Study of Acute Poisoning Cases in Children Admitted To Menoufia Poison Control Center ( MPCC ) During the Year ( 2016 ) " A Prospective Study "

Introduction oisoning is one of the most common causes of admission to pediatric emergency and intensive care units. Poisoning in children represents an important cause of injury-related morbidity and mortality in the developing as well as the developed world (Sandra, 2010). The U.S. poison control centers in 2014 provided telephone guidance for nearly 2.2 million human poison exposures. That’s about 6.7 poison exposures/1000 populations, 42.6 poison exposures in children younger than 6 years/1000 children (Mowry et al, 2015) Children are active and explore their world with all their senses specially taste. As a result, the home and its surroundings can be a dangerous place when poisonous substances are inadvertently ingested. Every year thousands of children are admitted to emergency departments. Poisoning patterns change according to age group, type of exposure and the nature and dose of the poison (WHO, 2008). The aim of this work is to describe the pattern of childhood poisoning cases admitted to Menoufia Poison Control Center (MPCC) at Menoufia University Hospital over one year (From the first of January 2016 to the end of December 2016), through analyzing the socio-demographic data, circumstances and motives, types of poisons, severity of poisoning and outcome of these cases . Patients and Methods This was a prospective study conducted on all cases of childhood poisoning admitted to Menoufia Poison Control Center (MPCC) during the period from 1st of Abstract Background: Poisoning of children is a major health problem in the developing as well as the developed world; it represents an important cause of morbidity and mortality in children and adolescents. Objectives: This study was designed to describe the pattern of childhood poisoning cases admitted to Menoufia Poison Control Center (MPCC) at Menoufia University Hospital over one year. Patients and Methods: This was a prospective study conducted on 760 children less than 18 year with acute poisoning and all required data about socio-demographic status, poison data and clinical assessment were collected and statistically analyzed. Results: The total number of cases during the period of study was (760) cases, males outnumbered females (55.5% versus 44.5% respectively). Those from 2 to 6 year were the highest age group which represented 62.1%. Pesticide poisoning was the most common exposure (34.4%) followed by household cleaning agents (30%). Most of poisoned cases were accidental (91.7%) while only 8.3% were suicidal. The most common route of poisoning was oral one (92.6%). Seasonal variation was noticed as regards rate of admitted cases with increased rate in summer and spring. Pesticides were the most common agents resulting in death (13cases of 15). According to poison severity score (PSS) 65.8% of cases were minor followed by moderate, asymptomatic and severe cases (21.7%, 9.7% and 2.8% respectively). About 9.6% needed ICU admissions, 95.9% of cases were cured and mortality rate was 2 %. Conclusion: Most children poisoning was accidental, mainly by oral route, more in summer and spring seasons, most commonly due to pesticides and household cleaning agents. Most of cases were completely cured. Recommendations: All medications and toxic products should be kept out of reach of children, availability of child resistant containers, mass media should create awareness about this problem and finally, good parental supervision is always necessary.


Introduction
oisoning is one of the most common causes of admission to pediatric emergency and intensive care units.Poisoning in children represents an important cause of injury-related morbidity and mortality in the developing as well as the developed world (Sandra, 2010).
The U.S. poison control centers in 2014 provided telephone guidance for nearly 2.2 million human poison exposures.That's about 6.7 poison exposures/1000 populations, 42.6 poison exposures in children younger than 6 years/1000 children (Mowry et al, 2015) Children are active and explore their world with all their senses specially taste.As a result, the home and its surroundings can be a dangerous place when poisonous substances are inadvertently ingested.Every year thousands of children are admitted to emergency departments.Poisoning patterns change according to age group, type of exposure and the nature and dose of the poison (WHO, 2008).
The aim of this work is to describe the pattern of childhood poisoning cases admitted to Menoufia Poison Control Center (MPCC) at Menoufia University Hospital over one year (From the first of January 2016 to the end of December 2016), through analyzing the socio-demographic data, circumstances and motives, types of poisons, severity of poisoning and outcome of these cases .

