Poisoning in children and adolescents in Kermanshah city, Iran

doi:10.21203/rs.3.rs-3133597/v1

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Poisoning in children and adolescents in Kermanshah city, Iran

https://doi.org/10.21203/rs.3.rs-3133597/v1

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published 22 Feb, 2024

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Background

Poisoning among children and adolescents is a public health problem worldwide. To take preventive measures, the pattern of this problem should be determined. This study aimed to describe the demographic characteristics of poisoning in children and to investigate the relationship between the types of poisoning and demographic factors in children in Kermanshah province.

Methods

This cross-sectional, descriptive-analytical study was conducted on 250 children and adolescents under 18 years of age who were referred to Mohammad Kermanshahi Pediatric Hospital in Kermanshah province due to poisoning during 2019 − 2012. The demographic and epidemiological data of patients were extracted from their medical files and analyzed.

Results

Out of 250 cases of poisoning, 173 (69.2%) cases were unintentional, 96 (77.1%) of whom were boys. Further, 77 (30.8%) cases of poisoning were intentional, of whom 49 (63.6%) were girls. There was a significant difference between gender and intentional and unintentional poisonings (p-value = 0.005). The median age of unintentional poisoning was 3 (IQR = 2.5) and that of intentional poisoning was 14 (IQR = 2). Most cases of poisoning were in cities, 145 (83.8%) of them were unintentional and 66 (85.7%) were intentional. Most cases of intentional and unintentional poisonings occurred in spring 2017 (35.1%) and autumn 2016 (34.6%), respectively. The most common causes of poisoning were narcotics (n = 36, 34.3%) and drugs (n = 35, 33.3%) in the age group 0–3 years and drugs (n = 46, 66.9) in the age group 11–18 years.

Conclusions

The most common causes of poisoning were narcotics and drugs in children and drugs in adolescents. To prevent poisoning in children, parents are required to increase their knowledge of the safe storage of narcotics and drugs, such as not storing methadone in a water bottle. Targeted evaluation and preventive measures are also needed in adolescent poisoning.

Intentional poisoning

Unintentional poisoning

Children

Adolescent

Iran

Toxins are potentially harmful substances that can harm the human body (1). Poisoning occurs when these toxins are ingested, inhaled, or absorbed through the skin, which can cause significant morbidity or mortality at high concentrations (2). Poisoning has a significant impact on society in terms of health, economy, and culture (3). Poisoning among children is a global public health problem and one of the leading causes of all unintentional injuries in children (4–6). It is also thought to be one of the main causes of disease in developing and developed countries. Poisoning accounts for about 2% of all deaths from injuries in developed countries and about 5% in less developed countries, which is generally associated with low morbidity and mortality (7–9).

Poisoning can be classified into two groups, intentional and unintentional. Young children are common victims because of their innate curiosity and exploratory nature. However, intentional poisoning is common among adolescents. Most intentional poisonings occur in developing countries, and a large number of cases lead to death due to the high toxicity of substances and the scarcity of medical centers (8, 10–12). According to the report of the World Health Organization (WHO) in 2012, 193,460 deaths are due to unintentional poisoning worldwide, 84% of which occur in low- and middle-income countries (6, 13). In addition, the highest rate of death due to unintentional poisoning is reported in children under 5 years of age, which is caused by their curiosity to taste or swallow harmful substances, and in adults over 55 years of age (14, 15). In the United States, it has been estimated that more than 70,000 visits to the emergency department annually are for unintentional poisoning of children, most of which occur due to unsupervised drug use in children under 6 years. Fortunately, the vast majority of these cases do not result in significant damage (16).

The underlying causes of poisoning in different countries vary depending on local customs and beliefs, demography, the socio-economic status of the population in that region, and the level of education. In addition, the patterns of poisoning may be different according to the people’s age and gender (17). Since children like to eat everything, ingestion is the most common route of poisoning in them, accounting for approximately 77% of cases. Further, because children are mostly kept at home, acute poisoning (90%) often occurs at home, which is mostly caused by various drugs and hydrocarbons such as petroleum, bleaching solutions, pesticides, insecticides, and cosmetics (10, 18–20).

