Project: Ghana Emergency Medicine Collaborative

Document Title: Toddler Toxicology: Drugs That Can Kill a Child With One

Pill or Swallow

Author(s): Joe Lex, MD, FACEP, FAAEM, (Temple University) 2013

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Toddler Toxicology: Drugs That Can Kill a Child with

One Pill or Swallow

Joe Lex, MD, FAAEM Temple University School of Medicine

Philadelphia, PA

How Far We’ve Come

• 1950: >400 pediatric overdose deaths

• 2003: 34 fatalities from overdose in children <6 years

• Can we be smug??

Peak Incidence: 1 to 3

• Attracted to toxic substances based on color or appearance of agent or container

• More willing to taste dangerous substances

• Hand-mouth behavior nearly 10 times / hour

Peak Incidence: 1 to 3

• Physical environment change plays significant role

• Half of accidental poisonings due to product in use at time of ingestion or recently moved from usual storage site

• Top category: cosmetics and personal care products

Peak Incidence: 1 to 3

• Plants also popular

• Amounts ingested by toddlers small

• Ingestion of toxic substance usually results in nontoxic or minimally toxic outcomes

Poison Hunting on eBay

10 month hunt on eBay

• 121 products identified

• 24 “supertoxic”: strychnine, arsenic trioxide, cyanide, etc.

• 63 “extremely toxic”

• 21 “very toxic”

• 13 “moderately-slightly toxic”

Cantrell FL. Clin Toxicol. 2005;43(5):375-9.

Baby Proof Home

“I baby-proofed my home, but the kids still somehow

manage to get inside.”

Gideon Koren’s Article

Koren G. Medications which can kill a toddler with one tablet or spoonful. Clin Toxicol 1993;31:407–13

• Identified medicines lethal to 10-kg child in single pill or swallow

Interest Builds

Liebelt EL,et al. Small doses, big problems: a selected review of highly toxic common medications. Pediatr Emerg Care 1993;9:292–7.

Interest Builds

Michael JB, Sztajnkrycer MD. Deadly pediatric poisons: nine common agents that kill at low doses. Emerg Med Clin North Am. 2004 Nov;22(4):1019-50.

Interest Builds

Matteucci MJ. One pill can kill: assessing the potential for fatal poisonings in children. Pediatr Ann. 2005 Dec; 34(12):964-8.

Gideon Koren’s Return

Bar-Oz B, Levichek Z, Koren G. Medications that can be fatal for a toddler with one tablet or teaspoonful: a 2004 update. Paediatr Drugs. 2004; 6(2):123-6.

Some Assumptions

• Assume healthy toddler with bodyweight 10 kg and normal drug metabolism

• Use lowest described fatal dose from literature

• Use maximal dose unit available

Major Miscreants

• TCAs

• Antimalarials

• Antipsychotics

• Anti-arrhythmics

• Methyl salicylate

• Oral hypoglycemics

• Calcium channel blockers

• Theophylline

• Narcotics

• Camphor

Liquids

Cydone, Wikimedia Commons

Camphor

Camphor – A Case Study

• Multiple pediatric deaths

• AAP editorial in 1978: Camphor: Who Needs It?

• 20% camphorated oil removed from US pharmacies

• OTC camphor concentration limited to 11% in OTCs Camphor: Who needs it? Pediatrics. 1978 Sep;62(3):404-6.

Camphor

• Topical rubefacient: induces local hyperemia, warmth

• Analgesic, antipruritic, and antitussive agent

• Variety of OTC liniments: Vick’s VapoRub, Ben-Gay, Absorbine, Tiger Balm

Camphor

• Aromatic terpene ketone derived from plants

• Distinct odor, pungent taste

• Some cultures use in cooking

• As little as 700 to 1000 mg fatal

AAP Policy Statement. Pediatrics 1994;94:127.

Camphor

• 7805 cases of topical camphor ingestion in children younger than age 6 reported to poison control centers in US in 2001

• Deaths rare since loss of 20% oil

Camphor

• Cause of death: respiratory depression, status epilepticus

• 3-year-old ingested 15mL Vicks VapoRub® seizures, coma, respiratory depression – 700 mg of camphor

Ruha AM, et al. Acad Emerg Med 2003;10:691.

