Factors affecting accidental poisoning among children in Bangladesh– Lessons learned from a tertiary level hospital, Dhaka

DOI: https://doi.org/10.21203/rs.3.rs-1477321/v1

Abstract

Introduction

Accidental poisoning is a leading cause of unintentional injuries among children in developing countries. The overall aspect of this unintentional poisoning is poorly understood in Bangladesh. The objectives of this study were 1) to explore the socio-demographic factors and circumstantial context of accidental poisoning and 2) the prevalence of the type of substances causing it.

Methods

A prospective cross-sectional study was conducted between April 2019 and February 2020 at a tertiary level hospital of the capital city Dhaka in Bangladesh. Children under 10 years of age admitted to the hospital with accidental poisoning were enrolled in this study. Parents of hospitalized children were interviewed face-to-face using a structured questionnaire. Descriptive statistics were used for data analysis.

Results

A total of 223 children were recruited in this study. Children between 2 to 5 years (60%), male (61%), and children with agile or aggressive behaviour (65.5%)  were among the prevalent victims. Most cases (65%) occurred in a nuclear family setting. Most mothers (85%) of these children were non-working, and most incidents took place in parents’ homes (~82%). Nearly 70% of the poisoning incidents took place in parents' presence, and over half of these occurred in the bedroom. Kerosene was the prevalent cause (33%) of accidental poisoning while insecticide/pesticide ranked second (26.5%) followed by medicines (17%) and household chemicals (12). In one-third (31.4%) cases, poisoning chemicals were stored in soft-drinks bottles, while two-thirds (67.3%) were kept in containers other than original ones. Although over 80% of parents knew that chemicals could be harmful to the children if they were ingested, most of them did not take safety measures.  

Conclusion

In this present study, we found that preschool-aged children were more victims of accidental poisoning, primarily by ingesting kerosene. A majority of the incidents occurred in the bedroom while parents were present at home. Our study findings would serve as a baseline for designing future intervention studies and policies.

Introduction

Globally, poisoning is one of the leading causes of all unintentional injuries in children (1). Poisonous substances can cause significant morbidity or mortality when ingested, inhaled, injected, or absorbed through the skin in a high concentration. Acute toxicity is linked with long-term neuropsychiatric health consequences (24). According to the World Health Organization, nearly 200,000 people die each year due to accidental poisoning. Around 80% of these deaths occur in low- and middle-income countries (LMICs) (1, 5, 6). Accidental poisoning accounts for 10% of the total burden of unintentional injuries among children in developing countries (79). Notably, about 15% of unintentional poisoning-related deaths occur below five years. Many cases go unreported, under-reported, or misreported (10).

The causative factors and outcome of unintentional poisoning cases are influenced by various socio-demographic and economic factors and the availability and the quality of the medical facilities in any given region (2, 9, 11). Accidental poisoning also has an economic impact on the family to get medical treatment for the victim as most of the cases are from LMICs. In a study conducted in Sri Lanka, on average, 31.83 USD was spent per patient for treatment purposes, with an addition of 14.03 USD per patient in transport (12).

Bangladesh is a low-middle income nation with over 30 million children under 10 (13, 14). A nationwide survey in 1997–1998 estimated an incidence of 11 poisoning cases per 100,000 per year in Bangladesh (15). Unlike developed countries, there is no awareness or practice of using child-proof containers for poisonous substances in Bangladesh. Government directives also have not adequately addressed the issue of using child-protective containers for chemical agents. Even though accidental poisoning is one of the leading causes of unintentional injury among children in developing countries, it has received little attention in Bangladesh. There is no comprehensive epidemiological study focusing on household factors for accidental poisoning among children in Bangladesh (10, 1618). All the prior studies had a small sample size and primarily focused on the prevalence of chemicals that caused accidental poisoning. Thus, we aimed to investigate the current prevalence of the type of chemical agents causing accidental poisoning and the socio-demographic and circumstantial context among children under the age of ten in Bangladesh.