Patients and Methods
This was a prospective study conducted on all cases of childhood poisoning admitted to Menoufia Poison Control Center (MPCC) during the period from 1st of January 2016 to the end of December 2016 after obtaining ethical approval from the Ethical Committee at Menoufia University Hospital and after taking written consent from their guardians.This center of control poisoning is the only center in the governorate, where any poisoning case that needs consultation is referred to.After taking approval from the director of MPCC data were collected in patient's clinical sheets developed for this purpose including all required data about sociodemographic data, circumstances, types of poisons, clinical presentation, severity of poisoned cases, (severity of poisoning was classified according to poisoning severity score (Persson et al., 1998) and their outcome.The poison severity score (PSS) is a scoring system which classify poisoned cases into four grades, None (0): no symptoms or signs related to poisoning, Minor (1): mild, transient and spontaneously resolving symptoms, Moderate (2): pronounced or prolonged symptoms, Severe (3): severe or life-threatening symptoms, Fatal (4): death.Investigations for the cases were done when needed in the form of biochemical laboratory investigations and specific toxicological screening tests for detection of type of poisons as choline esterase level for organophosphorous and carbamate poisoning, silver nitrate test for detection of aluminum or zinc phosphide poisoning, drug screening tests and radiological investigations when needed.Treatment in the form of observation with or without supportive measures together with decontamination whenever needed in asymptomatic and mild cases and when no antidotal therapy is present for that poisons.These measures were combined with antidotal therapy when available.Cases were admitted to intensive care unit when needed for continuous cardiac monitoring or mechanical ventilation.Neuropsychological consultation for cases with suicidal poisoning was done as a part of treatment.All data were kept anonymous to ensure confidentiality of data and with no conflict of interest.
Exclusion criteria included cases presented with allergic reactions to food or food poisoning cases, cases associated with work place hazards and cases of drug or substance abuse.

Statistical Analysis
Data were tabulated and statistically analyzed using Statistical Package for the Social Sciences (SPSS) for windows version 16.0.Statistical analysis and tabulation were done according to (Dawson and Trapp, 2001).Categorical data were expressed as number and percentage and were compared using chi square test.Pvalue of 0.05 or less is considered significant, P-value of 0.01 or less is considered highly significant and P-value of >0.05 is considered insignificant.

Results
The total number of cases during the period of study was (760) cases, males outnumbered females (55.5% versus 44.5% respectively).Patients were divided into 4 groups according to their ages: younger than 2 year, those between 2 and 6 years, those between 6 and 12 years, and those between 12 and 18 years.Those from 2 to 6 years represented the highest age group (62.1%) followed by age groups of 12 -18 years, less than 2years (15% and 12.9% respectively) and the least was 6-12 years (10%).Poisoned cases from rural areas represented (59.1%), while 40.9% were from urban areas (Fig. 1).
Pesticide poisoning was the most common exposure 34.4% of the total cases which include insecticides (26.8%) in the form of organophosphates and carbamates and rodenticides 4.1% in the form of zinc phosphide.
The second most common poisoning was household cleaning agents 30% mostly in the form of potash, phenol, bleaches and laundry detergents.Therapeutic drugs constituted 17.2% of the causes of poisoning.These drugs included cardiovascular drugs (36.7%), cold medications in the form of cough suppressants and antihistaminic (19.8%), hypoglycemic drugs (16.8%), neurologic drugs (14.5%) and lastly analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) in 12.2% of cases.Petroleum products like benzene and kerosene in (9.6%), carbon monoxide in 2.9% of cases, lastly animal bites in the form of snake bite and scorpion stings in (2.6%), while unidentified agents in (3.3%) of cases (Fig 2).
The most common route of poisoning was oral one (92.6%)followed by inhalation, animal bite and lastly through skin exposure (4.1%, 2.6 % and 0.7% respectively).Most of poisoned cases were accidental (91.7%) while only 8.3% were suicidal.Seasonal variation was noticed as regards rate of admitted cases, as the largest percent (33.4%) were poisoned in Summer followed by Spring (30.8%), while Winter and Autumn have lower rates (18.6 % and 17.2% respectively).Cases admitted to hospital from 2 to 4 hours of poisoning represented (49.2%), followed by cases which were admitted to hospital after more than 4 hours of the poisoning (30.8%) while (20%) of cases were admitted within two hours.The poisoned cases were classified according to poison severity score (PSS) where highest percent of cases (65.8%) were minor followed by moderate, asymptomatic and severe cases (21.7%, 9.7% and 2.8% respectively).smallpercent of cases (9.6%) needed ICU admissions while (90.4%) of cases were admitted to the poisoning control department.The majority of cases (74.6 %) stayed from 1 day to less than 3 days, 16% of cases stayed less than one day 8.6% stayed from 3 to 7 days and only 0.8 % stayed more than one week.Cure rate was (95.9%) of cases versus (2%) mortality rate and (2.1%) was of unknown outcome as they were discharged against medical advice (Table 1).
The relation between the sex and age of the affected children was highly significantly different, where males outnumbered females in age group 2-<6years and from 6 to 12 years (59.3% and 64.5% versus 40.7% and 35.5% respectively), while females outnumbered males in the age group 12-18years (63.2% versus 36.8% respectively) (X 2 = 21.815 and P value <0.01) (Fig 3).
Highly significant relation was found between the sex and mode of poisoning as the highest percent of suicidal poisoning (73%) were females, while 58.1% of accidental toxicity was males (X 2 = 22.662 and P value <0.