Camphor

• 2-year-old ingested 10mL Campho-Phenique

• Seizures in 10 minutes, then coma, respiratory depression lasting 24 hours

Gibson DE, et al. Am J Emerg Med 1989;7:41–3.

Vicks VapoRub® Cream

Tatsuo Yamashita, Flickr

Campho-Phenique® (10.8%)

• Pain relieving antiseptic liquid

• For insect bites, scrapes & minor burns

Today

• 1996: 9,387 camphor exposures reported to AAPCC

• 7404 in children under 6 years

• NO deaths reported

• Virtually eliminated as a source of lethality in this country

Methyl Salicylate

Salicylates

• Present in numerous over-the-counter products

– Aspirin (acetylsalicylic acid)

– Oil of wintergreen (methyl salicylate)

– Pepto-Bismol (bismuth subsalicylate)

Methyl Salicylate

• Methyl ester of salicylic acid

• Oil of wintergreen

• Deceptively toxic

• Minimal toxic ingested dose in children: 150 mg/kg

Methyl Salicylate

• Betula oil

• Panalgesic

• o-hydroxybenzoic acid methyl ester

• Gaultheria oil

• Methyl o-hydroxy -benzoate

• Sweet birch oil

• Teaberry oil

• Analgit

• Exagien

• Flucarmit

• 2-(methoxy carbonyl)-phenol

• Anthrapole ND

• 2-carbo-methoxyphenol

• Methyl hydroxybenzoate

• Linsal

• Metsal Liniment

Methyl Salicylate

• One teaspoon of 98% methyl salicylate contains 7000 mg of salicylate

• Equivalent to 90 baby aspirin

• > 4 times potentially toxic dose for 10-kg child

Methyl Salicylate

• Therapeutic serum ASA for analgesia: 15 to 30 mg/dL

• Signs and symptoms of toxicity: >30 mg/dL

• Life-threatening levels: >100 mg/dL

Methyl Salicylate

• Vd doubles or triples in toxic states

• Therapeutic half-life: 1 to 2 hours

• Toxic levels with acid urine: half-life up to 30 hours

Methyl Salicylate

• Children with rheumatoid disease at steady state: toxic through minor dietary changes

• Infants: may show just dehydration, rapid breathing

• Older kids: GI symptoms, CNS depression

Methyl Salicylate

Non-aspirin salicylates can be converted to “aspirin equivalent doses” with the help of tables found in any standard toxicology book

Methyl Salicylate 15%

Jeroen Elfferich, Flickr

Methyl Salicylate 29%

Eli Sagor, Flickr

Methyl Salicylate 40%

Steffen Buus Kristensen, Wikimedia Commons

Methyl Salicylate 0.06%

Jagwire, Wikimedia Commons

Methyl Salicylate

• 21-month-old: significant poisoning, peak serum concentration of 81 mg/dL, after ingesting 4 mL Howrie DL, et al. Pediatrics 1985;75:869–71.

• Fatality with ingestion <1 tsp Stevenson CS. Am J Med Sci 1937;193:772–88.

Methyl Salicylate

• 1996 report to AAPCC

• 10,733 toxic exposures to methyl salicylate

• 7,712 were children

• Two deaths reported, both in adults

Podophyllin 25%

Podophyllin 25%

• Resinous powder from rhizome of American Mayapple

• Used to treat genital warts

• Occasional adulterant in herbal medicines

• 1989: Hong Kong outbreak

Ng THK, et al. J Neurol Sci 1991;101:107-13.

Podophyllin 25%

• Transient toxicity: hallucinatory psychosis, bone marrow depression, hepatic dysfunction

• Persistent: severe peripheral neuropathy

Filley CM, et al. Neurology. 1982 Mar; 32(3):308-11.

Podophyllin 25%

• Minimal potential fatal dose: 15 – 20 mg/kg

• Maximal dose unit available: 1.25 g/5mL

• Volume for potential lethality:

1mL Filley CM, et al. Neurology. 1982 Mar; 32(3):308-11.