In Iran, several poisonings have been reported in children and adolescents (10, 21, 22). Epidemiological characteristics of poisoning in children vary in different countries and also the cities of a country. Therefore, knowledge of regional poisoning patterns can play an essential role in planning for the prevention, care, and treatment of patients. This study aimed to describe the demographic characteristics of poisoning in children and also to investigate the relationship between types of poisoning and demographic factors in children in Kermanshah province.

The population of this cross-sectional and descriptive-analytical study included children and adolescents under 18 years of age who were referred to Mohammad Kermanshahi Children’s Subspecialty Hospital (a teaching hospital affiliated with Kermanshah University of Medical Sciences) due to poisoning during 2019 − 2012. A total of 250 children were randomly selected and included in the study. The clinical records of all patients were available in the hospital archives. After studying the medical files, the demographic and epidemiological data, including sex, age, weight, Body Mass Index (BMI), residence, year and month of poisoning, type of poisoning (intentional and unintentional), death, and the rate and type of substance leading to poisoning were fed into SPSS-26 software for analysis. Also, the target age groups were 1–3, 3–6, 6–11, and 11–18 years. The substances leading to poisoning were divided into five categories: detergents, petroleum products, drugs, narcotics, and others (alcohol, castor oil, insect poisons, plants, cosmetic and health products, and gas). The Ethics Committee of Kermanshah University of Medical Sciences approved this study with the code (IR.KUMS.REC.1401.157).

Statistical analysis

The Kolmogorov-Smirnov test was used to evaluate the normality of the data. To describe the quantitative data, the median and the interquartile range (given the non-normality of the data) were used. Frequency and percentage were used to describe the qualitative data. Further, Chi-square, Fisher’s exact, and Mann-Whitney tests were used to analyze the data. Arc/GIS Desktop 10.8 software was used to display the geographical distribution of poisoning frequency based on age groups and the factors leading to poisoning in the neighborhoods of Kermanshah city. P < 0.05 was considered statistically significant.

Sample size

The sample size was determined according to the study of Ali Keshtkari (8). Accordingly, the mean age of the patients was 4.7 ± 3.95. By putting α = 0.05 and d = 0.13σ in the following formula, the minimum sample size of 228 children was estimated.

Demographic characteristics of patients

According to the results obtained from 250 cases of poisoning in children and adolescents under 18 years of age who were referred to Mohammad Kermanshahi Hospital during 2019-2012, 181 (72.4%) were from Kermanshah city, 44 (17.6%) were from Kermanshah towns, 18(7.2%) were from Kermanshah villages, and 7(2.8%) were from other cities of the country(Figure 1). The number of girls and boys was almost equal, 126 (50.4%) girls and 124 (49.6%) boys. The youngest patient in this study was 1 year old and the oldest one was 17 years old. The median age of the patients was 4 years (IQR=11); the median age of girls was 5 years (IQR=11.50) and that of the boys was 4 years (IQR=8.75), and there was a statistically significant difference between age and gender (p-value= 0.017). On the other hand, gender distribution in different age groups showed a statistically significant difference between age groups and gender (p-value=.036) (Tables 1 and 2).

Table 1

Distribution of age based on gender (median(IQR))
Variables		median(IQR)	p-value
Gender	Female	5(11.50)	.017
Gender	Male	4(8.75)	.017

Table 2

Frequency distribution of age category of poisoned children and adolescents based on gender
Gender	Age category				p-value
Gender	1–3	3–6	6–11	11–18	.036
Female	49(38.9)	23(18.3)	6(4.8)	48(38.1)
Male	61(49.2)	23(18.5)	12(9.7)	28(22.6)