01) (Fig 4).
There were different types of poisoning exposures among the selected age groups.Pesticides and household cleaning agents were the most common types of poisoning in children less than 2years and those aged 2-6 years while in the older age groups 6-12 years and 12-18 years pesticides and drugs were the most common types (Table 2).
As regards severity of poisoning in different age groups 51.4% of asymptomatic cases were encountered in children < 2years , most of mild and moderate severity of poisoning were found in children 2-6years, (64.6% and 76.4% respectively) while 61.9% of severe cases were aged 12-18years (Table 3).
Many risk factors were statistically significant affecting the outcome of the studied cases where (73.3%) of the dead cases were females, 44.8% and 37.9% of dead cases were in age group between 12-18 and 2-6 years respectively, 55.2% of dead cases came to hospital after 4 hours and 93.1% of dead cases were scoring as severe cases (grade 3) according to PSS. (X 2 = 9. 22, 80.919, 23.336 and 442.963 respectively and P value = 0.01, 0.001, 0.001 and 0.001 respectively) (Table 4).
As regards patient outcome in relation to the type of poison, most patients were cured in different types of poisoning while pesticides (insecticides and rodenticides) were the most common agents resulting in death (13cases of 15 cases) (X 2 =104.137,P value = 0.01) (Table 5).
As regards dead cases they were 15 cases; 13 cases were died from suicidal pesticide poisoning in the age of 12-18years old; 10 of them were due to zinc phosphide poisoning presented with severe cardiac depression and arrested within 24-48 hours in spite of supportive treatment and 3cases were due to organophosphorous poisoning presented with severe clinical manifestations and were admitted to ICU on mechanical ventilation but they were arrested in spite of standard treatment within 12-24 hours.Finally the remaining 2 cases were less than 2 years old died from accidental corrosive poisoning, they were represented with severe corrosion of mouth, they were admitted to ICU on mechanical ventilation then develop respiratory complications in the form of pneumothorax in one case and trachea-pleural fistula with development of hydropneumothorax in the other one, both cases were treated with intercostal tube insertion and with insertion of esophageal stent in the case which develop fistula but both cases were deteriorated with development of septicemia, coagulopathy and fever then arrested after 15 days in one case and 22 days in the other.
Treatment in the form of observation with or without supportive measures together with decontamination whenever needed was sufficient in asymptomatic and mild cases and when no antidotal therapy is present.These measures were combined with antidotal therapy when available.Intercostal tube insertion was done in 2 cases of corrosive poisoning.Neuropsychological consultation for cases with suicidal poisoning was done as a part of treatment.

