Accidental ingestion of substance, injurious to health is still common health problem among children from developing world; however literature is spare from South Asia including Pakistan.14 Most unintentional pediatric poisoning are preventable with little education, intervention and modification of risk factors. The study center is the largest children teaching hospital of the province which caters patients from whole of the city and around.
Age And Gender
Available literature from Pakistan identify that majority of child with unintentional ingestion were under 5years of age2, 15 studies have shown that age < 5 are adventurous and need to explore the world around them and use to participate in reckless actions if unsupervised and expose to injurious substances.10 Considering gender distribution we observed the same as was in most studies, males predominate female ratio of 1.3:1 in all age group, as mentioned in few studies range from 1.1–1.8:12, however children aged 10 and above we found an inverse ratio of 1:2 as female out numbers, reason behind was not investigated, interestingly most of these girls was exposed during night time this may be accidental or unintentional but suspicious of intentional may not be completely excluded because of age, level of understanding regarding poison and fear of the family.
Timing Of Ingestion And Number Of Siblings
This was also observed that timing of ingestion play an important role in exposure, and we found most children during afternoon hours interestingly around 50% of them were age five or less. It is difficult to point the reason, however as mention is previous study10, the long afternoon with warm and humid climate of Karachi mothers and other care givers use to take some rest (nap) and children use to be unattended and feel free to explore things and hazardous substances. This was not investigated in the past and need to be further evaluated. Unsupervised child during the afternoon hours lead to poison exposure either mother was out for job or caregiver was reckless. Petridou E. et.al.16 describe that absence of one parent was associated with an increased risk of unintentional poisoning. Absence of mother during daytime due to maternal employment and lack of family support was the two most deleterious risk factors recognized in his study. 12, 17
Literature identified that number of siblings relates to chance of poisoning exposure, we observed 40% of our children exposed to unintentional ingestion of hazardous things with > 3 siblings, literature do support this.2
Age Of Mother And Education Of Mother
Education in health also means prevention, to reduce pediatric poisoning a prevention program may be practiced in clinics, ED or in ward etc. parents need counselling, however maternal educational status and level of understanding counts a lot in perceiving and practicing the knowledge.18 Maternal education plays an important role in ingestion prevention as described by Bilal A. et.al. who identified a PAR (population attributable risk) score of 15% if maternal education level was of 10 years while it rose to 38% among mother with of no formal education.2, 12, 14 A multi-variant study demonstrates children of young mothers19 with tenth grade education were prone to poisonous exposure. Somehow similar findings we observed in our study.
Large family size seems to be protective with more available observing eyes on child, literature support with evidence, however in this study we found a reveres pattern and more children belong to joint family system with 5 or more adult members, however if there is lack of family support the risk remain high, one reason may be that our catchment area is of low socioeconomic category, 20 adult members may be on employment while children remain at home, this need to be evaluated further and it was missed in our study. Similarly number of children within a family is directly related to risk of ingestion which doesn’t favor from our study.12
Types Of Poison Ingestion
Kerosene oil, as single agent is the almost the most common hydrocarbon ingested in liquid form, different category of medicine remain on the top of list.2, 10, 21, 22 Kerosene oil is readily available in most houses and are still in use in stove for cooking purposes among low income families, we use it for few other purpose, hence present in most families. Accidental ingestion of hydrocarbons especially kerosene is common among children under five especially if they are kept in some containers in which the kerosene oil is stored container familiar to them like cup, can, glass, mineral water or attractive beverage bottles. Regarding another common ingestion of medicine, children use to take medicine which is readily available, looks like a candy and their curious nature of habit to follow what adults do. In this study we didn’t focus on which medicine children are exposed most, this entirely depends on availability of drugs. Some of the rare ingestions like plants products, pesticides, and detergents etc which were not discussed in this study.
We observed mortality of 4%, this seem to be a huge number however similar findings was observed by Manzar N et.al.2 This is may be partially dependent on age, amount and time of ingestion, delay in seeking medical treatment, and how and what treatment were executed and socioeconomic status of family. Mortality of 11.6% was observed from India, whereas 2.5–13.6% was observed from 2, 15, 22 Inadequate supervision either by mother or other caregivers is one of the key factor associated with unintentional ingestion.
Limitation And Strength
This was hospital base study which is the main limitation of our study. We need to conduct community based or multicenter study with more elaborated methodology in order to highlight the actual magnitude of the disease and to identify underlying risk factors. Though the study hospital is a referral center but this didn’t have toxicology department, poison center or a toxicologist.
Questionnaire was designed based on the variable available in literature was tested by study participants and institutional review board, expert review and epidemiologist input was not opted.
Data collection was not must from all cases, only those who gave consent was enrolled, hence a good number either didn’t gave consent or had doubtful history of ingestion and were excluded.
Under reporting of cases who do not seek treatment at health care facility may be one factor of limited cases.