis

• Epilepsy

• Head trauma

• Apnea

• ALTE/BRUE

• SIDS• Metabolic derangements

• Bleeding diatheses

• Gastroenteritis

Reece 2009

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Initial Investigation Scene (body if deceased)

Witnesses

Medical Hospital (Child Advocacy or Medical Examiner if

deceased)

Medical History – past medical records (see Wis. Stat. §146.82(11))

Investigation + Medical Evidence = Complete Picture

Confrontation Interviews

Confrontation Evidence

The Initial Investigation

Scene

Preservation of the scene

Documentation of the scene

Collection/Preservation of physical evidence

Witnesses

Detailed non-confrontational statements with caregiver(s)

Detailed account of child’s last 24,48,72, 96 hours…

Child Protective Services – Wis. Stat. § 48.981(7)(a)8

Re-enactments (recorded if possible)

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The Scene:

Document the entire scene

Photos and/or video

Document the condition of the home, including ANY safety concerns

Drugs/alcohol & weapons

Unkempt home

If caretaker provide accidental explanation for injury:

Document circumstances in detail

Do re-enactment if possible (on video)

The Scene:

Always collect the last bottle/cup used for a feeding

Document any prescribed medication/pills

When was the prescription filled last?

How often is the person supposed to take the medication?

Do all of the pills inside the container match?

Are there more than one prescription from different doctors?

Was the medication properly secured?

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Caregiver(s) Statements:

Lock them in!!!

Household information – who is home & when

When was child last normal?

When was child last fed? *** Any issues with last feeding(s) ***

Any recent concerns with child’s health?

Child’s developmental capabilities

Who found the child?

When was care sought? (anyone else sought care prior?)

Accidental explanation

Re-creation on video

Caregiver(s) Statements – Initial Statements

Develop a timeline (up to 96 hours) Non-accusatory

Non-confrontational

Go over events more than one time

Never interview caretakers together

Compare with statements of witnesses Forensic interviews of child witness(es)

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Confrontation Interviews – get detailed timeline to start. Then…

Inconsistencies in statements

Inconsistencies with witness accounts

Inconsistencies with the physical evidence

Inconsistencies with the medical evidence

Embrace the evolving history of the offender

Offender keeps trying to change the events to account for the severity of the injuries

Confrontation Interviews:

Delays in seeking treatment (just as valuable!) Description of child’s condition during delay is

critical – knowledge

If you get an admission…. It doesn’t end there!

Re-enactment on video

Share re-enactment with medical professionals –does it explain the injuries?

If not, you are not done!

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Medical Evidence + Thorough Investigation = TRUTH

• Not all ingestions are accidental.

• Identification requires a high index of suspicion.

• The right drug test can help.

• Investigation is crucial.

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• Dine MS, McGovern ME. Intentional poisoning of children–an overlooked category of child abuse: Report of seven cases and review of the literature. Pediatrics. 70(1):32–35;1982.

• Farst K, BB Bolden. Substance-exposed infants and children: forensic approach. Clin Pediatr EmergMed. 13(3): 221-8;2012.

• Gummin DD, Mowry JB, Spyker DA, Brooks DE, Beuhler MC, et al. 2018 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 36th Annual Report. Clin Toxicol (Phila). 2019 Dec;57(12):1220-1413.

• Henretig FM, Paschall R, Donaruma-KwohMM. Child abuse by poisoning. In: Child Abuse Medical Diagnosis & Management, 3rd ed, Reece R, Christian C (Eds), American Academy of Pediatrics, Elk Grove Village, IL;2009.

• Meadow R. ABC of child abuse. Poisoning. BMJ. 298(6685):1445-1446;1989.

• Moeller KE, Lee KC, Kissack JC. Urine drug screening: practical guide for clinicians. Mayo Clin Proc. 83(1):66-76;2008.

• Paschall R. The chemically abused child. In Child Maltreatment, Giardino A, Alexander R (Eds.), G.W. Medical Publishing, St. Louis, MO;2005.

• Toce MS, Burns MM. The poisoned pediatric patient. Pediatr Rev. 38(5):207-220;2017.

• Yin S. Malicious use of nonpharmaceuticals in children. Child Abuse Negl. 35(11):924-929;2011.

• Yin S. Malicious use of pharmaceuticals in children. J Pediatr. 157(5):832-6; 2010.

• Thank you to Dr. Lynn Sheets for additional slide content.

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