Methods

Study site and sample size

This cross-sectional study was conducted from 20 April 2019 to 21 FebrFebruary20 at Dhaka Medical College Hospital, a tertiary level hospital situated in the capital city Dhaka in Bangladesh. The hospital has one of the highest capacities to accommodate patients and the highest level of facilities for all the economic classes of the country. The admission capacity of the pediatric medicine department is approximately 30 children per day. Still, around twice more patients are admitted usually. Moreover, the hospital mainly serves middle to lower-income class people.

This study recruited children under ten years of age who were admitted through the emergency department with a diagnosis of poisoning (unintentional) by the duty doctors at the emergency facility or attending physicians at the ward. Children above ten years of age and cases with food poisoning, adverse drug reactions, snake bite, animal venom, or insect bite were excluded.

Definition of poisoning substances

A poisonous substance was defined as any agent that had the capacity or potential to produce toxic effects or morbidity or mortality to the child while ingested, inhaled, injected, or absorbed through the skin in quantities enough to cause physiological and neuropsychological effects. Thus, compounds such as pharmaceuticals, petroleum products, household chemicals, insecticides, and pesticides were considered poisonous in this study.

Questionnaire and data collection

The study questionnaire was developed based on existing literature and expert opinion (including a pediatrician and public health researcher) to understand the epidemiology and possible factors related to childhood accidental poisoning in Bangladesh (19, 20). In the questionnaire, basic demographic information included: age of the child, parents’ age and their marital status, education, profession, monthly family income, place of living (urban/semi-urban/rural). One question was asked about the child’s agility (yes/no). Questions related to poisoning included: type of poisonous substance ingested/inhaled, time and exact place of the incidence, parents’ presence at that time, time taken to seek medical care, type of container, and how chemicals and medicines were stored in the house. Parents/guardians were asked: whether they knew the substance taken by the child was harmful (yes/no), whether they alerted the child about the harmful sides of stored chemicals/medicines/kerosene (yes/no). The draft questionnaire was piloted on five parents and revised accordingly.

Face-to-face interviews with attendants of children were conducted using a structured questionnaire in the native language (Bangla). Two of the authors (medical students) and an intern physician took part in the data collection procedure. No children were interviewed; instead, information about accidental poisoning incidents was provided by their parents or guardians.

Statistical analysis

Data were stored and secured in Research Electronic Data Capture (REDCap) platform hosted at Biomedical Research Foundation (21). Descriptive statistical analysis was performed using R statistical software. When applicable, descriptive data were expressed as percentages, means, and standard deviation. Pearson's chi-square test was performed to determine the association between categorical data, and a p-value smaller than 0.05 was considered statistically significant.

Ethical consideration

The study protocol was approved by the institutional review board of Biomedical Research Foundation, Bangladesh (Ref. no: BRF/ERB/20191004). Each subject provided verbal and/or written informed consent at their discretion. The parents were approached first and informed about the study's nature and objective. Participants were registered for an interview following consent (oral and/or written). Some respondents could not sign their names; in these instances, the questionnaire was marked as a verbal agreement. For data collection, approval was taken from the head of the pediatric medicine department, Dhaka Medical College Hospital.

Results

A total of 223 children with accidental poisoning were enrolled in the study. Unintentional poisoning was prevalent among children aged between 2 and 5 years (60%) and in male children (61%). Around two-thirds, (65.5%) of the children were agile or aggressive in behaviour (Table 1). Nearly 43% of the mother had more than ten years of schooling, while it was 36.8% for fathers. More than 85% of mothers were stay-at-home mothers (Table 1). The majority of incidents occurred in a nuclear family setting (65%). In most families, fathers were the bread-winner (83%); and the monthly incomes of a significant portion of the families (~ 80%) were below USD 300 (Table 1).

