Transcript of interview between Dr Annette Katelaris and Dr Ruth Barker. Part 3 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 - There are other things that don’t immediately jump to mind as a parent that people may not think of as toxic, you know, things like eucalyptus oil. I believe that that’s one of the most common causes of poisonings in Australia.
RB - Eucalyptus oil is used both as a medicinal product - you use it to put in vapourisers - but also as a cleaning agent - it’s good for removing sticky things - and it’s sold in a variety of different formulations. So if you’re buying really small bottles of eucalyptus or other essential oils, they tend to have little flow restrictors in them so that you can’t get very much out very quickly. But if you buy bigger bottles of eucalyptus oil, they don’t have any flow restrictors and they frequently don’t have a child-resistant cap. And a teaspoon of eucalyptus oil is sufficient to cause kids to heave seizures. Similar with many of the other essential oils. And these are things that parents just don’t realise.
Probably the other thing that parents wouldn’t think of as being highly toxic is iron tablets, and iron tablets can commonly be prescribed to mothers after they’ve had a baby. And I have seen a little girl who managed to swallow 20 iron tablets and when we X-rayed her, they were all stacked up in her oesophagus. They cause both a caustic injury to the oesophagus and then they cause a systemic toxicity as you start to absorb the iron tablets. So that little girl managed to swallow 20. The container didn’t have a child-resistant cap on it. She ended up getting an endoscopy, having all these tablets pulled out of her oesophagus and then spent the night in intensive care. If you asked a 2-year-old to swallow a tablet she wouldn’t but when you turn your back they’re able to swallow 20. It’s a paradox.
AK - Yes it’s really important for us to think about the human side of this. Can you tell us anecdotally of any, you know, ways that poisonings have happened?
RB - So I think that you have to realise that kids who do this, they’re often pre-verbal and they don’t articulate what they’re going to do, they just think it up and then suddenly they do it. So I saw a mum who had been prescribed some verapamil, which is an anti-hypertensive. She had, I think, a new baby and a 2-year-old. She was packing to go away for the weekend. She had a kitchen/lounge room and she was packing stuff in the middle of the dining table, things that she needed for the weekend, and she put her tablets in the centre of the dining table. She didn’t even leave the room and her 2-year-old daughter got up on a chair, got up to the dining table, and got into the verapamil box and then popped out a tablet from the blister pack and ate that. And what that mother hadn’t been told about the verapamil was that one of those tablets was sufficient to kill her 2-year-old. So she came in and spent hours being observed in the emergency department looking to see how much that little girl had taken and whether she had a significant dose. We didn’t really know whether she’d actually swallowed the tablet, whether she’d swallowed one, whether she hadn’t swallowed any. So it can be a period of great uncertainty and those parents feel particularly vulnerable and criticised I guess, because a lot of people think that they’re irresponsible and in fact they’re just like you and I, and this could happen to me.
AK - Yes, absolutely. In fact it was an experience that I had when I was a medical student that made me pursue the development of Juno ChildSafe. When I was a student I saw an 18-month-old baby who got into his grandmother’s handbag and ate the quinine that is bitter and you know, you wouldn’t think a child would go near, but yet the child consumed these quinine tablets and was permanently blinded. And the whole family was torn apart by this and it just struck me that there’s got to be a way to stop this happening.
RB - I think you raised an interesting point about bitter. As I said before, kids will eat bat poo, they’ll eat dog poo. It doesn’t taste very good but they will still eat it, so they will eat things that you or I might think are completely distasteful. With regard to bitterness, it doesn’t seem to be a big deterrent for children and genetically, not everybody can taste bitter. We have looked at some products that have been coated with a bittering agent and when I passed it around the office to see who could actually taste it, only half of my staff could taste it.
AK - That’s an interesting adventure for your staff.
RB - It is.
AK - It’s sobering though isn’t it because things that we think would be a natural deterrent aren’t a natural deterrent. So we mentioned briefly one pill can kill, and there’s been a very big campaign, especially in the United States, about that. What are the most dangerous drugs that children can be exposed to?
RB - I think if you’re looking at toxicity related to a small dose, then probably a lot of the cardiac medication that adults get put on, things like beta blockers, calcium channel blockers. These are things that are used for blood pressure often. Also, anti-epileptic medications generally and then a lot of anti-psychotic medications. And often these are medications that in combination are prescribed to adults who have chronic illness, and sometimes those adults get medications in dosette boxes or multi-dose packs. And we certainly see kids who access one of the sachets of the multi-dose packs, and therefore they get one anti-psychotic and one anti-hypertensive and so on, and sometimes the effect of those medications can be cumulative and quite significant. If you’re looking more broadly at what toddlers get into commonly and what commonly can cause problems and reasons for presentation, then it would probably be paracetamol syrup and eucalyptus oil as the top two.
AK - Okay. Some of the studies have identified children who are particularly at risk. I believe most studies show that males are slightly more likely than female toddlers to self-poison.
RB - I think males generally have a tendency towards injury generally, so if you look at kids 0 to 18, males generally are about twice as likely to be injured as females. If you get down to the toddler age range, the disparity isn’t quite as big. So some of the kids that I’ve seen who’ve had significant poisonings have actually been females. But yes, males tend to be a little more exploratory, I guess, of their environment, so generally they tend to be more injury prone, they tend to do more climbing activities and getting into stuff.
AK - And children with attention-deficit disorder and autism are also slightly at greater risk.
RB - I think it’s very interesting when you look at the demographic of kids who ingest medications and also foreign bodies. What we’re finding when we’re starting to look at foreign bodies more broadly, and we’ve been doing a lot of work looking at kids who ingest magnets like those small powerful magnets, and kids who ingest disc batteries, and what we’re finding is that kids on the autistic spectrum seem to continue with this mouthing activity until they’re 5, 6, 7, sometimes 8. So it’s like an extended sort of normal developmental risk.
AK - Right. Education has got to be a big part of a campaign to reduce the number of childhood poisonings. I guess if we could, you know, put a call out to our colleagues who are prescribing and to pharmacists, I can’t help thinking that the parents aren’t adequately warned about the risk of medication to children.
RB - I think it’s really, really important. And when I talk to parents about whether or not they got any advice about the medication when it was dispensed, there’s a lot of focus on advising patients about the direct health implications associated with that medication, but there’s not a lot of thought that goes into the context within which you’re prescribing that medication. So in particular, if you have mums with postnatal depression and you’re prescribing them anti-psychotics, or young mums and you’re prescribing them anti-hypertensive agents, think about 'Do they have toddlers at home?' And it’s a question that I regularly ask when I’m prescribing something that I think might be toxic potentially if eaten.
AK - Anything else you’d like to tell us about this subject?
RB - I think that issue of communication with families goes both for the doctor who’s prescribing the medication, but also it would be really great if pharmacists could pick up on this and talk to parents about how they might keep medications safe within the household. Often the interaction when you’re getting medication from the doctor is you’re busy with a whole lot of other questions that you’ve got. Sometimes when you go to the pharmacist to pick it up, it might be an opportunity to maybe start a new conversation about drug safety or build upon what the GP might have already started.
AK - Dr Barker thanks for talking to us. Thanks for giving us insights and possible solutions to the terrible problem of childhood medication poisonings.
RB - Thanks Annette.