Discussion
Acute poisoning is one of the important causes of emergency unit admissions.Identification and documentation of epidemiological aspects and other variables in childhood poisoning are of great importance for determination of proper preventive measures.In the present study the total number of the admitted cases during the period of study was (760) case which accounted for 34.5% of acute poisoning cases admitted to the toxicology department through the period of the study.The higher percentage of male to female patients in this study (55.5% versus 44.5% respectively) is in line with most studies (Ahmed et al, 2011 andAkhtar, 2006) as males are more active than females and have more freedom to go outside to the field with their parents or for playing which increase their liability to accidental poison exposure.
Children less than 6 years age constituted about 75% of cases (62.1% were between 2 -< 6years and 12.9% were less than 2years).In this age range, children are curious about the surrounding environment, unaware of the impending danger and explorative in behavior and tend to have accidents, especially from putting substances or colored objects in the mouth.These findings agree with worldwide findings (Hahn et al, 2013 andAndrade et al, 2012).
In the present study, there is a highly statistically significant relation between both sexes in different age groups where males outnumbered females in age groups 2-<6years and 6-<12years while females were more frequent in poisoning of older age group (12 -<18y).These data were similar to those described in a study carried out in Ankara, Turkey by Andiran and Sarikayalar, 2004 who found that in 489 poisoning cases poisonings <10 years of age were more frequent in males whereas poisonings >10 years of age were more common in females as in this older age poisoning is usually suicidal in nature which is more common in females.
Oral route was the most common route of poisoning (92.6%) as young child is used to explore objects found in the surrounding environment by putting it in his mouth and also older children were exposed to toxic substances mainly by ingestion due to the bad habit of putting these toxic substances in non-original containers thus resulting in unintentional poisonings and also suicidal poisoning is mainly done by oral route.These results were in agreement with several of studies as Alije et al, 2014 reported that oral route constituted 81.65% and Alazab, 2012 stated that 99.3% of the poisonings occurred via oral routes.
The current study showed that the number of poisoned children was higher in rural areas than that in urban areas; these results were in agreement with that of Hassan and Siam, 2014.This was probably due to the fact that neglect of parents to their children is more common in rural areas in addition to more availability of these poisons in rural areas either at home or at field for agricultural purposes.This result was in contrary with that noted by Alazab, 2012 in his study in Egypt, who reported higher incidence in urban areas (79.9%) versus rural ones (20.1%),but this is may be due to different nature of the selected area of his study which is mainly urban in nature.
As regards mode of poisoning in the current study, the vast majority of cases was poisoned accidentally (91.7%) similar to those reported by Paudyal, 2005 (unintentional poisoning 98.4%).Cases of suicide in our study represented only (8.3%) of cases with no homicidal exposures.Suicidal cases were adolescents and more common in females.Bacha and Tilahun, 2015 in their study reported 15.5% intentional poisoning.Different suicidal rates in different studies may be due to different study designs and cultures.The reason for the high frequency of suicide attempts of female adolescents compared to male adolescents can be explained by the fact that male adolescents have more freedom of decision and action, in comparison to female adolescents, who are restricted by customs and traditions which make them more affected by family disorders, loss of a parent member, divorced parents, failure in love or education.As regards seasonal variation of poisoned cases in the present study, it was noticed that Summer and Spring were the most vulnerable period for poisoning in children (33.4% &30.8%respectively) as these hot dry seasons children became thirsty and took liquid poisons contained in the soft drink bottles and mineral water unintentionally and also in this period is accompanied with increased cleaning activities of mothers against insects and ants.
In the study by Matityahu & Vladimir, 2000 most poisonings were observed to occur in Summer and Autumn as compared to other seasons Pesticides were the most common cause of poisoning in the present study which constituted about 34.4% (26.8% insecticides versus 4.1% rodenticides), followed by cleaning agents and medications (30% and 17.2%, respectively) due to the availability of pesticides which are used in a wide range at home to eliminate insects or rodents or at field in agriculture.Also this reflected the bad habit of still using concentrated cleaning substances for washing and cleaning and leaving them within reach of children.These findings were somewhat in agreement with those noticed by Abd El-Megid & Salem, 1995 who noted that the leading cause of acute poisoning among children in Alexandria Poison Center, Egypt during the year 1992 was household agents followed by food poisoning then drug poisoning respectively.Also Aglan, 2007 noted in his study of acute poisoning in children admitted at Ain Shams University in Cairo poison control center during the year 2004, that chemical and household products represent the highest percentage of poisoning (43.0%), most of them were Insecticide (29.53%),Corrosives (29.4%) and Hydrocarbons (20.54%).On the other hand medicinal products represent the second highest percentage of poisoning (36.0%) in his study.Our findings were also in agreement with the findings in studies conducted in some developing countries like in India (Rathore et al., 2013) and Nepal (Budhathoki et al., 2009) where ingestion of household products like chlorine bleach (Clorox), pesticides, disinfectants, kerosene and unidentified products ranked first.Whereas in studies conducted in Turkey and Iran (Andiran &Sarikayalar, 2004 andAnsari-Moghaddam et al, 2012) other agents such as poisoning due to medication over-dose was found to be the most common cause.