Of patients, 110 (4%) were in the age group 1–3, 46 (18.4%) were in the age group 3–6, 18 (7.2%) were in the age group 6–11, and 76 (30.4%) were in the age group 11–18. The highest frequency of poisoning (n = 8, 7.3%) was in the age group 1–3 years in Jafar Abad district, followed by the age group 11–18 years (n = 6, 7.9%) in Elahieh district (Fig. 2). The highest frequency of patients’ birthplace was 185 (74%) in Kermanshah province. Among the different districts of Kermanshah city, Elahieh with 16 (6.4%) patients and Jafar Abad with 15 (6%) patients had the highest frequency. Further, 211 (84.4%) patients lived in urban areas and 39 (15.6%) lived in rural areas. Of poisonings, 86 (34.4%) occurred in fall, 62 (24.8%) in winter, 55 (21.6) in summer, and 48 (19.2) in spring. Moreover, 106 (44.2%) drugs, 74 (30.8%) narcotics, 30 (12.5%) other substances, 19 (7.9%) detergents, and 11 (4.6%) petroleum products were among the poisoning causes in children and adolescents (Table 3).

Table 3

Demographic characteristics of poisoned children and adolescents in study
Variable	Frequency	Percentage
Gender
Female	126	50.4
Male	124	49.6
Age(year)
1–3	110	44
3–6	46	18.4
6–11	18	7.2
11–18	76	30.4
Living area
Urban	211	84.4
Rural	39	15.6
Season
Spring	48	19.2
Summer	55	21.6
Fall	86	34.4
Winter	62	24.8
Cause of poisoning
detergents	19	7.9
petroleum products	11	4.6
drugs	106	44.2
narcotics	74	30.8
other substances	30	12.5

Demographic characteristics of patients for intentional and unintentional poisoning

Out of 250 cases of poisoning, 173 (69.2%) were unintentional, of whom 96 (77.1%) were boys. Moreover, 110 (63.6%) patients were in the age group 3 − 1, 46 (26.6%) in the age group 3–6, 12 (6.9%) in the age group 6–11, and 5 (2.9%) in the age group 11–18. Furthermore, 77 (30.8%) cases of poisoning were intentional, of whom 49 (63.6%) were girls; 6 (7.8%) cases were in the age group 6–11 and 71 (92.2%) patients were in the age group 11–18. There was a significant difference between gender and intentional and unintentional poisonings (p-value = 0.005) (Table 4).

Table 4

Frequency distribution of intentional and unintentional poisoning based on demographic characteristics
Variables		Intentional	Unintentional	P-value
Gender	Female	49(63.6)	77(44.5)	.005
Gender	Male	28(36.4)	96(55.5)	.005
Age	1–3		110(63.6)	< .001
	3–6		46(26.6)
	6–11	6(7.8)	12(6.9)
	11–18	71(92.2)	5(2.9)
Leaving area	urban	66(85.7)	145(83.8)	.702
Leaving area	Rural	11(14.3)	28(16.12)	.702
season	Spring	27(35.1)	21(12.1)	< .001
	Summer	10(13)	44(25.5)
	Fall	26(33.8)	60(34.6)
	Winter	14(18.2)	48(27.71)

The median age of unintentional poisoning was 3 (IQR = 2.5) and that of intentional poisoning was 14 (IQR = 2). In unintentional poisonings, the median age of girls was 3 (IQR = 2) and that of boys was 2.5 (IQR = 3). As for intentional poisonings, the median age of girls was 14 (IQR = 2) and that of boys was 14 (IQR = 3), indicating no significant difference between intentional and unintentional poisonings in terms of age (Table 5).

Table 5

Distribution of age based on gender in intentional and unintentional poisoning (median(IQR))
Variables		unintentional	P-value	intentional	p-value
age	female	3(2)	.566	14(2)	.521
age	male	2.5(3)	.566	14(3)	.521

Of poisonings in cities, 145 (83.8%) were unintentional and 66 (85.7%) were intentional. The highest frequency of intentional poisoning was 7 (9.1%) in Elahieh district and 10 (5.8%) in Jafar Abad district. In Jafar Abad, narcotic drugs (n = 7, 70%) had the highest frequency in unintentional poisonings, and in Elahieh, drugs (n = 4, 66.7%) were the most frequent in intentional poisonings (Fig. 2). The most frequent cases of intentional poisoning occurred in the spring of 2017 (35.1%) and fall of 2016 (33.8%) and the most frequent cases of unintentional poisoning happened in the fall of 2016 (34.6%) Table (4).

