International Variability in Santiago Mintegi, MD, PhD,​a Stuart R. Dalziel, MBChB, PhD,​b Beatriz Azkunaga, MD, PhD,​a Javier Prego, MD,c​ Eunate GastrointestinalArana-Arri, MD,d​ Yordana Acedo, MD,​a Lorea Martinez-Indart, Decontamination MSC,d​ Javier Benito, MD, PhD,​a Nathan Kuppermann, e WithMD, MPH,​ on behalf Acute of the Pediatric PoisoningsEmergency Research Networks (PERN) Poisoning Working Group

BACKGROUND AND OBJECTIVES: abstract

Identifying international differences in the management of acute pediatric poisonings may help improve the quality of care. The objective of this study was to assess the international variation and appropriateness of gastrointestinal decontamination (GID) procedures performed in children and adolescents who present with acute poisonings METHODS: to emergency departments. This was an international, multicenter, cross-sectional prospective study including children <18 years with poisoning exposures presenting to 105 emergency departments in 20 countries from 8 global regions belonging to the Pediatric Emergency Research Networks. Data collection started between January and September 2013 and continued for 1 year. The appropriateness of GID procedures performed was analyzed using the American ’ Academy of Clinical Toxicology and the European Association of Poisons Centres and Clinical Toxicologists recommendations. Multivariate logistic regression was performed to RESULTS: identify independent risk factors for performing GID procedures. – We included 1688 patients, 338 of whom (20.0%, 95% confidence interval 18.1% 22.0%) underwent the following GID procedures: activated charcoal (166, 49.1%), – activated charcoal and gastric lavage (122, 36.1%), gastric lavage (47, 13.9%), and ipecac (3, 0.9%). In 155 (45.8%, 40.5% 51.2%), the GID procedure was considered appropriate, with significant differences betweenP regions. Independent risk factors for GID procedures included age, toxin category, mechanism of poisoning, absence of symptoms, and the region CONCLUSIONS: where the intoxication occurred ( < .001). Globally, there are substantial differences in the use and appropriateness of GID procedures in the management of pediatric poisonings. International best practices need to be better implemented. aPediatric Emergency Department, Cruces University Hospital, University of the Basque Country, Bilbao, What’s Known on This Subject: Thousands of children are Basque Country, Spain; bChildren’s Emergency Department, Starship Children’s Hospital and Liggins Institute, managed in emergency departments annually worldwide. The University of Auckland, Auckland, New Zealand; cDepartamento de Emergencia Pediátrica, Centro Hospitalario American Academy of Clinical Toxicology and the European d Pereira Rossell, Montevideo, Uruguay; Clinical Epidemiology Unit, Cruces University Hospital, BioCruces Health Association of Poisons Centres and Clinical Toxicologists previously e Research Institute, Basque Country, Spain; and Department of Emergency Medicine and Pediatrics, Davis have released statements on gastrointestinal decontamination School of Medicine, University of California, Sacramento, California (GID) procedures to guide evidence-based practice. Participating networks include the following: the Pediatric Emergency Care Applied Research What This Study Adds: This study demonstrates substantial Network, the Pediatric Emergency Medicine Collaborative Research Committee of the American international management differences in both the prehospital Academy of Pediatrics, Pediatric Emergency Research Canada, Pediatric Emergency Research and emergency department settings related to acute pediatric in the United Kingdom and Ireland, Pediatric Research in Emergency Departments International poisonings and specifically to GID procedures. When performed, Collaborative, and Research in European Pediatric Emergency Medicine. GID procedures were not appropriate in more than 50% of the Dr Mintegi conceptualized and designed the study, supervised data collection, analyzed the data, patients. and wrote the initial draft of the manuscript; Dr Azkunaga collaborated in the design of the data To cite: Mintegi S, Dalziel SR, Azkunaga B, et al. International Variability in Gastrointestinal Decontamination With Acute Poisonings. Pediatrics. 2017;140(2):e20170006

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 140, number 2, August 2017:e20170006 Article Globally, poisoning exposures remain We hypothesized that there would understanding of text, suitability of a major public health problem,1,2​ be significant differences in the data collection at all participating particularly in children. ‍ Each year, frequency of GID procedures that are sites, and to ensure clarity of the final tens of thousands of children are performed in children with poisoning data collection. All queries regarding evaluated and managed in emergency exposures among global regions. data collection were addressed by departments (EDs) around the The objective of this study was to 1 investigator (S.M.) to maintain world, frequently for unintentional assess the variation in frequency and consistency in the data collection ingestions of toxins that are appropriateness of GID procedures and quality. After patients were secondary to exploratory behavior that are performed in children and identified by ED physicians, the following demographic, clinical, and of young children and infants3 adolescents who present with acute within their environments. To our poisonings to EDs that are part of management data were collected via knowledge, no study has evaluated the Pediatric Emergency Research interviews of patients and caregivers: international practice variation Networks (PERN), which is a global age, sex, time of presentation to regarding the treatment of poisoning consortium of the major pediatric the ED, the toxin involved, the (specifically gastrointestinal mechanism of poisoning, amount emergency medicine research18 decontamination [GID]) or evaluated networks around the world. of time between poisoning and ED if its management across countries Methods presentation, the route of poisoning, is consistent with international the location of poisoning, previous guidelines. It is pressing to establish Design similar episodes, prehospital whether variation exists and measure management, clinical symptoms and practice against standards of care signs in the ED, management in the to guide local and global poisoning This was a cross-sectional study of ED, consultation with poison control knowledge-translation endeavors. childhood poisoning presentations centers, and patient disposition and outcome. The study questionnaires This is a critical step in improving from a prospectively collected, were completed by the physician the quality of care that is provided to international, multicenter registry responsible after ED discharge for poisoned children worldwide. involving 105 EDs from 20 countries in the PERN19 that used purposeful those patients who were discharged sampling. All children (<18 years from the hospital and after discharge Historically, preventing the of age) presenting for an acute for patients who were admitted to absorption of an ingested toxin poisoning exposure on the fourth, the hospital to ascertain complete by the gastrointestinal tract to 14th, and 24th days of every month patient information and ED and limit systemic toxicity was felt had specific electronic questionnaires hospital outcomes. The completed to be an appropriate, important completed via Google Drive. EDs