Pastes, Ointments, Liniments

Scott Ehardt, Wikimedia Commons

Dibucaine

Dibucaine

• Potent amide anesthetic

• Topical uses: hemorrhoids, sunburn, episiotomy pain

• 10x as toxic as lidocaine

• 20x as toxic as procaine

• Mixed with secobarbitone, used IV to euthanize large animals (Somulose®)

Dibucaine

CNS toxicity

• Seizure

• Coma

Dibucaine

Cardiotoxicity • Increased PR • Widened QT • Slowed conduction • Slowed repolarization • Reentrant dysrhythmias

– SVT – PVC

Dibucaine

• ~1% of topical anesthetics sold in US

• <5% nonfatal exposures to topical anesthetics

• Caused 3 of 4 deaths due to topical anesthetics over last 20 years Dayan PS, et al. Ann Emerg Med. 1996 Oct; 28(4):442-5.

Dibucaine

• In 1995, US Consumer Product Safety Commission issued rule requiring childproof packing for containers with >0.5 mg dibucaine or >5 mg lidocaine

Corticaine® Dibucort®

Dibusone® Nupercainal®

Dibucaine

• Ointment USP, 1%

• Topical Anesthetic

• For External Use Only; Do not use in the eyes

Pills, Tablets & Capsules

Chaos, Wikimedia Commons

Anti-Arrhythmics

Quinidine

• D-isomer of quinine

• Derived from cinchona bark

• Side effects and toxicity similar to quinine

• Main concerns: dysrhythmias, cardiogenic shock, coma, seizures, retinal damage Dellocchio T, et al. Pediatrics. 1976 Aug; 58(2):288-90

Interesting History

• Founder of homoeopathy, Dr. Samuel Hahnemann, took large daily dose of quinine bark

• After 2 weeks, he felt malaria-like symptoms

• “Like cures like” philosophy was start of homoeopathy

Disopyramide

• Another Class 1A

• Falling out of favor

• More anticholinergic than others in class

• 1 pill potentially lethal

Singer P, et al. J Anal Toxicol. 1995 Oct; 19(6):529-30.

Encainide

Encainide (Enkaid®) removed from American market voluntarily, still available on “compassionate” basis

• Case report: infant swallowed 1 tablet (25 mg) with rapid onset V-tach, but survival

Mortensen ME, et al. Ann Emerg Med. 1992 Aug; 21(8):998-1001.

Propafenone

Propafenone (Rhythmol®)

• 2 year-old ingested less than one tablet rapid cardiovascular collapse

• Eventual recovery

McHugh TP, et al. Ann Emerg Med. 1987 Apr; 16(4):437-40.

Antiarrhythmics

Drug Minimal potential fatal dose

Maximal dose

available

No. of tabs that can cause fatality

Quinidine 15 mg/kg 324 mg 1

Disopyramide 15 mg/kg 150 mg 1

Procainamide 70 mg/kg 1000 mg 1

Flecainide 25 mg/kg 150 mg 1 – 2

Antimalarials

Quinine

• See quinidine

CYL, Wikimedia Commons

Chloroquine

• Primary treatment for malaria – Anti-inflammatory

– Antihistamine

– Anti-prostaglandin

• Hydroxychloroquine: chemically similar

Chloroquine

• Quinolone family

• Now used to treat rheumatoid arthritis, systemic / discoid lupus erythematosus, other connective tissue disorders

Chloroquine

• Initial symptom may be cardiac arrest

• Pediatric overdoses: neuro symptoms in 30 min to 1 hour

• Death seems related to cardiac conduction system depression and myocardium

Chloroquine

• Severity of hypokalemia closely correlates with level of chloroquine toxicity

• Potassium concentrations less than 1.9 mEq/L correlated with severe, life-threatening ingestion

Angel G, et al. Lancet. 1995 Dec 16; 346(8990):1625.

Chloroquine

• GI absorption: rapid, almost complete

• Peak plasma concentration: 1.5 to 3 hours

• Elimination half-life in children: 75 to 136 hours

Cann HM, et al. Pediatrics 1961;27:95–102.

Chloroquine

• Therapeutic dose: 10 mg/kg

• Toxic effects: 20 mg/kg

• Lethal dose: 30 mg/kg

• Confirmed toddler death at 27 mg/kg

• Equivalent to 300mg tablet in 8 kg 12-month-old

Cann HM, et al. Pediatrics 1961;27:95–102.