Table 1

Socio-demographic characteristics of hospitalized children and their parents

Characteristics

N (%)

Characteristics of children

Child age group (years) (n = 223)

 

Median age

3

< 2

57 (25.6)

2–5

134 (60.1)

5+

32 (14.3)

Sex (n = 223)

 

Male

136 (61.0)

Female

87 (39.0)

Agile/aggressive in nature (n = 222)

 

Yes

146 (65.5)

No

76 (34.1)

Characteristics of parents

 

Father’s age (years) (n = 217)

 

Median age

34

≤ 25

9 (4.0)

26–40

63 (28.3)

31–35

71 (31.8)

36–40

44 (19.7)

> 40

36 (16.1)

Mother’s age (years) (n = 219)

 

Median age

28

≤ 25

86 (38.6)

26–30

71 (31.8)

31–35

53 (23.8)

36–40

9 (4.0)

> 40

4 (1.8)

Father’s education (n = 220)

 

Illiterate

24 (10.9)

Primary

29 (13.2)

Secondary

82 (36.3)

Higher secondary

54 (24.6)

Graduation

31 (14.1)

Mother’s education (n = 222)

 

Illiterate

28 (12.6)

Primary

45 (20.3)

Secondary

96 (43.2)

Higher secondary

32 (14.4)

Graduation

21 (9.5)

Father’s profession (n = 221)

 

Service

91 (41.2)

Business

68 (30.8)

Farming

12 (5.4)

Day labor

15 (6.8)

Others

35 (15.8)

Mother’s profession (n = 222)

 

Housewife

191 (86.0)

Service

15 (6.8)

Business

2 (0.9)

Farming

2 (0.9)

Day labor

0 (0)

Others

12 (5.4)

Monthly family income (USD) (n = 223)

 

< 180

75 (33.6)

180–300

103 (46.2)

301–590

38 (17.0)

> 590

7 (3.1)

Employment status of parents (n = 222)

 

Only the father works outside

186 (83.8)

Both parents work outside

32 (14.4)

Both parents stay home

1 (0.45)

Other

3 (1.4)

Residence (n = 223)

 

Metropolitan

97 (43.5)

Suburban

83 (37.2)

Village

43 (19.3)

Type of family (n = 223)

 

Nuclear

145 (65.0)

Large

78 (35.0)

Figure 1 reports on the type of chemicals causing accidental poisoning. Ingestion of kerosene caused in nearly one-third (33%) hospitalized cases, with insecticides/pesticides being the second most common cause (26.5%). Poisoning from ingestion of medicines was found to occur in 17% of cases. In contrast, poisoning due to household chemicals such as bleach/toiletries/phenyl occurred in 12% of cases. Type of poisoning was found to be associated with the place in the home the incident took place (p < 0.005) (Table 3).

Table 3

Cross-tabulation between type of poisoning and the place in home the incident took place in

Type of poisoning

Place in home where incidents took place

 

Bedroom

Drawing/Dining room

Kitchen

Store room

Yard

Other

Total

Medicines

35 (89.7%)

2 (5.1%)

0

(0.0%)

0

(0.0%)

0

(0.0%)

2

(5.1%)

39 (100%)

Kerosene

28 (38.4%)

8 (11.0%)

16 (21.9%)

4

(5.5%)

7

(9.6%)

10 (13.7%)

73 (100%)

Household chemicals (bleach/toiletries/phenyl etc.)

12 (46.2%)

4 (15.4%)

3 (11.5%)

1

(3.8%)

0

(0.0%)

6 (23.1%)

26 (100%)

Insecticide/

Pesticide

28 (47.5%)

6 (10.2%)

11 (18.6%)

7 (11.9%)

3

(5.1%)

4

(6.8%)

59 (100%)

Other

11 (42.3%)

1

(3.8%)

3 (11.5%)

1

(3.8%)

2

(7.7%)

8 (30.8%)

26 (100%)

Total

114 (51.1%)

21 (9.4%)

33 (14.8%)

13 (5.8%)

12 (5.4%)

30 (13.5%)

223 (100%)

Chi-square = 50.48;  df = 20;  p = 0.0002. Fisher’s Exact test p = 0.00099

Table 2 reports the circumstantial context of poisoning incidence. More than two-thirds of the incidents (82.1%) took place in parents’ homes, only 9% in the grandparents’ homes, and 57% were apartment buildings. Half of the cases (51.1%) took place in bedrooms within the house, while 14.8% occurred in the kitchen. About 30% of incidents occurred before noon, while 24.2% of incidents took place at night and 16.6% in the afternoon. Over two-thirds of incidents (~ 73%) occurred in the presence of at least one parent at home, while nearly 27% of incidents took place when none of the parents were at home. Interestingly, incidents during the morning were linked to both parents being outside, while nighttime incidents were linked to both parents being at home (p < 0.005).