questionnaires were then sent management strategy4 for many reported data over a 1-year period, electronically to the principal types of poisonings. The reduced thus collecting data for 36 days per investigator (S.M.). absorption concept led to several GID site (10% of the calendar year) with Countries were categorized according strategies including gastric lavage, data collection starting at the sites to the regional classification system administration of an adsorbent, between January and September of the World Health Organization and induced emesis. For the last 2 2013. The purposeful sampling on (Africa, the Americas, Southeast Asia, decades, the American Academy of 3 set calendar days per month for Europe, the Eastern Mediterranean, Clinical Toxicology and the European 1 calendar year allowed a large and the Western Pacific regions). Association of Poisons Centres and number of sites to participate Countries from the Americas were Clinical Toxicologists have released without an overwhelming research further divided into North and international consensus statements– burden and avoided bias because of South America, and those from on various GID strategies to guide seasonal variation or only sampling ’ 5 14 Europe were further divided per the evidence-based practice. ‍‍ In most on a specific day of the week. The United Nations Statistics Division s cases of poisoning exposure, the electronic poisoning-reporting classification into Northern, ingested toxicant has minimal or no system previously had been Southern, Western, and Eastern clinically important toxic effects, and successfully used by the Spanish Europe. so GID is not recommended. These Society of20 Pediatric Emergency recommendations, however, are not Medicine. Questionnaires, in We included children <18 years of always followed by physicians, and addition to a study manual of age. However, only 67 of the 105 EDs variation has been15 described both operations, were distributed to site (64%) evaluated patients >14 years in studies 16,of17​ EDs and in single investigators (ED physicians) before old, which reflects the variability in countries. ‍ the initiation of the study to confirm the upper age limit of patients who Downloaded from www.aappublications.org/news by guest on September 29, 2021 2 Mintegi et al Results are treated in different pediatric EDs a given toxin was considered to be around the world. appropriate if it was listed as such in During the study period, there were the Medical Toxicology Antidote Card Toxicants were categorized as 363245 pediatric ED presentations provided by the American College of follows: carbon monoxide, cosmetic, 21 to the 105 EDs on the 36 days that Medical Toxicology. therapeutic drugs, ethanol, ethanol Ethics and Human Subjects each site participated, of which and illicit drugs, pesticides, plants, 1727 were for poisoning exposures household products, other, and (0.48%). Of the 1727 episodes, 39 unknown. Mechanisms of poisoning We obtained overall approval (2.3%) were excluded because of were categorized as dosage errors, from the Clinical Research Ethics lack of required informed consent unintentional or accidental, Committee of the Basque Country. or because of episodes missed recreational, suicide attempt, and Approval for the study was granted prospectively. The underlying other. by the institutional review boards mechanisms of the remaining 1688 poisonings were as follows: 1157 The appropriateness of a GID and ethics committees at each (68.5%) unintentional poisonings, procedure was determined by 2 participating institution, which 233 (13.8%) suicide attempts, investigators (S.M. and J.B.) who determined if informed consent 180 (10.7%) recreational uses of a reviewed all patients who were was required by participants. When toxicant, 64 (3.8%) dosage errors, treated with GID procedures. required, informed consent was and 54 (3.2%) other mechanisms.– Disputes were resolved with a obtained from parents or guardians, consensus from a third investigator and informed assent obtained from In the ED, 832 (49.3%; 46.9% (S.R.D.). The appropriateness of participants when they were >12 51.7%) children received treatment – GID procedures was determined Syearstatistical old was Analysis deemed appropriate. for their poisoning. Of these, 338 according to the international (20.0%; 18.1% 22.0%) received consensus statements on various GID GID procedures with the following: procedures released by the American AC (166, 49.1%), AC and gastric We described qualitative variables Academy of Clinical Toxicology lavage (122, 36.1%), gastric lavage with frequency tables, percentages, and the European– Association (47, 13.9%), and ipecac (3, 0.9%). and 95% confidence intervals (CIs). of Poisons Centres and Clinical χ A nasogastric tube was used to 5 14 To compare categorical variables, we Toxicologists. ‍ We considered 2 administer the AC in 123 patients used the test. a single dose of activated charcoal (42.7% of those who received – (AC) to be appropriate after the We initially performed bivariate AC). In 155 patients (45.8%; ingestion of a toxicant except for logistic regression to evaluate 40.5% 51.2%), the GID procedure those known not to be bound by associations with the use of GID. was considered appropriate, with AC or when its use is clearly not When associations with performing significant differences across indicated (pesticides, potassium, a GID were found, those variables regions. South America, Eastern hydrocarbons, acids, alkali, alcohols, were included in a multivariate Europe, Southern Europe, and iron, insecticides,13 lithium, and logistic regression analysis that the Eastern Mediterranean had solvents). We considered multiple was performed to identify the low rates of appropriate use of doses of AC to be potentially independent risk factors for GID when compared with North appropriate for the ingestion of America, Western Europe, Northern performing a GID procedure.P antimalarial (quinine), dapsone, We included all variables with Europe, and the Western Pacific carbamazepine, phenobarbital, bivariate associations of < .10 in regions (Fig 1, Supplemental Table methylxanthines, phenytoin, 3). Independent risk factors for the multivariate stepwiseP model. digoxin, valproate, nadolol, sotolol, In the final multivariate analysis, GID procedures being performed phenylbutazone, thyroid, and only variables with values <.05 included the age of the patient, the salicylates. Gastric lavage was always remained in the model. We reported toxin category, the mechanism of deemed inappropriate except in the results of the modeling as poisoning, the method of poisoning, cases of potentially lethal ingestions odds ratios (ORs) and 95% CIs. the absence of symptoms, and when the toxin is known not to bind We calculated the area under the the (global) geographical region to AC. The combination of AC and where the intoxication occurred receiver operating characteristic – gastric lavage (and administration of curve for the final models. (area under the curve = 0.87 [95% ipecac syrup) was considered to be CI, 0.85 0.89]) (Table 1). Of these inappropriate. We also determined We performed all statistical analysis independent risk factors, the global the appropriateness of an antidote using SPSS Version 23.0 statistical region in which the intoxication for a given toxicant. An antidote for software (IBM, Armonk, NY). occurred had the largest effect Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 140, number 2, August 2017 3 FIGURE 1 GID procedures performed in the ED.