Chloroquine

Antimalarials

Drug Minimal potential fatal dose

Maximal dose

available

No. of tabs that can

cause fatality

Chloroquine 20 mg/kg 500 mg 1

Hydroxy-chloroquine

20 mg/kg 200 mg 1

Quinine 80 mg/kg 650 mg 1

Clonidine

Clonidine

• Initially nasal decongestants

• Later marketed as central acting antihypertensive

• Alpha2-adrenergic agonist – central adrenergic tone

• Also bind to imidazoline receptors in medulla

Imidazolines

• Decongestant imidazolines: naphazoline, oxymetazoline, tetrahydrozoline, xylometazoline

• Ophthalmologic brimonidine and apraclonidine used to treat glaucoma

Imidazolines

• 2001: 1438 clonidine exposures in children younger than 6 years old

• 922 tetrahydrozoline exposures in preschool children

Toxicity

• Oral, transdermal delivery

• Patches contain 2.5 mg, 5 mg, and 7.5 mg of clonidine,

• OD resembles opioid: LOC, bradycardia, hypotension, respiratory depression, miosis, hypotonia

Toxicity

• Toxicity in 30 to 90 minutes

• May persist for 1 to 3 days

• Children most at risk for bradycardia, respiratory depression, intermittent apnea

Cases

• Case series: 80 children admit for clonidine ingestion

• Average time to onset of symptoms: 35 minutes

• Most common presenting sign or symptom: reduced level of consciousness (96%)

Nichols MH, et al. Ann Emerg Med 1997;29:511

Cases

• Six required intubation

• No deaths reported

• 54% of the clonidine belonged to patients’ grandmothers

Nichols MH, et al. Ann Emerg Med 1997;29:511

Cases

• 21-month-old girl: coma, bradycardia, hypotension after ingesting 0.3-mg tablet

• 6-year-old girl: obtundation, bradycardia after applying patch she mistook for bandage Killian CA, et al. Pediatr Emerg Care 1997; 13:340–1.

Neuvonen PJ, et al. Clin Toxicol 1979;14:369–74.

Cases

• 9-month-old boy lethargic 90 minutes after sucking on a discarded clonidine patch

• 2-year-old child bradycardic, recurrent apnea after ingesting 5 mL apraclonidine Everson G, et al. J Toxicol Clin Toxicol 1999; 37:629.

Caravati EM, et al. Ann Emerg Med 1988;17:175

Management

• Imidazoline: supportive

• Symptomatic patients respond variably to naloxone up to a total of 10 mg

• Retrospective review: 39 / 80 patients (49%) got naloxone – Positive response in 4 patients

Nichols MH, et al. Ann Emerg Med 1997;29:511

Management

• Symptomatic bradycardia: start with atropine

• Hypotension unresponsive to fluid resuscitation or complicated by persistent bradycardia: dopamine

Maggi JC, et al. Clin Paediatr 1986;25:453–5.

Tricyclic Anti-depressants

Cyclic Antidepressants

• Leading cause of poisoning fatality in the United States until 1993

• Presently 2nd most common class of agents ingested in fatalities reported to AAPCC

Litovitz TL, et al. Am J Emerg Med 2002; 20:391–452.

Cyclic Antidepressants

• All TCAs dangerous in excess

• Desipramine seems especially dangerous in children

• Anticholinergic toxidrome (remember the mnemonic??)

Toxidrome Mnemonic

“blind as a bat” – dilated pupils

“dry as a bone” – dehydrated

“mad as a hen” – hallucinations

“red as a beet” – skin flushing

urinary retention

tachycardia

Pathophysiology

• Mortality 2o to cardiotoxicity, CNS toxicity

• BP may be 2o arrhythmia-induced cardiogenic shock, PVR 2o to alpha-adrenergic blockade, sympathomimetic amine depletion

Pathophysiology

• Seizures associated with cyclic antidepressant toxicity typically generalized tonic-clonic, self-limited

• Status epilepticus has been reported

Lipper B, et al. Am J Emerg Med 1994;12:451–7.

Pathophysiology

• Seizure activity greatest in antidepressants showing dopamine and norepinephrine reuptake inhibition: bupropion, amoxapine, venlafaxine

• Significant toxicity presents within 6 hours of ingestion

Lipper B, et al. Am J Emerg Med 1994;12:451–7.

Morbidity / Mortality

• 10 to 20 mg/kg ingestion of most TCAs likely to result in significant CNS, CV symptoms

• 15 to 20 mg/kg ingestion believed to represent lethal exposure

Frommer DA, et al. JAMA 1987;257:521–6.