The majority of cases 49.2% were admitted to hospital from 2 to 4 hours of poisoning followed by cases which were admitted to hospital after 4hours of the poisoning (30.8%) while 20%were admitted within two hours.This is in agreement with Alazab, 2012 who found that 65.5% of the studied patients reached the poisoning unit within 2 to 4 hours of poisoning, (24%) cases reached there within 4 to 6 hours, (7.3%) cases reached there after more than 6 hours, while (3.2%) cases reached there within less than 2 hours.
Early arrival time to hospital and seeking medical advice is significantly associated with high percent of cure in the present study where 69.5% of cured cases came to hospital within 4 hours of the onset of toxicity, while 73.3 % of dead cases arrived to hospital after more than 4 hours of the toxicity.The time between ingestion and hospital admission was reported to have a great effect on the outcome; this might be due to the early management and treatment especially poison antidotes.Bryant and Singer (2003) stated that the effectiveness of certain treatments depends upon how much time has elapsed since the poison was ingested.Other Studies recommended an early hospital admission in case of a suspected poison incident has occurred (Alanazi et al, 2016).
According to poison severity score (PSS), 65.8% and 9.7% of patients were of minor toxicity or asymptomatic cases respectively, this might be due to most of poisonings were accidental exposure to toxic agents with lower percent of suicide.This was in agreement with previous study in India by Jose et al, 2012 where the largest number of poisoned cases in his study was score 1 or 0. On the contrary Alije et al, 2014 noted that according to clinical manifestations of cases in his study, moderate to severe cases were about 55.8% of cases while mild to asymptomatic cases were about 44.2%.
The majority of cases were admitted to toxicology department (90.4%) and 9.6% of cases who needed continuous monitoring or mechanical ventilation were admitted to the intensive care unit.This result was in agreement with that of Hassan & Siam ,2014.As regards period of stay in hospital 74.6% of cases in the present study stayed from 1-<3 days , 16 % stayed less than one day, 8.6% stayed from 3 to 7 days and only 0.8 % stayed more than one week.
This was in contrast with results of the study done by Alazab, 2012 who showed that 67.3% of cases were discharged from hospital within less than 6 hours, 26.5% of cases were discharged within 6 to 12 hours, and 6.2% of cases were discharged after more than 12 hours.He noted that the severity of these cases was milder with cure of all cases without deaths as the selected age group in this study was those less than 5years with no suicidal poisoning.
As regards the outcome in the current study, the majority of cases (95.9%) were completely cured, 2.1% with unknown and discharged against medical advice on child guardian ´s responsibility.The death rate was about 2%.The mortality rate in other studies of pediatric poisoning ranging from 0.4% to 13% as Andiran &Sarikayalar, 2004 (0.4%), Rama et al, 2014 (7.4%) and Rathore et al, 2013 (13%).
As regards age with outcome for the fatal cases reported during the present study, 86.7% of dead cases were in age group between 12-18 years, while the least was in the age less than 2 years (13.3%).This may be explained by that quantities ingested in the younger age groups were small because these cases were accidental.On the contrary higher fatality in older children which were mainly females can be explained by that cases were due to intentional poisoning and with large quantity of poisons.This was in agreement with Rama et al, 2014 who noted that all except for one child aged 2 years were aged between 14 and 15 years.Significant relation in the current study was noticed between the (PSS) and the outcome of the studied cases as 86.7% of the dead cases had score 3 with severe toxicity this seems logic as the higher the severity of toxicity and life-threatening symptoms in patients the higher the liability for mortality.
Significant relation between the type of poisoning and the outcome was noted, as most of dead cases (86.7%) were due to pesticides poisoning (13cases of 15) as pesticides are easily available and poorly regulated in the developing world and were mainly due to zinc phosphide poisoning (10 cases zinc phosphide versus 3 cases organophosphorous poisoning) because zinc phosphide is highly toxic substance, rapidly absorbed with no known antidotes besides that these cases were suicidal in nature which usually take large amount of poison.

Conclusion
In conclusion, the peak age of poisonings in children occurs in preschool age children, with a seasonal variation favor of Summer and Spring season.Pesticides and household cleaning agents were the most frequent agents of poisoning.The majority of cases was accidental and was completely cured.PSS is a good predictor of the outcome of the poisoned cases.

Recommendations
We recommend that parents or any other caretakers of children must ensure that all medications, household cleaning agents or chemicals and toxic products are kept out of reach of children in a safe place and to keep it in their own containers, not to keep them in soft drink bottles.There should be legislation for the use of child resistant containers for household agents and drugs.To keep clean house with no holes or cracks so prevent snakes to get into the house and also not to walk outdoors with bare feet to avoid animal bites.Mass media such as television, radio and newspaper should create awareness about the problem and the potential hazards of these household poisons and give health education to parents to prevent this poisoning.There should be known hot lines for toxicological centers for communication.Early seeking of medical advice after exposure to poisoning is very important to save the patient and lessen the complication.PSS should be used in hospitals for classification of poisoned cases.Finally, good parental supervision is always necessary to prevent both accidental and suicidal poisoning specially in adolescents.

Fig 1 :
Fig 1: Distribution of acute poisoned cases according to age, sex and residence.