estimate, with ORs for GID procedure ICU, and suicidal patients who were Despite the cooperative efforts – use in Eastern Europe (12.8, 95% reviewed by psychiatric services) is – between European and North CI 6.5 25.3), South America (10.9, shown in Supplemental Table 5. An – – American Toxicology societies 95% CI 5.5 21.4), Southern Europe antidote was given to 116 children – and their recommendations for (8.2, 95% CI 4.4 15.1), and Eastern (6.9%; 95% CI 5.7% 8.1%), with developing international consensus Mediterranean (4.7, 95% CI 1.7 13.3) significant differences across regions, statements on compiling– the being compared with North America and it was considered appropriate evidence to guide GID and5 14 other (Table 1). in 109 cases (94.0%) (Table 2). No therapeutic strategies,​ ‍ we patients died. found great variability in the use Before ED presentation, 519 of GID procedures in our study. patients (30.7%) contacted health Discussion In addition, when performed, GID professionals, and 257 (15.2%) was not appropriate in >50% of received some treatment. Of these, the patients. Furthermore, our a GID procedure was performed definition of appropriate use of in 51 before arriving at the ED (AC Thousands of children and teenagers AC only considered if the ingested [35], gastric lavage [7], AC and with an acute poisoning are toxicant was known to be bound gastric lavage [9]). All of the gastric treated annually worldwide. Our to charcoal. Because of the limited lavages were performed in Europe, study demonstrates international data availability, we did not consider South America, and the Eastern variability in the GID procedures the time between ingestion and Mediterranean region. Of the GID performed on children with “ ” administration of charcoal in our procedures performed before ED poisoning exposure. Of note, the definition of appropriate,​ which presentation, 15 (29.4%) were region where the intoxication occurs potentially classified treatment as considered to be inappropriate was an independent risk factor for appropriate when the time between (Supplemental Table 4). performing a GID procedure. In addition, one-half of GID procedures ingestion and charcoal would Variability related to other aspects performed in the EDs were not have allowed for a clinically of ED management (tests practices, deemed to be inappropriate. This is meaningful effect. Of note, in some contact with poison control centers, particularly concerning and requires regions (such as South America, antidotes, admission to a ward or interventions to remedy. Eastern Europe, Southern Europe, Downloaded from www.aappublications.org/news by guest on September 29, 2021 4 Mintegi et al TABLE 1 Bivariate and Multivariate Analysis for the Identification of Risk Factors for Performing GID Procedures in the ED and the Eastern Mediterranean), Bivariate Multivariate it is common to combine gastric P OR (95% CI) OR (95% CI) lavage and the administration of AC despite the lack of evidence that this Region (ref North America) <.001 12,13​ South America <.001 5.392 (2.917 9.967) 10.895 (5.539 21.432) combination is useful. ‍ AC therapy – – Western Europe .215 0.578 (0.243–1.374) 1.116 (0.455–2.738) involves the oral administration or Eastern Europe <.001 4.009 (2.177–7.382) 12.848 (6.523–25.306) instillation by nasogastric tube of an Northern Europe .010 0.188 (0.053–0.668) 0.220 (0.061–0.792) Southern Europe <.001 4.139 (2.322 7.377) 8.167 (4.424 15.077) aqueous preparation 7of AC after the – – ingestion of a poison. Sometimes, Eastern Mediterranean .084 2.286 (0.894–5.843) 4.724 (1.674–13.332) Western Pacific .119 0.302 (0.067–1.362) 0.363 (0.079–1.672) the placement of a nasogastric tube Age (ref <1 y), y <.001 to administer AC may facilitate the 1–6 .002 2.784 (1.468–5.281) 2.577 (1.240–5.358) performance of a gastric lavage after 7–10 .397 1.485 (0.595–3.706) 1.441 (0.511–4.065) or before giving the AC, although ≥11 .160 1.613 (0.827–3.142) 1.575 (0.567–4.371) there is no evidence that supports Previous contact with other medical or .483 1.098 (0.845–1.427) — toxicology service (yes) this practice. Additionally, in Eastern Presence of symptoms (yes) <.001 0.501 (0.387–0.649) 0.536 (0.377–0.763) Europe, gastric lavage is the most Physical examination (altered) .001 0.595 (0.434–0.817) commonly used GID procedure in Method of poisoning (ref ingestion) <.001 the ED, although it is well recognized Inhalation <.001 0.028 (0.004–0.201) 0.104 (0.013–0.815) that gastric lavage should not be Other <.001 0.059 (0.008–0.429) 0.075 (0.010–0.587) 12 Mechanism of poisoning (ref <.001 performed routinely. On the unintentional) other hand, ipecac has been nearly Recreational <.001 0.242 (0.130–0.453) 2.032 (0.606–6.816) abandoned in EDs globally,14 as has Suicide attempt .210 1.234 (0.888–1.714) 1.851 (0.784–4.368) been recommended. Dosage error .101 0.532 (0.250–1.130) 0.345 (0.148–0.800) Other .407 1.303 (0.698–2.433) 1.921 (0.834–4.428) Toxin category (ref drugs) <.001 Furthermore, it should be noted Ethanol and/or illicit drugs <.001 0.076 (0.035–0.164) 0.070 (0.023–0.211) that the treatment of a child with Pesticides .717 0.901 (0.514–1.580) 0.523 (0.278–0.987) a poisoning exposure must begin Household products <.001 0.038 (0.0.17–0.087) 0.024 (0.010–0.056) as soon as possible, and GID Carbon