The epidemiology of pediatric poisoning differs across the countries. This study is of particular interest because it estimates the current pattern of child poisoning reflecting a large central district of Greece. At first, male predominance is noted. Also, most cases involved children aged 13 to 24 months old. This can be explained by the developmental milestones they acquire at this age. In particular, their newly obtained skill of grasping in conjunction with the exploratory behavior at this age place them at risk for poison exposures. These results come in agreement with previous studies of the only Greek Poison Center(PCC) in Greece, located in Athens[4] and also, a 10-year-study in Northern Greece[5].
Most exposures to poisons in children are non-toxic, however there are some chemicals that can cause mortality in small doses, defined as one-pill killers[6]. The main categories of chemicals that are fatal in small doses include alcohols, antiarrhythmics, antimalarials, benzocaine, b-blockers, calcium channel antagonists, clonidine and other imidazolines, cyclic antidepressants, hydrocarbons, laundry pods, camphor, diphenoxylate/atropine, organophosphorus pesticides and insecticides, opioids and opiates, salicylates and sulfonylureas[6–8]. In this study, the majority of cases included medications and cigarettes. As far as medications are concerned, the main categories were ibuprofen and vitamins. Interestingly, among medications ingested there are some categories that belong to the one pill killers list mentioned above. Specifically, 22% of the total poisonings in the study are regarded chemicals lethally dangerous in small doses for a young child. This finding is quite alarming, raising concerns for investing in awareness campaigns particularly regarding these chemicals.
Second cause of poisoning was cigarette consumption. Smoking habits of parents are a strong risk factor to be addressed in these situations. The high rate of poisoning involving cigarettes is quite disturbing; children whose parents are smokers are at higher risk of poisoning from chewing or swallowing cigarettes or cigarette butts when left unattended. This phenomenon is apparent in this study, since the presence of a parent smoker in the family of children exposed to cigarette ingestion was 100%.
The Poison Severity Score (PSS) was created by the European Association of Poisons Centers and Clinical Toxicologists (EAPCCT), the International Program on Chemical Safety and the European Commission in the 1990s[9]. It is based on categorizing symptoms of different systems after the exposure to a toxic substance and rating the clinical severity of the patient. Specifically, score 0 means no symptoms present, score 1 corresponds to minor symptoms, score 2 is considered moderate severity, with prolonged symptoms, score 3 is severe poisoning, with life- threatening symptoms and score 4 means fatal poisoning. PSS is quite underused due to its complexity or limited knowledge on its proper application[10]. The difficulty in its use is due to many clinical parameters needed and some subjective findings, which cause low internal reliability[11].
According to the results, based on the fact that all our cases had a poison severity score of 0, the unnecessary admission of a large percentage of patients to the pediatric clinic is a common phenomenon. The examinations carried out at the emergency department were, in most cases, unnecessary and the patients' stay was long. Also, the excellent prognosis in our pediatric poisoning cases can be explained, since most poisoning cases involved accidental ingestion of small amounts or minimal toxic substances. Furthermore, hospital treatment focused mainly on observation of the patients for the possible development of symptoms in the first 24 hours post-ingestion. This observation period is considered a safe approach to poisoned children, suggested from the Greek PCC. However, it would be useful to re-evaluate this policy in non-toxic exposures, taking into consideration the unnecessary and possible traumatic experience of a child’s hospital admission as well as the economic burden on the healthcare system.
During the COVID-19 pandemic, the pediatric admissions showed a significant decline. This is confirmed by the hospital admissions and studies in many hospitals globally[12–14].In Greece, as well, there was a decrease in the number of visits at the Pediatric Emergency Departments of the country's Hospitals. Research from a tertiary Children's Hospital in Greece highlights a decline in the number of children attending the emergency department or hospitalized at the pediatric clinic in a large city of Greece[15].Moreover, a study performed at a pediatric clinic of a great Province of Greece can confirm this observation[16]. More precisely, the research revealed that during the first lockdown (March, April, May 2020) there was a significant decrease in general attendance at the pediatric emergency department by 60%.