Frequency distribution of the type of substance leading to poisoning

Regarding the type of poisoning, 19 (7.9%) were caused by detergents, 11(4.6%) by hydrocarbons, 106 (44.2%) by drugs, 74 (30.8%) by narcotics, and 30 (12.5%) by other substances. The most common causes of poisoning were narcotics (n = 36, 34.3%) and drugs (n = 35, 33.3%) in the age group 0–3 years, and drugs (n = 46, 66.9%) in the age group 11–18 years. Also, the most common cause of poisoning was drugs in boys (n = 64, 53.3%) and girls (n = 42, 35%). Among unintentional cases, narcotics were the most frequent (n = 62, 37.1%), and among intentional cases, drugs were the most frequent (n = 49, 67.1%). There was a statistically significant difference between poisoning causes and each of the demographic characteristics (Table 6).

Table 6

Frequency distribution of the type of substance leading to poisoning based on demographic characteristics
Variables		type of substance leading to poisoning					p-value
Variables		Detergents	petroleum products	Drugs	Narcotics	Other
Age	1–3	13(12.4)	8(7.6)	35(33.3)	36(34.3)		< .0001
	3–6	3(6.5)	3(6.5)	19(41.3)	20(43.5)
	6–11	2(11.8)	0	6(35.3)	5(29.4)
	11–18	1(1.4)	0	46(66.9)	13(18.1)	.007
Gender	Female	4(3.3)	3(2.5)	64(53.3)	36(30)		007
Gender	Male	15(12.5)	8(6.7)	42(35)	38(31.7)	.013	007
Living area	Urban	16(7.8)	7(3.4)	97(47.5)	63(30.9)		.013
Living area	Rural	3(8.3)	4(11.1)	9(25)	11(30.6)	< .001	.013
Type of poisoning	unintentional	18(10.8)	11(6.6)	57(34.1)	62(37.1)		< .001
Type of poisoning	intentional	1(1.4)	0	49(67.1)	12(16.4)	11(15.1)	< .001

Among the patients with poisoning referred to Mohammad Kermanshahi Hospital in Kermanshah during 2019–2022, 250 patients in the age group 1–18 years were randomly included in the study. Of them, 126 (50.4%) were female and 124 (49.6) were male, which was almost equal in terms of gender distribution. The highest frequency of poisoning was in the age group 1–3 years; 110 (44%) patients were in the age group 1–3 years, 46 (18.4%) in the age group 3–6 years, 18 (7.2%) in the age groups 6–11, and 76 (30.4%) in the age group 11–18. The highest frequency of poisoning was in the studies of Shirkosh (22) in Babol and Ghasempouri (23) in the age group 1–3 years, Jung Lee (24) in Taiwan in the age group 1–2 years, Alinejad (25) in the age group 3–5 years, and Abdulmaged Alwan (4) in Malaysia in the age group 0–5 years.

According to the results of this study, most of the poisonings occurred in cities (n = 211, 84.4%), which is consistent with the results of Ahsan Ahmed (6) in Bangladesh, Shirkosh (22) in Babol, Nasiri in Qaemshahr (26), Feiz Disfani (27) in Mashhad, and Ghasempouri (23) in Iran. In this study, most poisonings occurred in autumn (34.4) 86, but in Jung Lee’s study (24) in Taiwan and Zrinka Laido’s study in Australia (28), most poisonings happened in spring. However, most poisonings were reported in summer in the studies of Shirkosh (22) and Alinejad (25) in Babol, Momayyezi (29) in Yazd, and Abdelrahman Ahmed in Qatar (30).

The most common causes of poisoning were drugs (n = 106, 44.2%) and narcotics (n = 74, 30.8%) in the current study, drugs and other substances in the studies of Shirkosh (22) in Babol and Jung Lee (24), kerosene and pesticides in the study of Ahsan Ahmed (6), detergents and chemicals in the study of Sultan Alghadeer (31), and drugs and detergents in the studies of Momayyezi (29), Mohammed A (32), Abdulmaged Alwan (4), and Abdelrahman Ahmed (30).