monoxide .997 — — procedures may be performed in Other <.001 0.360 (0.146–0.526) 0.243 (0.157–0.377) Unknown .022 0.095 (0.013–0.709) 0.107 (0.013–0.892) the prehospital setting. The timing Contact with poison control center .251 1.161 (0.900–1.498) — of charcoal administration is crucial to its efficacy in oral overdose, and prehospital AC does not appear to markedly delay transport or arrival 22 or ambulances are only used to all are telephone based. In some of overdose patients into the ED. transport patients rather than to countries, poison centers may Although it is not appropriate for 23 “ initiate treatment. offer consultation only to medical many children, in our study, the ” personnel. In others, the poison rate of GID that was performed We also found significant center is a treating unit within a inappropriately was lower in the variability related to other aspects prehospital setting when compared of management in the ED. There hospital. In any case, increasing with the ED, perhaps because of the were differences in the use of the availability of poison control difficulties performing gastric lavage poison control centers, the types centers globally and encouraging in the out-of-hospital setting. In our of laboratory tests performed their use when a poisoning occurs study, one-third of the poisoned and antidotes administered, and may improve the quality and cost children and their families sought patient dispositions. Although effectiveness of the care provided to medical attention before going to poison control centers are effective these children. On the other hand, the the ED, mainly from prehospital gatekeepers for patients who are administration of an antidote may emergency medical services. This seeking treatment of poisonings, be critical to the management of a poisoned patient. Shortcomings in differed significantly by geographic and others have reported24 them to be region. These differences may highly cost-effective,​ they appear the types and quantities– of antidotes, reflect the regional epidemiology of to be underutilized in certain global antivenoms, and 25antitoxins28 have been poisonings and also the differences regions. The availability (and lack widely reported. ‍ In our series, an in how health services are organized of availability) of these centers infant with methemoglobinemia did globally. In some regions, it worldwide may explain some of not receive the antidote (methylene seems that medical vehicles and/ this variability. In the United States, blue) because of a lack of local Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 140, number 2, August 2017 5 TABLE 2 List of the Types, Uses, and Appropriateness of Antidotes Antidote Toxicant Appropriate since ingestion. It is likely that a Oxygen (40) Carbon monoxide (40) Yes number of GID procedures that N acetyl cysteine (37) Acetaminophen (37) Yes Biperiden (7) Antipsycotics (4) Yes were undertaken may have been Metoclopramide (2) Yes considered inappropriate because Antiepileptic drugs (1) Yes the time between ingestion and Naloxone (7) Opioids (6) Yes the GID procedure would make the Detergent (1) No Flumazenil (4) Benzodiazepine (2) Yes decontamination futile. Thus, our Atropine, propranolol, and barbiturate (1) No overall estimate of inappropriate Ketazolam, escitalopram, and otilonio bromuro No use of GID procedures is likely to (1) be underestimated. In addition, K vitamin (4) Pesticides (2) Yes the EDs involved in the study are Coumarin drugs (2) Yes Diphenhydramine (3) Antipsycotics (2) Yes members of PERN and are therefore Metoclopramide (1) Yes self-selected and may not be truly Hydroxocobalamin (2) Acrylonitrile Yes representative of all pediatric EDs Physostigmine (2) Antimuscarinic Yes globally. Nevertheless, the EDs Mixed scopolamine, hyoscyamine, and atropine Yes Dimercaptosuccinic acid (1) Lead Yes included both secondary and tertiary Pralidoxime (1) Organophosphate Yes EDs; pediatric, mixed pediatric, and Octreotide (1) Sulfonylurea Yes adult EDs; rural and urban EDs; and Glucose (1) Insuline Yes EDs with small and large volumes. Methotrexate (1) Folic acid Yes Therefore, it seems unlikely that self- Phytomenadione/phytonadione (1) Warfarin Yes Paraffin oil (1) Acetone No selection would have significantly Tropatepine (1) Risperidone No biased the results. On the other hand, Pseudoephedrine (1) Tadalafil No international differences related to Thiamine (1) Mixed ethanol and cannabis No poison control center availability and functionality, the availability of a telephone hotline for poisonings, and prehospital medical services availability. The infant received included was not the same in all may bias the number of children vitamin C and did well. Finally, global regions, thus data from the with poisonings who are brought suicide attempts are the most Eastern Mediterranean and Western to the EDs by region. However, this common mental health29 emergencies Pacific regions need to be interpreted possibility does not limit the analysis among adolescents. A first self- with this in mind. However, the of the management of children with poisoning episode is a strong sample was sufficiently large to poisonings presenting to EDs across predictor of subsequent30 suicide and detect important differences in GID broad regions of the globe. premature death. Consultation