Operational Pathway for Paediatric Urine Toxicology

• Target Group
• Poisoning - when to consider it
• Accidental poisoning
• Intentional poisoning
• Urine Toxicology Pathway
• Contact Information
• Appendix

This Pathway covers the following

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Target Group

This Guideline applies to Paediatric patients (up to 16th birthday). It is aimed at Doctors and Nurses on Paediatric wards and units and in the Emergency Department. The aim of this guideline is to improve patient care where poisoning has been considered, through a process where a quick toxicology result is achieved.

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Poisoning - when to consider it

Poison is defined as a substance causing illness or death when eaten, drunk or absorbed into the body by other means.
Poisoning may be:

• Accidental
• Neglectful or due to single acts of omission
• Deliberate - clearly a form of child abuse.

Gray & Bentovim (1996) described 11 cases with children ranging from 4 weeks to 12 years and 3 months where a carer had ‘actively administered substances which were harmful to the child or where a parent had been actively interfering with the child's medical treatment’.

Repeated poisoning may be due to negligence but the consequences for the child may be equally as catastrophic as poisoning by intent or in order to fabricate illness and should be assessed as possible abuse.

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Accidental poisoning

Accidental poisoning: seldom fatal, 15% of children symptomatic related to the ingestion. The peak age 2–3 years, adult supervision was faulty and ingestions took place at home. In 60% of cases the substance ingested was not in its usual storage place and 60% of substances were not in child-resistant containers; 22% of children were admitted to hospital, < 10% needed intensive care and there were no fatalities.

Accidents may occur even in well-regulated homes but repeated ingestion should be looked at as neglectful, and deliberate poisoning considered. It is also appropriate to look at parental behaviour: is the mother depressed, or impaired by the use of drugs or alcohol? Are there other signs of neglect within the family?

The drugs ingested include analgesics, anxiolytics, the contraceptive pill, cough medicine and iron. Bleach, detergents and petroleum products account for most of the household substances ingested.

If symptoms are severe – for example seizures, coma, intractable vomiting – consider whether an unusual substance such as salt, insulin or anti-convulsants has been administered. Laxatives, easily available, are also often used.

The age of the child is also important. Toddlers aged 18 months to 3 years explore, test and taste whatever they find; by 4–5 years most children will know not to eat pills. When a young infant (not yet at the crawling stage) is brought, the facts of the story need to be very carefully obtained and a vigilant stance adopted.

Parents may misread instructions on a bottle and overdose a child but then the history is clear, whereas if parents deliberately overdose their child they will conceal the history. Children from 3 years are able to give a history and tell if they ‘ate grandpa's sweeties’ or if mummy gave them herself. Children as young as 6 years do deliberately overdose, but this is rare under 10 years. If any child or adolescent overdoses the reasons why must be explored.

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Intentional poisoning

See Table 1 for features of poisoning, whether due to accident, neglect or willful intent by care giver.

• Gray & Bentovim describe a case of a 2.5-year-old child with the highest ever reported salt levels in her system for which ‘only active administration of salt could account for this finding’.
• Rogers et al (1976) described deliberate poisoning of infants by salt, barbiturates, and other drugs. Two of the children in that study died of salt poisoning. There is considerable overlap, but the more bizarre the clinical situation the greater the likelihood of intentional poisoning, whether as an attempt to kill the child or factitious illness.
• Meadow's (1993) study of deliberate salt poisoning described 12 children with this condition. The children in this study presented below the age of 6 months. Ten children did well in alternative care; several of them additionally suffered from fabricated symptoms. Two of the children died. Meadow (1993) described 12 children who were diagnosed as having non-accidental salt poisoning: seven out of the 12 mothers admitted to the poisonings and explained how they had done this and two of the children died as a result.
• Drugs are also used to keep children quiet, for example the use of sedatives at night, or to make the child compliant, with high doses of anxiolytics.
• Drugs have been used to allow sexual abuse to occur.
• Adults who abuse drugs may also involve even very young children in their habit, and a child may present to hospital stuporous on the parent's heroin or methadone.
• There are many examples of children of all ages dangerously intoxicated with alcohol. This may be deliberate poisoning, or unsupervised drinking, often in a house where heavy drinking occurs.

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Urine Toxicology Pathway

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Contact Information

It is essential that the toxicology section is made aware as soon as possible that the sample is coming and that the result is needed urgently.  Failure to inform the lab or deliver the sample directly will lead to delayed sample processing.

Toxicology is based at Specialist Laboratory Medicine, Block 46 , St James Hospital, Beckett Street, LS9 7TF
Laboratory 66063 (main number), 64256, 66679, 64851
Sample reception 64195
Advanced Biomedical Scientists: James Booth & Bryan Hill 64204
Clinical Scientists: Dr Carys Lippiatt 67174 Dr Elizabeth Fox 64860
If toxicology section cannot be contacted, please contact the Duty Biochemist on 26922 (Option 2) or bleep 80-2607.
General Paediatrics Registrar phone 23927 or bleep 2111
Specialities Registrar bleep 1904
PICU Registrar via ward 27447
Paeds ED 25549

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