In this study, poisonings were divided into two groups: intentional (77 patients) and unintentional (173 patients). The highest frequency of unintentional poisoning was in the age group 1–3 years. In some studies in other countries, the highest frequency of unintentional poisoning has been reported in the age group under 5 years (6, 16) or 1–3 years (31, 33). In Iran, most studies have reported the highest frequency for the age group 1–3 years (19, 22, 34). Exploratory swallowing by toddlers is a common reason for visiting a doctor (16). Young children are naturally curious and explore their environment with all their senses. As a result, they tend to taste things and put them in their mouths. Developmentally, they are unaware of potential dangers and are attracted to colorful things, such as bottles containing household products and some medications. Preschool children also often imitate the behavior of adults, including the use of medicinal products. These factors together change the exploratory consumption leading to potential accidental poisoning into a common problem in this age group (35).

On the other hand, the highest frequency of intentional poisonings was in the age group 11–18 years (n = 71, 92.2%), which indicated a statistically significant difference between intentional and unintentional poisonings in age groups (p-value < 0.001). The highest frequency of poisoning was in the age group 15–19 years in the study of Zrinka Laido in Austria (28), in the age group 16–25 years in Khademi’s study in Kermanshah (36), in the age group 6–11 years in the study of Shirkosh (22), in the age group 12–17 years in the study of Jung Lee (24), and in the age group 13–18 years in the study of Iqdam Abdulmaged Alwan (4). Intentional poisoning in the adolescent age group can be caused by vulnerability to stress, failure or disappointment in relationships and exams, as well as incompatibility with and inability to cope with family expectations. Adolescents are not emotionally stable and mature enough to bear intense mental or physical pressure (37). On the other hand, intentional poisoning can be caused by significant psychological problems, depression, or substance abuse disorders (38).

In the present study, the frequency of unintentional poisoning was higher in boys than in girls (n = 96, 55.58%). It was the same in some studies in other countries as well as in Iran (4, 22, 23, 39). It seems to be due to the nature of boys who are more active and adventurous than girls, however, the exact reason is unknown (4, 17). Yet, the frequency of unintentional poisoning was higher in girls in the studies of Momayyezi (29) in Yazd, Iran, and Sultan Alghadeer (31) in Saudi Arabia.

On the other hand, the prevalence of intentional poisoning in this study was higher in girls (n = 49, 63.6), and there was a statistically significant difference between gender and intentional and unintentional poisoning so that the prevalence of poisoning in girls increased with age (p-value = 0.005). The prevalence of intentional poisoning was higher in girls in the studies of Kanita Dervic in Australia (40), Zrinka Laido in Austria (28), Jung Lee in Taiwan (24), Gonzalez-Urdiales, Paula MD in Spain (41), and Britni Overall in America (42). This gender difference in intentional poisoning can be due to a higher rate of psychiatric problems, especially depression, more emotional crises in adolescence, premature puberty, and hormonal changes in girls (25).

In the current study, most of intentional (n = 66, 85.7%) and unintentional (n = 145, 83.8%) poisonings occurred in Kermanshah city, which is consistent with the results of the studies of Feiz Disfani in Mashhad (27), Ahmadabad (19) in Tabriz, Shirkosh (22) in Babol, Ghasempouri (23), and Alinejad (25). The increase in poisonings in urban areas can be associated with more child neglect by working mothers and more access to drugs, detergents, and chemicals in urban areas. Further, the population in urban areas is higher, so more referrals are made to hospitals as a result of poisoning (23, 25).

In addition, the frequency of unintentional poisoning was higher in autumn (34.4) 60, which was consistent with the results of the study ofAhmadabad (19) in Tabriz. However, the highest frequency was in spring in the studies of Rezaei Orim (43) in Qaimshahr and Jung Lee in Taiwan (24), but the highest frequency was in summer in the studies of Alinejad (25) and Shirkosh (22).