with procedures between regions and psychiatrists and/or mental health fulfill the main objective of the study. Globally, there are substantial professionals also showed great One-third of the participating EDs management differences in both variability. only see children >14 years of age. the prehospital and ED settings Nevertheless, all of these The types of poisoning and their related to acute poisonings in recommendations to improve the severity differ significantly between children and specifically to GID quality of care (such as harmonized young children and adolescents, and procedures. When performed, GID best practices for childhood this might bias the analysis of the procedures were inappropriate in poisoning [specifically GID], better use of GID procedures. Nevertheless, >50% of the patients. Predictors of access to and utilization of poison this does not alter the analysis of the receiving GID procedures included control centers, availability of appropriateness of the procedure, the global geographic region, the age prehospital medical services and and the geographical region in which of the patient, the toxin category, advice hotlines, more mental health the poisoning exposure occurred the mechanism of poisoning, evaluation referrals, and better was an independent risk factor for and the absence of symptoms. antidote stocking) require specific GID procedures in the multivariate International best practices need to resources that have to be allocated by analysis. Appropriateness of GID be identified for the management countries, and they need political and procedures was determined solely of acute pediatric poisonings and, social willpower to be realized. on the basis of the appropriateness specifically, GID procedures. Our This study has several limitations. of the GID for a given toxin study also highlights the importance The number and percentage of EDs without consideration of the time of international research networks Downloaded from www.aappublications.org/news by guest on September 29, 2021 6 Mintegi et al ’ á to perform such broad and Bradin (C.S. Mott Children s Hospital, Donna e del Bambino, Azienda generalizable studies. Ann Arbor, Michigan). Ospedaliera-Universit di Padova); Acknowledgments The Pediatric Emergency Medicine Stefania Norbedo (IRCCS Burlo Collaborative Research Committee of Garofolo, Trieste); Renna Salvatore the American Academy of Pediatrics, and Carla Debbia (IRCCS G. Gaslini Genova); Alberto Arrighini (Ospedale When the study was approved, United States; Arnold Palmer Hospital for Children emergency dei Bambini Brescia); Patrizia executive committee members of Botarelli (DEA Meyer Firenze); the PERN included the following: department; and Jose Ramirez and ù Samuel Stephenson (Florida). Mara Pisani (IRCCS IRCCS Ospedale Nathan Kuppermann, MD, MPH pediatrico Bambino Ges Roma); (Pediatric Emergency Care Applied Paediatric Research in Emergency and Eduardo Ponticiello and Enzo Research Network, United States); Departments International Tipo (Ospedale Santobono, Napoli). Collaborative. In Australia: Anna á Javier Benito, MD, PhD (Research ’ In the Netherlands: Henriette Moll in European Paediatric Emergency Carison and Franz E. Babl (The Royal (Sophis Children Hospital). In Medicine, Spain); Yehezkel Waisman, Children s Hospital and Murdoch Portugal: Xavier Bilhota (Centro MD (Research in European Childrens Research Institute, Hospitalar Leiria Pombal); Ana Paediatric Emergency Medicine, Melbourne); Simon Craig (Monash Garrido (Centro Hospitalar Vila í çã Israel); Martin Osmond, MD, CM Medical Centre, Melbourne); Andis Nova de Gaia, Vila Nova de Gaia); Lia á — (Pediatric Emergency Research Graudins (Dandenong Hospital, Gata and Patr cia Ma o (Hospital á í Canada, Canada); David Johnson, Melbourne); John Cheek (Casey Pedi trico Centro Hospitalar e MD (Pediatric Emergency Research Hospital, Melbourne); and Stuart R. Universit rio de Coimbra); Sof a ’ ú á Canada, Canada); James Chamberlain, Dalziel and Megan Bonish (Starship Costa Lima (Hospital Beatriz Angelo í MD (Pediatric Emergency Care Children s Hospital, Auckland, New [Lisboa]); and Gabriela Ara jo e S í Applied Research Network, United Zealand). and Sof a Almeida (Hospital de Santa States); Charles G. Macias, MD, MPH Research in European Paediatric Mar a [Lisboa]). In Romania: Mihai (Pediatric Emergency Medicine Emergency Medicine. In Belgium: Gafencu and Alina Babeu (Emergency Collaborative Research Committee, Patrick Van de Voorde and Said Children Hospital Louis Turcanu, United States); Anupam Kharbanda, Timisoara); Diana Moldovan Hachimi Idrissi (University Hospital í MD (Pediatric Emergency Medicine Ghent). In the Czech Republic: (Hospital Tirgu Mures, Romania); Collaborative Research Committee, Alexandra Petrovska (University and Daniela Mar a Mitrofan (Hospital United States); Franz E. Babl, MD Hospital Motol, Prague). In France: for Children Cluj, Napoca). In Spain: ô (Paediatric Research in Emergency Jean Christophe Mercier and Francisco Javier Humayor Yanez é é é Departments International Laurence Morin (H pital Robert (Basurto University Hospital, Collaborative, Australia); and Stuart Bilbao); Ana Gloria Andr s Andr s Debr , Paris) and Gerard Cheron ó á ñ Dalziel, MBChB, PhD (Paediatric (Necker Enfants Malades Hospital, (Complejo Asistencial