Rebecca Karb, MD
Emergency Medicine resident,
Brown University, Department of Emergency Medicine

More than 70,000 children are evaluated in Emergency Departments each year for unintentional medication and poison exposures¹. Children under 6 are at particularly high risk of unintentional ingestions. In 2014, there were more than 1 million calls to Poison Control Centers for unintentional exposures in children under 6 years old, accounting for nearly half of all calls to Poison Control². Fortunately, despite their high rate of exposure, children under 6 only account for 1.4% of all exposure-related fatalities2. While children ingest a variety of things, they often do not ingest large quantities. Therefore, providers must be familiar with common drugs and household items that can be fatal to small children in very small doses. The following tables present prescriptions medications, over the counter formulations, and common household products that can be fatal to a 10 kg child³.

Prescription Medications

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Drug	Potentially Fatal Dose (mg/kg)	Highest Dose Available (mg)	Mechanism of Toxicity	Signs/Symptoms of Toxicity
Calcium Channel Blockers	15	360	Myocardial suppression	PR prolongation, bradydysrhythmias, hypotension, CHF
Tricyclic Antidepressants	15	150	Na channel blockade, alpha 1 blockade	Coma, seizures, tachycardia followed by hypotension and bradydysrhythmias
Antimalarials	20	500	Na channel blockade, direct retinal damage	Prolonged QRS/QT, torsades, hypotension, tinnitus, vision loss, headache, vertigo, seizures
Opiates
Codeine	10	60	Respiratory depression	Miosis, CNS depression, hypopnea
Hydrocodone	1-5	30
Methadone	1-2	40
Fenatyl Patch	1-2mcg	300mcg/hr
Sulfonylureas	0.1	10	Activates insulin release	Hypoglycemia, irritability, lethargy, seizures and coma
Class 1 Antiarrhythmics	25	1 50	Na channel blockade	prolonged PR/QRS, QT (Class 1A agents), headache, nausea/vomiting

Adapted from: Bar-Oz B, Levichek Z, Koren G. Medications That Can Be Fatal For a Toddler with One Tablet or Teaspoonful A 2004 Update. Pediatric Drugs, 2004; 6(2): 123-126

OTC and Household Products

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Drug	Commonly Found In	Fatal Dose (mg/kg)	Highest [ ] Available	Mechanism of Toxicity	Signs/Symptoms of Toxicity
Camphor3	Vaporub, Orajel, Tigerbalm	50	550mg/tsp	Unknown mechanism of neurotoxicity	Nausea, vomiting, agitation, myoclonus, hyperreflexia, intractable seizures
Oil of Wintergreen (Methyl Salicylate)3,4	Icy Hot, pure essential oil	400	7g/tsp	Organic ester, crosses BBB and interferes with cellular metabolism	Mixed respiratory alkalosis/metabolic acidosis, vertigo, AMS, coma, pulmonary edema
Liquid Nicotine5	Vaping solution	1-13	35mg/ml	nAChR agonist at low doses, mAChR agonist at higher doses	Biphasic pattern: hypertension, tachycardia, vomiting, followed by autonomic ganglionic blockade, hypotension, bradycardia, coma
Selenium Dioxide6	Gun bluing solution	7	25mg/ml	oxidative stress, direct myocardial depression	Hypotension, prolonged QT, Pulmonary edema, delirium, coma
?	Laundry Detergent Pods8,9	?	?	?	Nausea/vomiting, followed by respiratory and CNS depression.

References:

1. Schillie SF, Shehab N, Thomas KE, Budnitz DS. Medication overdoses leading to emergency department visits among children. Am J Prev Med 2009;37:181-7.
2. Mowry JB, Spyker DA, Brooks DE, McMillan N, Schauben JL. 2014 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 32nd Annual Report Clinical Toxicology, 2015; 53(10): 962-1147
3. Bar-Oz B, Levichek Z, Koren G. Medications That Can Be Fatal For a Toddler with One Tablet or Teaspoonful A 2004 Update. Pediatric Drugs, 2004; 6(2): 123-126
4. Davis JE. Are one or two dangerous? Methyl salicylate exposure in toddlers. The Journal of Emergency Medicine, 2007; 32(1): 63-69
5. Bassett RA, Osterhoudt K, Brabazon T, Nicotine Poisoning in an Infant. N Engl J Med, 2014; 370:2249-2250
6. Chomchai C1, Sirisamut T, Silpasupagornwong U. Pediatric fatality from gun bluing solution: the need for a chemical equivalent of the one-pill-can-kill list. J Med Assoc Thai, 2012; 95(6):821-4.
7. Kim, Ji Won MD; Baum, Carl R. Liquid Nicotine Toxicity. Pediatric Emergency Care, 2015; 31(7): 517–521
8. Bonney AG, Mazor S, Goldman RD. Laundry detergent capsules and pediatric poisoning. Canadian Family Physician, 2013; 59.
9. Stromber PE, Burt MH, Rose SR, et al. Airway compromise in children exposed to single-use laundry detergent pods: a poison center observational case series. American Journal of Emergency Medicine, 2014; 33(3):  349–351

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