On the other hand, most intentional poisonings occurred in the spring and the least in the summer (35.1%), which showed a statistically significant difference between the type of poisoning and season (p-value < 0.001). In the study of Zrinka Laido (28), most of the poisonings occurred in the spring. In the study of Britni Overall (42) in America, most of the poisonings occurred in the fall and the least in the summer. In Benjamin Hansen’s study (44), most cases of poisoning were in the winter and the least in the summer, which shows the reduction of suicide during the summer months coincides with a distancing from the stress of secondary education. Also, various studies have reported school and exam problems stimulate adolescent suicide (40, 45, 46).

In the current study, the most common types of drug poisoning in the age groups 1–3 and 3–6 were drugs with a frequency of 36(34.3%) and 20(43.5%), respectively, and the most common type of poisoning in the age groups 6–11 and 11–18 was drugs with the frequencies of (n = 6, 35.3%) and (n = 46, 66.9%), respectively, indicating a statistically significant difference between age and type of poisoning (p-value < 0.0001). The most common type of poisoning in the age group under 7 years was drugs in the study of Ayubi (21), medicines and narcotics in the study of Alinejad (25), drugs in the studies of Jung Lee (24), Abdulmaged Alwan (4), and Shirkosh (22) in children and adolescents, and household chemicals in the study of Dayasiri (47). One of the reasons for easy access to drugs is neighboring countries such as Afghanistan and Pakistan, which use Iran’s strategic position to smuggle these drugs to Europe (48, 49). Another reason for drug poisoning in young age groups was the use of methadone, which was mistakenly placed and stored in water/drinking bottles by parents (50, 51). Moreover, among the causes of drug poisoning, the availability of these products, due to the lack of safe storage tips and the fact that children may observe other family members taking the drug, and the development of imitative behaviors around the age of 2 years may somewhat explain the higher risk of drug poisoning in young children (4, 52).

In the present study, the frequency of using detergents, petroleum products, narcotics, and other substances was higher in boys than in girls, but the percentage of the use of drugs was higher in girls than in boys, indicating a statistically significant difference between gender and the type of substances causing poisoning (p-value = 0.007). In the study of Rezaei Orimi, the percentage of using narcotics and insecticides was higher in boys than in girls, and the use of drugs was more in girls. In the study of Shirkosh (22), the use of drugs, detergents, and hydrocarbons was higher in boys than in girls. In Britni Overall’s study (42), the consumption of alcohol, household detergents, and insecticides was higher in boys, and the consumption of drugs, including painkillers, supplements, vitamins, and hormones, was higher in girls.

Most poisonings occurred in cities in the age group 1–3 years. The frequency of unintentional poisonings was higher in autumn in boys. However, the frequency of intentional poisoning was higher in spring in girls. The most common cause of unintentional poisoning was narcotic, and the most common cause of intentional poisoning was drug. The frequency of using detergents, petroleum products, narcotics and other substances was higher in boys, but the frequency of using drugs was higher in girls.

Authors’ contributions

MH and SF contributed to the conception and design of the study. FG and SF organized the database. SF and AM performed the statistical analysis. BA revised this research and provided important suggestions. All authors contributed to the manuscript revision, read, and approved the submitted version.

Funding

Not applicable

Availability of data and materials

The dataset used and/or analyzed during the current study can be downloaded through the link below. https://www.uplooder.net//files/b1935c72b325fca47c0970d3f8ad4beb/data.rar.html

Ethical approval and consent to participate

All the methods and procedures carried out in this study were in accordance with relevant guidelines and regulation of Declaration of Helsinki.

The Ethics Committee of Kermanshah University of Medical Sciences approved this study with the code (IR.KUMS.REC.1401.157).

This study used the clinical records of all patients were available in the hospital archives and it did not contain patient' s identity information, Therefore, according to the approval of the Ethics Committee of Kermanshah University of Medical Sciences, there is no need to obtain informed consent from the patient.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Acknowledgements

Not applicable.

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No competing interests reported.

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Poisoning in children and adolescents in Kermanshah city, Iran

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Background

Methods

Statistical analysis

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Results

Demographic characteristics of patients

Demographic characteristics of patients for intentional and unintentional poisoning

Frequency distribution of the type of substance leading to poisoning

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