Universitario “ ” é Research in Emergency Departments de Le n); Tom s del Campo Mu oz Paris). In Hungary: Eva Szabo and í International Collaborative, New Richard Nagy ( Csolnoky Ferenc (Complejo Hospitalario de Ja n); ’ ó à Zealand). Roc o Mendivil and Irene Baena Teaching Hospital, Veszprem); í á Zsolt Bognar (Heim Pal Children s Olomi (Corporaci Sanit ria Parc PERN intoxications working group “ ” é ó Hospital, Budapest); Gabor Simon Taul de Sabadell); Jordi F brega i site investigators included the ö ’ ( Szent Gyorgy Teaching Hospital, Sabat (Fundaci Sant Hospital de following: É á La Seu d Urgell); Itziar Iturralde Szekesfehervar); and Gy rgy Balla ó Orive (Hospital Alto Deba); Andreu Pediatric Emergency Care Applied and va Juh sz (University of á Debrecen, Debrecen). In Ireland: Roca (Hospital de Terrassa); Ram n Research Network. In the United ’ ñ ó Fern ndez (Hospital Universitario States: Nathan Kuppermann and Ciara Martin and Rincy Koshy í (National Children s Hospital, de Cabue es, Gij n); Ana Jorda Mark Sutter (University of California, ’ í Davis School of Medicine); Daniel Tallaght, Dublin 24) and Roisin Mc Lope and V ctor Canduela (Hopsital ’ de Laredo); Sof a Mesa (Hospital Cohen and Julia Lloyd (Nationwide Namara (Temple Street Children s í Children s Hospital and The Ohio University Hospital, Temple Street, Universitario 12 de Octubre); Carlos ’ á Dublin 1). In Israel: Yehezkel (Hezi) Garc a-Vao Bel (Hospital del Tajo); State University); Elizabeth Duffy ’ ó ó Waisman and Lisa Amir (Schneider Alberto Barasoain Mill n (Hospital and Prashant Mahajan (Children s ´ Hospital of Michigan, Detroit, Children s Medical Center of Israel). Fundaci n Alcorc n); Laura Herrero ’ (Hospital Mendaro); Carmen Campos Michigan); George Sam Wang In Italy: Liviana Da Dalt (Ca Foncello ñ (Children s Hospital Colorado, Hospital, Treviso); Carlo Moretti Calleja (Hospital Miguel Servet); Aurora, Colorado); and Stuart A. (Dipartimento della Salute della Juan Carlos Molina (Hospital Ni o Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 140, number 2, August 2017 7 ú Á í í Jes s); Maria ngeles Garc a Herrero and Sergio Manzano (University de Resistencia Chaco, Chaco). In Brazil: á (Hospital Pr ncipe de Asturias, Hospitals of Geneva). In Turkey: Francisco Bruno (Hospital Sao Lucas ó ó Alcal de Henares, Madrid); Carlos Eylem Ulas Saz and Ali Yurtseven de PUCRS [Pontificie Universidade é Canduela (Hospital Quir n Bizkaia); (Ege University School of Medicine, Cat lica do Rio Grande do Sul]). In ó á Pablo Bello Guti rrez (Hospital Rey Izmir); Murat Anil (Izmir Tepecik Paraguay: Laura Godoy and Viviana í ñ Ñ Juan Carlos, M stoles); Roberto Teaching and Research Hospital, Pavlicich (Hospital General Pedi trico í á Velasco (Hospital R o Hortega); Lidia Izmir); and Sinan Oguz, Deniz Tekin, Ni os de Acosta u, San Lorenzo). In é í é Mart nez S nchez (Hospital San Joan and Funda Kurt (Ankara University Uruguay: Wilfredo Casella (Centro ñ de D u); Laura Mart nez Mengual Faculty of Medicine, Ankara). In the Comero, Cooperativa M dica de á í á ’ ó ñ United Kingdom: Mary Ryan and Abi Rocha); Gustavo Alberto Giachetto (Hospital San Pedro [Logro o]); í é Juli n Rodr guez Su rez (Hospital Hoyle (Alder Hey Children s NHS Larraz (Asociaci n Espa ola Primera Foundation Trust, Liverpool); Mark en Salud); Mar a In s Ferreira (Casa Universitario Central de Asturias); ú Santiago Mintegi and Nerea Salmon D. Lyttle and Sarah Potter (Bristol Galicia); Adriana Pedemonti and Á ñ ’ é (Hospital Universitario Cruces); Royal Hospital for Children, Bristol); Estela Ant nez (Centro de Asistencia ó ’ á Jose ngel Mu oz Bernal (Hospital and Rodrick Babakhanlou (St. Mary s del Sindicato M dico del Uruguay); Á Universitario Donostia); Javier L pez Hospital, Newport). Patricia Dall Orso (Hospital Brit nico, á ó á Servicio de Emergencia Pediatrica); vila (Hospital Universitario de ó Salamanca); Paula V zquez L pez Other participating sites and Mariana M s and Patricia Torello ñó ó (Hospital Universitario Gregorio investigators include the following: (Hospital Militar); Ver nica Parodi and á Mara n); Elena May (Hospital Red de Investigaci n y Desarrollo Soledad Pandolfo (Hospital Policial); é í Universitario Mutua Terrassa); Juan de la Emergencia Pedi trica de Javier Prego (Hospital Pereira-Rosell, í ó ñ “ ì Cozar Olmo (Hospital Universitario Latinoam rica. In Argentina: Sandra Montevideo); Loreley Garc a Gariglio ” é San Agust n, Linares); Victoria L pez Cagnasia (Hospital de Ni os V ctor (Centro Asistencial Medico del Oeste ñ Corominas (Hospital Universitario J. Vilela de Rosario); H ctor Berzel de Colonia); Edit Arreseigor, Humberto í ó í “ é ” é ú Son Espases, Palma de Mallorca); and Elda Cargnel (Hospital de Ni os Gugliemone, and Lourdes Yemini Mar a Tall n Garc a (Hospital Ricardo Guti rrez Buenos Aires); (Sociedad M dico Quir rgica de Salto). é ñ í Universitario Xeral de Vigo); Esther Eugenia Gordillo and Nilda Gait And in Pakistan: Nadeem Qureshi and é á ó í Crespo Rup rez (Hospital Virgen de (Hospital del Ni os de la Sant sima Jabeen Fayyaz (Agha Khan University é la Salud); Amalia P rez S ez (Hospital Trinidad, C rdoba); Marta Mar a Hospital, Karachi). ó Zumarraga); Monica Sancosmed M ndez and Adriana I. Haas (Hospital ’ Abbreviations Ron and Pablo Velasco Puy (Vall Nacional Profesor