TCA Case Reports

• 3-year-old girl: seizures, cardiac dysrhythmias after ingestion 100 mg desipramine

• 250 mg imipramine, amoxapine have resulted in child fatality

Jue SG. Drug Intell Clin Pharm 1976;10:52–3.

Linakis JG. Clin Toxicol Rev 1988;10.

Manoguerra AS. Crit Care Q 1982;43–51.

Management

• Lecture in itself

• Sodium bicarbonate remains mainstay of treatment to reverse cardiotoxic effects

• Beneficial with even normal arterial pH

• Optimal dosing strategy remains to be determined

Tricyclic Antidepressants

Drug Minimal potential fatal dose

Maximal dose

available

No. of tabs that can

cause fatality

Amitriptyline 15 mg/kg 100 mg 1 – 2

Imipramine 15 mg/kg 150 mg 1

Desipramine 15 mg/kg 75 mg 1 – 2

Calcium Channel

Antagonists

Epidemiology

• 9264 CCA exposures in 2001

• 100% increase from 1990

• 2249 in children under 6 years

• 88 moderate to major outcomes

• No pediatric deaths reported

• 10 CCAs available in US

Categories

• Phenylalkylamines: verapamil

• Benzothiaprines: diltiazem – Act predominantly on cardiac

tissue

• Dihydropyridines: nifedipine – Acts predominately on vascular

smooth muscle

Presentation

• Hallmark: disturbance of cardiovascular system

• Classic manifestations: hypotension, bradycardia,

• Reflex tachycardia can be seen with dihydropyridines

Presentation

• Conduction: 2nd and 3rd degree heart block

• Negative inotropy: cardiogenic shock or cardiac arrest

• Can be delayed in sustained-release preparation ingestion

Presentation

• Hypotension can last >24 hours despite therapy,

• Hyperglycemia: multifactorial – Hyperglycemia in setting of

bradycardia and hypotension suggests CCA ingestion

Case #1

• 11-month-old girl developed seizures 45 minutes after ingesting 400 mg verapamil

Passal DB, Crespin FH. Pediatrics 1984;73:543–5.

Case #2

• 14-month-old girl pale, hypotensive, tachycardic after ingesting single 10 mg nifedipine tablet – Aggressive interventions

– Bradycardia pulseless

– Died 3 hours after presentation

Lee DC, et al. J Emerg Med 2000;19:359–61.

Case Series

• Pediatric case series: 16 symptomatic patients among 283 recorded exposures

• Five occurred after ingestion single tablet

• Maximal time to symptom onset from 3 to 14 hours

Belson MG, et al. Am J Emerg Med 2000;18:581.

Therapy

• Atropine: 1st-line agent in bradycardia, only moderately successful

• Optimal pharmacotherapy poorly defined

• Calcium: conflicting data – Most beneficial in mild toxicity

Therapy

• TOC refractory CCA toxicity: high-dose glucose-insulin – Insulin: positive inotrope

• Case series: 5 patients with refractory shock after CCA overdose improved after glucose-insulin infusions

Yuan TH, et al. J Toxicol Clin Toxicol 1999;37:463–74.

Calcium Channel Blockers

Drug Minimal potential fatal dose

Maximal dose

available

No. of tabs that can

cause fatality

Nifedipine 15 mg/kg 90 mg 1 – 2

Verapamil 15 mg/kg 360 mg 1

Diltiazem 15 mg/kg 360 mg 1

Sulfonylureas

Sulfonylureas

• Children 12 years and under

• Hypoglycemia in 56/185 (30%)

• 54/56 (96%) developed hypoglycemia within 8 hours of ingestion

• Clinical observation with oral feeding alone appears safe Spiller HA, et al. J Pediatr. 1997 Jul;131(1 Pt 1):141-6.

Sulfonylureas

• Clear symptoms hypoglycemia or glucose levels < 60 mg/dL: admit for supplemental glucose (oral or IV), monitor

• Refractory to IV glucose: octreotide, diazoxide may help

Little GL, et al. J Emerg Med. 2005 Apr; 28(3):305-10.

Sulfonylureas

• 2-year-old boy observed to ingest 5 mg glipizide

• Activated charcoal given within 35 minutes

• Hypoglycemia with serum glucose 49 mg/dL 11 hrs later

Szlatenyi CS, et al. Ann Emerg Med. 1998 Jun; 31(6):773-6.