Table 2

Circumstantial context for accidental poisoning

Characteristics

N (%)

Household factors

 

Type of household (n = 223)

 

Apartment building

127 (57.0)

House-made of Tin

89 (39.9)

House-made of mud/wood/thatch

6 (2.7)

Slum

1 (0.4)

Where the incident took place- (n = 223)

 

Parents home

183 (82.1)

Grandparents’ home

20 (9.0)

School

1 (4.0)

Other

19 (8.5)

In which part of the house the incident took place- (n = 223)

 

Bedroom

114 (51.1)

Drawing/Dining Room

21 (9.4)

Kitchen

33 (14.8)

Storeroom

13 (5.8)

Yard

12 (5.4)

Other

30 (13.5)

When the incident took place- (n = 223)

 

Morning

65 (29.1)

Noon

67 (30.0)

Afternoon

37 (16.6)

Night

54 (24.2)

Parents’ presence during the incident- (n = 223)

 

None

60 (26.9)

Only one

123 (52.2)

Both

40 (17.9)

Time taken to bring the child to medical attention- (n = 223)

 

Less than 2 hours

150 (67.3)

2–4 hours

54 (24.2)

4–6 hours

15 (6.7)

More than 6 hours

4 (1.8)

Safety issues

 

The poison was in its original container- (n = 223)

 

No

150 (67.3)

Yes

73 (32.7)

Chemical stored in soft-drinks’ bottles- (n = 223)

 

No

153 (68.6)

Yes

70 (31.4)

Chemical/medicine stored in an unsafe place at home- (n = 223)

 

No

64 (28.7)

Yes

159 (71.3)

Event of poisoning happened earlier with the children or with siblings- (n = 223)

 

No

220 (98.7)

Yes

3 (1.3)

As for the storage of chemical/medicine, about 71.3% of the respondents reported that the chemical/medicine substances were kept in places within the child’s reach. In one-third of the cases (31.4%), chemicals such as kerosene were stored in bottles of soft drinks.

Almost all incidents (~ 99%) took place for the first time in the family. About 20% of parents were unaware whether ingested substances were harmful. Most parents (78.4%) did not take protective measures for storing chemicals at home (Suppl. Figure 1). Two-thirds of the children (~ 67%) were taken to medical attention within 2 hours, while 24.2% were within 2–4 hours and 8.5% in more than 4 hours. More than half the children (53.81%) stayed at the hospital for a day, while 39.5% of them for 2 days (Suppl. Figure 2). The mean hospital stay was 1.82 days (SD: 2.42).

Discussion

This is the first comprehensive study from Bangladesh to understand the circumstantial factors related to unintentional poisoning in children to the best of our knowledge. We found that kerosene was the most prevalent poisoning agent. A majority of the incidents occurred in the bedrooms while parents were present at home.

In South Asian countries, kerosene remains the most prevalent cause of accidental poisoning among children. Our study finding is consistent with previous studies from this region (2, 20, 22, 23). In contrast, household chemicals and medicine are the leading causes of children’s accidental poisoning in developed countries (24, 11, 24). Bangladesh consumes 100,000 tons of kerosene a year (25). This is mainly used for cooking and lighting in shanties in the metropolitans, peri-urban and rural areas where there is no or limited service for natural gas. Most hospitalized children in the present study came from underdeveloped (shanties and peri-urban) areas of Dhaka metropolitan. In nearly all kerosene poisoning cases, liquid hydrocarbon was stored in soft drink bottles (plastic).