Alejandro Posadas); d Hebron University Hospital, Maria Graciela Quevedo and Maria Barcelona); Judith Mesa (Canarias Macarena Parot Varela (Hospital AC: activated charcoal University Hospital, Tenerife); Neus Italiano de Buenos Aires); Marcela í á CI: confidence interval Pociello (Hospital Arnau de Vilanova, Regnando (Hospital de la ciudad Ú í “ ED: emergency department Lleida); and Mar a Gal n Mercado de Trelew); Pedro Bonifacio Rino ’ ” ó GID: gastrointestinal (Hospital de beda). In Switzerland: (Hospital de Pediatr a Prof Dr Juan P. é decontamination Michelle Seiler (Children s Hospital, Garrahan ); Ver nica Torres Cerino ô ’ é OR: odds ratio Zurich); C line Rey-Bellet Gasser and (Hospital Universitario Austral, á PERN: Pediatric Emergency Anne Pittet (H pital de l Enfance, Buenos Aires); and H ctor Tobares Research Networks Lausanne); and Alain Gervaix (Hospital Pedi trico Dr, Av. Castelan collection system, had oversight responsibility of data collection from all participating sites, and critically revised the manuscript; Dr Prego was the coordinator of the study in South America and critically revised the manuscript; Dr Dalziel was the coordinator for the Western Pacific region, revised various versions of the initial manuscript, and critically revised the final manuscript; Dr Arana-Arri and Ms Martinez-Indart (statistician) collaborated in the design of the study, analyzed the data, and critically revised the manuscript; Dr Acedo collaborated in obtaining the data regarding poisonings from the participating sites and critically revised the manuscript; Dr Benito revised the design of the study, drafted the initial manuscript, and critically revised the manuscript; Dr Kuppermann was the coordinator for North America, revised multiple versions of the initial manuscript, and critically revised the final manuscript; and all authors approved the final manuscript as submitted. DOI: https://​doi.​org/​10.​1542/​peds.​2017-​0006 Accepted for publication May 1, 2017 Address correspondence to Santiago Mintegi, MD, PhD, Pediatric Emergency Department, Cruces University Hospital, Plaza de Cruces s/n, E-48903 Barakaldo, Bizkaia, Spain. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Downloaded from www.aappublications.org/news by guest on September 29, 2021 8 Mintegi et al Copyright © 2017 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

References 1. Holder Y, Matzopoulos R, Smith N, et al, Toxicologists. J Toxicol Clin Toxicol. emergency department. Pediatr Emerg eds. World Report on Child Injury 1997;35(7):743–752 Care. 2004;20(8):493–498 Prevention. Geneva, Switzerland: World 9. American Academy of Clinical 16. Reid SM, Neto GM, Clifford TJ, Health Organization and UNICEF; 2008. Toxicology and European Association Randhawa N, Plint A. Use of single- Available at: http://​whqlibdoc.​who.​int/​ of Poison Centres and Clinical dose activated charcoal among publications/​2008/​9789241563574_​eng.​ Toxicologists. Position statement Canadian pediatric emergency pdf. Accessed May 29, 2017 and practice guidelines on the use physicians. Pediatr Emerg Care. 2. Mbeledogu CN, Cecil EV, Millett C, of multi-dose activated charcoal in 2006;22(10):724–728 Saxena S. Hospital admissions for the treatment of acute poisoning. 17. Mintegi S, Fernández A, Alustiza J, et al. unintentional poisoning in preschool American Academy of Clinical Emergency visits for childhood children in England; 2000-2011. Arch Toxicology; European Association poisoning: a 2-year prospective Dis Child. 2015;100(2):180–182 of Poisons Centres and Clinical multicenter survey in Spain. Pediatr Toxicologists. J Toxicol Clin Toxicol. 3. Franklin RL, Rodgers GB. Unintentional Emerg Care. 2006;22(5):334–338 1999;37(6):731–751 child poisonings treated in 18. Klassen TP, Acworth J, Bialy L, et al; United States hospital emergency 10. Buckley NA, Eddleston M. The PERN. Pediatric emergency research departments: national estimates revised position papers on gastric networks: a global initiative in of incident cases, population- decontamination. Clin Toxicol (Phila). pediatric emergency medicine. Pediatr based poisoning rates, and 2005;43(2):129 130 – Emerg Care. 2010;26(8):541–543 product involvement. Pediatrics. 11. Thanacoody R, Caravati EM, Troutman 19. Mintegi S, Azkunaga B, Prego 2008;122(6):1244–1251 B, et al. Position paper update: whole J; Pediatric Emergency Research 4. Greene S, Harris C, Singer J. bowel irrigation for gastrointestinal Networks (PERN) Poisoning Gastrointestinal decontamination of decontamination of overdose patients. Working Group, et al. International the poisoned patient. Pediatr Emerg Clin Toxicol (Phila). 