This striking reduction in pediatric hospital visits could be explained by various factors[15]. At first, on the peak wave of the pandemic in the country, which coincided with the lockdown regulations, people were anxious about the viral transmission. Possibly, there was parental fear of exposure to SARS-CoV-2 in the hospital setting. In addition, the protective measures such as social distancing and use of masks, possibly led to reduced respiratory infections and, therefore, no need for hospital visits. Also, community pediatricians handled some pediatric cases, probably through virtual consults, using the tools of telemedicine. However, there is no literature on this subject yet.
Self-protection measures and social distancing were the cornerstones of the lockdown, leading to an extended stay at home. Teleworking and distance learning were quite popular in middle- and high-income countries. Adults and children spent more time in home settings, with the consequence of coming in daily contact with numerous household products. A lot of children had easy access to these chemicals at home, especially toddlers, who are characterized by their exploratory behavior and curiosity as stated above.
During the COVID-19 pandemic and especially, on the peak incidence, pediatric poisoning rates presented a significant increase in many countries, according to the literature. Moreover, the constant use of antiseptics and disinfectants, as protection against virus transmission brought some drawbacks. Some studies have mentioned the high rate of antiseptic poisonings in that period. More precisely, poisoning due to antiseptics and disinfectants increased, probably due to their greater availability.
Specifically, studies in the USA highlighted a rise in calls to PCC regarding hand sanitizer poisoning confirm this observation[17].Furthermore, research from the USA outlines an increase in poisonings among hospitalized children in intensive care units during the Covid-19 peak wave[14]. Notably, French data state that gel dispensers often are close to children's faces leading to corneal lesions[18].Furthermore, South Africa highlighted a 60% increase in calls regarding exposure to antiseptics compared to pre-pandemic time[19]. A rise in poisonings has also been seen in Canada, probably associated with the school closure and homestay during the lockdown[12]. An Italian study highlighted that the most frequent poisons during the pandemic were medications and hand sanitizers[20]. Also, there was a high percentage of poisonings in Turkey compared to pre-pandemic years[13]. In China, this was confirmed through studies performed at pediatric hospitals[21]. According to the data collected from different European Poison Control Centers, during the pandemic, the calls to Poison Centers significantly amplified[22]. At Children's Hospital in Kuwait, it was noted that during the six months of Covid-19 pandemic, there was an increase in child poisoning compared to the same period of the previous year[23]. According to the researchers, this can be attributed to the virtual schooling of the children and general spending more time at home in calls and household poisonings during the lockdown.
This is the first approach to recording the unintentional child poisoning at a referral Children’s Hospital during Greek COVID-19 lockdown, as indicated through the study of the available literature. Through this study, it is highlighted that poisonings were significantly increased in the trimester of lockdown 2020 compared to the same trimester of the pre- pandemic preceding year. It seems that not only did the relative numbers of pediatric poisoning rise in this period, but also, the absolute numbers showed a statistically significant increase (p<0,001).
This phenomenon could be possibly explained in different ways. The school closure and the extended home confinement could have led to longer contact with household products. Children, and particularly toddlers, often present restless behavior, when they are not occupied with organized activities. In addition, the overuse of chemicals, due to the pandemic could be considered another variable, as well. Possibly, these factors in combination with the lack of supervision of the caregiver contributed to the increased cases of poison exposure.
The evaluation sample was relatively small, and our data derive from only one pediatric hospital in Greece. However, it should be noted that the study was conducted at a referral tertiary Children's Hospital, covering a large district of Athens, which could reflect the activity at a regional level.
Since it was a retrospective study, it is possible that some data were not recorded; sociodemographic characteristics, such as the time of the exposure, the duration of the delay, the caregiver’s occupation and first reaction have not been studied. Moreover, children that were admitted due to ingestion of batteries, magnets or due to envenomation were referred to the surgical unit and therefore, there is a lack of recording regarding these cases. Furthermore, the incidents were reported by the caregivers, who brought the poisoned child in an anxious state and hence, possible recall and/or cognitive bias is present.
In addition, this research did not include the pediatric intentional poisonings. Thus, the number of poisonings, particularly during the COVID-19 lockdown can be underestimated. Notably, the period studied regarded the first lockdown of the pandemic, meaning that there might be different results in the periods following.