Oral Hypoglycemics

Drug Minimal potential fatal dose

Maximal dose

available

No. of tabs that can cause

fatality

Chlorpropamide 5 mg/kg 25 mg 1

Glibenclamide 0.1 mg/kg 2.5 mg 1

Glipizide 0.1 mg/kg 5 mg 1

Opioids & Opiates

Epidemiology

• 5914 reported ingestions by children younger than 6 years old in 2001

• Most common: hydrocodone with acetaminophen (Vicodin®)

• Time to peak toxicity: 1 hour

• Most deaths 2o to respiratory depression, hypoxia

Pathophysiology

• Infants and children more susceptible to toxic effects

• Half of children exposed to more than 1 mg/kg of codeine develop toxicity

• 2.5 mg of hydrocodone has been lethal in infant

OMA Committee on Pharmacy. Codeine: Ont Med Rev 1977;44:447–8.

Treatment

• Supportive

• Naloxone as needed – Onset of action: < 2 minutes

– Duration of action: 20 – 90 minutes

– Elimination half-life: 60 – 90 minutes

Opioids / Narcotics

Drug Minimal potential fatal dose

Maximal dose

available

No. of tabs that can

cause fatality

Codeine 7-14

mg/kg 60 mg 1 – 2

Hydrocodone elixir

1.5 mg/kg

60 mg / 5mL

<1 tsp

Methadone 1-2

mg/kg 40 mg 1

Special Case: Lomotil®

• Antidiarrheal agent – 2.5 mg opioid diphenoxylate

– 0.025 mg antimuscarinic atropine

• Both absorbed rapidly – May be delayed in overdose

Special Case: Lomotil®

• Diphenoxylate metabolized to difenoxin, 5x more active than parent compound

• Elimination half-life 12 – 14 hours

• Little correlation between ingested dose and outcome

Special Case: Lomotil®

Classically described as “biphasic reaction”

• Initial antimuscarinic symptoms in 2 – 3 hours

• Delayed opioid symptoms

• Recent studies show this occurs in only few cases

McCarron MG, et al. Pediatrics 1991;87:694–700.

Special Case: Lomotil®

Case series

• 4/36 developed early anticholinergic symptoms

• 15/36 developed opioid toxicity only

McCarron MG, et al. Pediatrics 1991;87:694–700.

Special Case: Lomotil®

• Catastrophic outcomes reported after ingestion by children Wasserman GS, et al. Am Fam Physician 1975; 11:93–7.

• Toxicity reported after ingestion of one-half tablet Ginsberg CM, et al. Clin Toxicol 1969;2:377–82.

Management

• Similar to other opioids

• Initial symptoms, including coma, may be delayed

• Symptoms have recurred 24 hours after initial resolution

• Recommend: admit, monitor for no less than 24 hours Manoguerra AS, et al. Poisindex, Vol. 117; 9/2003.

Household Products

• Methanol in deicing solutions, windshield washer fluid, carburetor cleaners

• Concentration may be 95%

• Ingestion of 4 mL by 10-kg toddler serum methanol concentration of 50 mg/dL

Household Products

• Ethylene glycol in antifreeze, some fire extinguishers, inks, and adhesives

• Concentration may be 95%

• Ingestion of 2.9 mL by 10-kg toddler serum ethylene glycol concentration of 50 mg/dL

…and Don’t Forget

• Theophylline still in use

• Extended release preparation available

• Minimal fatal dose: 8.4 mg/kg

• Maximal available unit dose: 500 mg

• One tablet can definitely kill

Primum non Nocere

• No literature suggests better outcomes with charcoal

• Deaths reported from activated charcoal aspiration – Some in children when they

consumed nontoxic products

Menzies DG, et al. BMJ 1988;297:459–460.

Harsch HH. N Engl J Med 1986;314:318.

Elliott CG, et al. Chest 1989;96:672–674.

Drugs Causing Toddler Deaths: 1990-2000

Number of Fatalities

Iron supplements 32

Antidepressants 13

Methadone 6

Nifedipine 5

Methyl salicylate 3

Diphenoxylate 1

Clonidine 1

Flecainide 1

Glipizide 1

Summary

• Vast majority of toddler ingestions are benign

• Dozen or so medicines can kill 10-kg toddler with one pill or swallow

• Treatment: usually supportive

• Activated charcoal can kill