2015;53(1):5–12 epidemiological differences in Care. 2008;24(3):176 186, quiz 187 189 – – 12. Benson BE, Hoppu K, Troutman WG, acute poisonings in pediatric 5. Krenzelok EP, McGuigan M, Lheur P. et al; American Academy of Clinical emergency departments [published Position statement: ipecac syrup. Toxicology; European Association online ahead of print January 24, American Academy of Clinical of Poisons Centres and Clinical 2017]. Pediatr Emerg Care.10.1097/ Toxicology; European Association Toxicologists. Position paper update: PEC.0000000000001031 of Poisons Centres and Clinical gastric lavage for gastrointestinal 20. Azkunaga B, Mintegi S, Bizkarra I, Toxicologists. J Toxicol Clin Toxicol. decontamination. Clin Toxicol (Phila). Fernández J; Intoxications Working 1997;35(7):699–709 2013;51(3):140–146 Group of the Spanish Society of 6. Vale JA. Position statement: gastric 13. Chyka PA, Seger D, Krenzelok EP, Vale Pediatric Emergencies. Toxicology lavage. American Academy of Clinical JA; American Academy of Clinical surveillance system of the Spanish Toxicology; European Association Toxicology; European Association Society of Paediatric Emergencies: of Poisons Centres and Clinical of Poisons Centres and Clinical first-year analysis. Eur J Emerg Med. Toxicologists. J Toxicol Clin Toxicol. Toxicologists. Position paper: single- 2011;18(5):285–287 1997;35(7):711–719 dose activated charcoal. Clin Toxicol 21. American College of Medical (Phila). 2005;43(2):61 87 7. Chyka PA, Seger D. Position statement: – Toxicology. Medical toxicology antidote card. Available at: www.​acmt.​net/_​ single-dose activated charcoal. 14. Höjer J, Troutman WG, Hoppu K, et al; American Academy of Clinical American Academy of Clinical Library/​Membership_​Documents/​ Toxicology; European Association Toxicology; European Association ACMT_​Antidote_​Card_​May_​2015.​pdf. of Poisons Centres and Clinical of Poison Centres and Clinical Accessed June 6, 2016 Toxicologists. J Toxicol Clin Toxicol. Toxicologists. Position paper update: 22. Villarreal J, Kahn CA, Dunford JV, 1997;35(7):721–741 ipecac syrup for gastrointestinal Patel E, Clark RF. A retrospective decontamination. Clin Toxicol (Phila). review of the prehospital use of 8. Barceloux D, McGuigan M, Hartigan-Go 2013;51(3):134 139 activated charcoal. Am J Emerg Med. K. Position statement: cathartics. – 2015;33(1):56 59 American Academy of Clinical 15. Osterhoudt KC, Alpern ER, Durbin – Toxicology; European Association D, Nadel F, Henretig FM. Activated 23. Salazar J, Zubiaur O, Azkunaga B, et al. of Poisons Centres and Clinical charcoal administration in a pediatric Intoxication Working Group of Spanish

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 140, number 2, August 2017 9 Society of Pediatric Emergencies. 26. Dar t RC, Stark Y, Fulton B, provide emergency care. Ann Emerg Prehospital care of the pediatric Koziol-McLain J, Lowenstein Med. 2009;54(3):386–394.e1 poisonings in Spain [in Spanish]. SR. Insufficient stocking of 29. King CA, Kerr DCR, Passarelli MN, Emergencias. 2017;29:178–181 poisoning antidotes in Foster CE, Merchant CR. One-year 24. Dar t RC, Bronstein AC, Spyker DA, hospital pharmacies. JAMA. follow-up of suicidal adolescents: et al. Poisoning in the United States: 1996;276(18):1508–1510 parental history of mental health 2012 emergency medicine report 27. Martínez Sánchez L, Mintegi S, problems and time to post- of the National Poison Data System. Molina Cabañero JC, Azkunaga B. hospitalization attempt. J Youth Ann Emerg Med. 2015;65(4): Quality of emergency care for acute Adolesc. 2010;39(3):219–232 416–422 poisoning in children. Emergencias. 30. Finkelstein Y, Macdonald EM, Hollands 25. Fountain JS, Sly B, Holt A, MacDonell S. 2012;24:380–385 S, et al; Canadian Drug Safety and Availability of antidotes, antivenoms, 28. Dar t RC, Borron SW, Caravati EM, et al; Effectiveness Research Network and antitoxins in New Zealand Antidote Summit Authorship Group. (CDSERN). Risk of suicide following hospital pharmacies. N Z Med J. Expert consensus guidelines for deliberate self-poisoning. JAMA 2015;128(1411):23–33 stocking of antidotes in hospitals that Psychiatry. 2015;72(6):570–575

Downloaded from www.aappublications.org/news by guest on September 29, 2021 10 Mintegi et al International Variability in Gastrointestinal Decontamination With Acute Poisonings Santiago Mintegi, Stuart R. Dalziel, Beatriz Azkunaga, Javier Prego, Eunate Arana-Arri, Yordana Acedo, Lorea Martinez-Indart, Javier Benito, Nathan Kuppermann and on behalf of the Pediatric Emergency Research Networks (PERN) Poisoning Working Group Pediatrics 2017;140; DOI: 10.1542/peds.2017-0006 originally published online July 20, 2017;

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/140/2/e20170006 References This article cites 28 articles, 2 of which you can access for free at: http://pediatrics.aappublications.org/content/140/2/e20170006#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Emergency Medicine http://www.aappublications.org/cgi/collection/emergency_medicine_ sub Environmental Health http://www.aappublications.org/cgi/collection/environmental_health_ sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 29, 2021 International Variability in Gastrointestinal Decontamination With Acute Poisonings Santiago Mintegi, Stuart R. Dalziel, Beatriz Azkunaga, Javier Prego, Eunate Arana-Arri, Yordana Acedo, Lorea Martinez-Indart, Javier Benito, Nathan Kuppermann and on behalf of the Pediatric Emergency Research Networks (PERN) Poisoning Working Group Pediatrics 2017;140; DOI: 10.1542/peds.2017-0006 originally published online July 20, 2017;

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/140/2/e20170006

Data Supplement at: http://pediatrics.aappublications.org/content/suppl/2017/07/18/peds.2017-0006.DCSupplemental

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2017 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

Downloaded from www.aappublications.org/news by guest on September 29, 2021