As a consequence, children are deceived into thinking of kerosene as soft drinks. A similar practice is also reported from some other South Asian countries (20, 26). Single-use plastic bottles/containers, mainly soft drinks bottles, are repeatedly used in developing countries for storing food and liquids. Given the popularity of soft drinks, particularly Coca-Cola, Pepsi, Sprite, and other local ones, storing kerosene or liquid chemicals in these empty soft drink bottles is very common in day-to-day life here. Therefore, popular soft drinks companies should also contribute to raising community-level awareness to prevent accidental poisoning in children, particularly in developing countries.

Despite 85% of mothers being homemakers (stay-at-home), over 70% of accidental incidents occurred when parents were at home. Like prior studies in developing countries, most mothers were younger (2730). Nearly all incidents happened for the first time in the family. Similar to other studies, preschool-aged male children were more prone to accidental poisoning (3135). Lack of experience in parenting and not taking practical measures might contribute to these incidents. Even though most parents were aware of the potential accident, they could not translate their knowledge into practice. The home environmental factors might have served as barriers to proper safety practice since bedrooms were the most typical place where half of the incidents took place in our study. However, prior studies reported kitchens and yards were the prevalent locations for accidental poisoning (36). In our study, most poisoning cases were from disadvantaged families (lower economic stratum) who were mostly living in small apartment houses with only one or two small rooms. Due to lack of enough space, all the daily chores and commodities are confined and crowded in these small houses. Moreover, Bangladeshi families hardly practice store room keeping and usually store substances near to hand. Because of the exploratory nature of children, poisonous substances easily find their way into children's hands. Effective parental (mother-centric) awareness and child protective containers could be a viable solution for preventing unintentional childhood poisoning in Bangladesh.

Limitations

A large sample and in-house context exploration are the strengths of this study. However, most childhood poisoning cases were from metropolitan or nearby areas. Therefore, our study did not portray the scenario of rural areas where nearly 70% of the Bangladeshi population lives there. Our findings are also not generalizable to other urban areas of the country.

Conclusion

In this present study, we found that kerosene was the most prevalent causative agent of poisoning among children. A majority of the incidents took place in the bedroom while parents were present at home. Our study findings would serve as a baseline for designing future intervention studies and policies.

Abbreviations

LMIC

Low- and middle-income countries

REDCap

Research Electronic Data Capture

Declarations

Ethics approval and consent to participate

The study protocol was approved by the institutional review board of Biomedical Research Foundation, Bangladesh (Ref. no: BRF/ERB/20191004). All methods were carried out in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki. Each parent provided verbal and/or written informed consent at their discretion. Parents were approached first and informed about the study's nature and objective. Participants were registered for an interview following consent (oral and/or written). Some respondents could not sign their names; in these instances, the questionnaire was marked as a verbal agreement.

Consent for publication

Not applicable 

Competing interests

The authors declare that there is no conflict of interest regarding the publication of this article.

Availability of supporting data

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Funding

No founding was associated with this project.

Author contributions

MSH conceived the idea. MSH and AA designed and developed the questionnaire. ER designed the study. AA led the data collection stage along with MS. ER along with MMH analyzed data. AA, MSH, MHBS, MS, ER, MMH contributed in the result preparation. AA prepared the draft and MHBS and MSH reviewed and revised it. All read and approved the final manuscript. 

Acknowledgement

The authors would like to impart their immense gratitude to Dr. Golam Moktadir for contributing and all the doctors and nurses of the pediatric medicine department of Dhaka Medical College for being supportive at the data collection stage. The authors are especially grateful to Prof. Sayeeda Anwar, the then head of the pediatric medicine department of Dhaka Medical College Hospital, and Prof. Zohora Jameela Khan, the head of the pediatric hematology and oncology department of Dhaka Medical College Hospital, for providing required assistance needed at the study site.

Authors’ information

Affiliations

Department Biomedical Research Foundation, Dhaka, Bangladesh

Ahsan Ahmed: [email protected] 

Md. Hasanul Banna Siam: [email protected] 

Md. Mahdi Hasan: [email protected]  

Enayetur Raheem: [email protected] 

Mohammad Sorowar Hossain: [email protected]

Dhaka Medical College, Dhaka, Bangladesh

Mohammad Shojon: [email protected] 

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