Transcript of interview between Dr Annette Katelaris and Dr Ruth Barker. Part 1 of 3.
Dr Ruth Barker is an emergency paediatrician at Brisbane’s Mater Children’s Hospital, Director of the Queensland Injury Surveillance Unit and a member of Standards Australia Committee for child-resistant packaging.
AK - Hello and thanks for joining me to talk about medication safety and childhood poisoning. My name is Dr Annette Katelaris. I’m a medical practitioner and co-developer of Juno ChildSafe, a lockable child-resistant bag to carry medication. I’m delighted to welcome Dr Ruth Barker, an emergency paediatrician from Brisbane’s Mater Children’s Hospital, Director of the Queensland Injury Surveillance Unit and a member of Standards Australia Committee for child-resistant packaging. Dr Barker thanks for joining me.
RB - You’re welcome Annette.
AK - Each year in the United States, more than one million poisonings in small children are reported to poison centres and one child every eight minutes is treated in an emergency department for medicine poisoning (1). What’s the situation in Australia?
RB - Well Annette we know that in Queensland approximately a thousand toddlers every year present to Queensland emergency departments for a medication-related poisoning, and we also know that the Queensland Poisons Information Centre fields many more calls than that, both in relation to medication poisoning and also other sorts of toddler poisonings, and they’re able to manage many of those less severe poisonings at home.
AK - So it’s a major health issue for young children?
RB - It certainly is, and I think the important thing that I want to get across to parents is that children are visual predators and they’re really omnivorous when it comes to objects around the home, and you would probably be surprised by what they will tackle and what they will actually swallow. I have seen children who’ve swallowed wedding rings, bracelets, tablets and bat poo. They will get into anything.
AK - I guess there are other characteristics of toddlers that put them at extreme risk, you know, things like, they have no sense of right or wrong, that they discover the world through their mouth. They’re a high-risk group for a number of reasons.
RB - They are and I think developmentally this is a normal phase that all children go through, but probably some are a little more adventurous or a little more extreme or a little more adept than others at getting themselves into trouble. It’s also interesting that when we look at other things that kids access at a slightly later age, children tend to poke things up their nose or in their ears. So one of the big things that we’ve been focusing on lately is not specifically medication but disc batteries, and we know that younger children tend to like swallowing metallic objects in particular, coins and disc batteries. And then if you look at the slightly older group, they get the smaller ones and poke them up their nose or in their ears, and this is a normal developmental phase. The other really important thing to let parents know is that a lot of these kids are pre-verbal and they don’t actually tell you what they’re thinking or what they’re cooking up, they just go and do it. They watch their environment, they watch what you’re doing all the time, they watch where you leave things, and then they just go and do it.
AK - Yes. Any mother will vouch for what you’ve just said there. They’re very fast learners when it seems to be doing the wrong thing.
RB - Yes.
AK - So let’s talk about what is in place to protect children from say, medication poisoning in the first instance. How are medications packaged and what protection do they offer?
RB - So the Poisons Prevention Act in the States I think came in back in the 1970s and a lot of other countries followed suit with child-resistant closures on bottles of medication, and this certainly made a huge difference to the rate of children accessing poisons. As a member of the Child-Resistant Packaging Standards Committee though, I believe that a lot of parents are a bit confused about what child-resistant packaging does and what child-resistant screw caps on bottles do. I see a lot of people calling it child proof and it is not child proof. Those caps are designed to keep 80% of toddlers out and designed to let 80% of adults in. So they are never child proof and at best they are a time delay, and you will certainly have some kids who are really adept at getting into things and some kids who will never defeat those child-resistant closures.
The other thing that I notice in the emergency department is that I don’t believe that many of those child-resistant closures are actually properly activated when they’re stored at home, and this is due to a number of different factors, partly because there are either no or poor quality assurance programs with the manufacturing process. So that means that you can design a child-resistant cap or a bottle but you don’t actually need to test that it functions at the end of the production line.
AK - So faulty caps are getting through?
RB - So faulty caps will get through and I certainly have seen and have written about a case of a faulty cap, and there are only a very few number of organisations that I’m aware of that actually test their product at the end of the production line.
AK - Okay.
RB - So the other problem is that the caps are not designed with any kind of clear indicator that tells you that the child-resistant mechanism is engaged. So the cap can be back on, you might think it’s engaged but it’s actually not engaged. So if you take a look at some of your medication that’s packaged with the child-resistant cap on it and you close it, very often there’s a click or a little bit of resistance and you think that the thing is actually closed but in fact, if you turn it back the other way, it’s really still functioning as a screw cap. The way to test it is to close it and give it a really good twist and then try to spin it open again and see if it spins freely, or whether the screw engages and the cap comes off. And the third thing is that often there can be medication that’s crystallised around the top or maybe the bottle’s damaged and the cap doesn’t fit back on properly. So there are many reasons why those child-resistant caps aren’t actually child resistant in real life.
AK - That’s very disturbing. They were the medications that I think most of us assumed were safely packaged, unlike blister packs where it’s obviously penetrable by the child.
RB - So blister packs are an interesting issue. For many, many years they were considered to be child-resistant but some work by the Consumer Product Safety Commission many years ago demonstrated that toddlers are able to unpack between one and 85 tablets in a five-minute period, and clearly 85 tablets of pretty much anything is too much for a toddler to eat. I see a lot of kids who access blister packs, particularly from handbags because they tend to be the sorts of things that you might carry in handbags, and it’s very easy for them to pop out the tablets.
AK - That’s a terrifying figure, especially when you’re talking about drugs like paracetamol. Just tell us, how many tablets would a 2-year-old need to take to get into trouble with paracetamol?
RB - So paracetamol is interesting in that it comes in lots of different formulations and the big problem with paracetamol is not so much the tablets, because they’re not sugar coated, they’re fairly large, they don’t taste very good and they’re a bit chalky. So we don’t tend to see a lot of children swallowing paracetamol tablets but they do access paracetamol liquid, and the dangerous one that we tend to see the more significant ingestions with is the super-concentrated paracetamol liquid, the 100mg/mL baby paracetamol, because if you drink a bottle of that you can get quite a significant dose, and some of those toddlers do end up needing to be treated with an n-acetylcysteine, which is an antidote.
1. Safe Kids Worldwide research report - Keeping Families Safe Around Medicine (March 2014)