Intentional poisoning among preadolescents: a case

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physical examination , diagnostic tests. Hospital outcome: Length of stay (LOS) in hours, LOS: time between admission and discharge. hospital bill (Cost) in US ...
Intentional poisoning among preadolescents: a case series report from a single poison center, Saudi Arabia Menyfah Alanazi1 Majed Al-Jeraisy2 and Mahmoud Salam2 1Drug

Policy and Economics Center; 2King Abdullah International Medical Research Center (KAIMRC) ; King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), King Abdulaziz Medical City, Riyadh, Saudi Arabia.

5th Research Day on 05 May 2016

Background

Suicidal thoughts, also known as suicidal ideation, are thoughts about how to kill oneself, which can range from a detailed plan to a fleeting consideration and does not include the final act of killing oneself.

Background 

The epidemiology of intentional poisoning among preadolescents in conservative communities such as Saudi Arabia needs further exploration.



Preadolescence (9 - 14 years) 1 is a remarkable human developmental stage with a heightened risk for suicidality, often less discussed than adolescence 2-4.



In Saudi Arabia, suicide is strictly forbidden by both religious and cultural principles, in addition to strict criminal legislations against substance abuse5.

Background  



About 17% of the Saudi Arabian population is under the age of 14 (as 2015), a community witnessing rapid growth and a large cohort of youths. Intentional poisoning at one tertiary care facility in Riyadh (capital of Saudi Arabia) was observed in 79 cases (age 15-40) within a 3 year period study5, while 160 cases of suicide due to other factors beside poisoning were observed within a 5 year period study in the Eastern region7. Poisoning in preadolescents, whether intentional or accidental, are often observed in Saudi pediatric emergency departments8. However, socio-cultural pressures often lead to under reporting or even improper assessment of suicidal behaviors in preadolescents within such communities. 45 or more 40 to 44

35 to 39 30 to34

29.77

6.80 8.01 9.14

25 to 29

9.91

20 to 24

9.96

15 to 19

9.82

10 to 14 5 to 9

8.86 7.72

17%

Aim of the study The aim of this study was to present a report on intentional poisoning incidents among preadolescents visiting a single poison center, central Saudi Arabia. This was fulfilled by: a. identifying suspected cases of intentional medication and chemical product poisoning, b. presenting their patient, incident and outcome characteristics.

Methodology Design:

Case series report.

Area/Setting:

Emergency pediatrics department, King Abdulaziz Medical City (KAMC), Riyadh

Inclusion criteria:

Intentionally poisoned preadolescents (age: 9 -14 years)

Sampling technique: Consecutive (convenient), between 2009-2011. Ethical consideration: Scientific/IRB approval (Protocol#: RR08/019).

Methodology…Continued Data collection tool 

Informed consent: verbally obtained by phone call.



Preadolescent characteristics: Age, gender, medical/psychiatric history, body mass index (BMI), family characteristics.



Incident characteristics: Poison type (medication vs. chemical product), amount, exposure route Reason behind the incident: classification (suicidal attempt vs. non-suicidal self injurious).  Suicidal attempt was accounted if the child specifies the intention of death.  Non-suicidal self injurious was accounted if no death intention was specified.





Outcome characteristics: Clinical outcomes: the Canadian triage 5 level assessment scale, arrival time, vital signs , physical examination , diagnostic tests. Hospital outcome: Length of stay (LOS) in hours, LOS: time between admission and discharge. hospital bill (Cost) in US dollars. Admission: stay > 24 h in the ED and/or in-hospital admission.

Methodology…Continued

Data collection:

Review of poison reports / patient charts / phone calls

Data collectors:

35 ED physicians/on-call toxicologists and 2 clinical research coordinators from (KAIMRC).

Validation of the collected data was done by verifying it with the electronic records and phone calls (1–2 days after the incident).

Results Case 1

M.AD. is a 12 year old boy who was rushed to the ED after intentionally ingesting 11 tablets of acetaminophen with complains of nausea, abdominal pain, and vomiting (Triage level III). A previous history of poisoning in the family was reported. Although the boy confessed that the ingestion was intentional, and conflict with family but he didn't specify the death intention. After being stabilized in the ED, he was transferred to the ward for more than 48hr with a referral to a psychiatric clinic. Case was classified as non-suicidal self injurious.

Results Case 2: A 9 year old boy with a history of bronchial asthma was rushed to ED complaining of nauseas, vomiting and abdominal pain (Triage level III). The boy had confessed to ingesting 10 tablets of desmopressin intentionally, with no clear reason. The case was stabilized in ED, transferred to a pediatric ward for observation, and then discharged after 48 hours. The family was instructed to consult the psychiatrist after that.

Results Case 3: A 13 year overweight female (S.AG) was delivered to the ED complaining of altered conscious, tachycardia, and hypercalcemia (Triage level II). The patient confessed that she orally ingested 6000 mg of Augmentin and 100ml Benylin (1 bottle each) with a clear intention of death. The patient was discharged from hospital after being admitted to a pediatric ward for 36 hours and later referred to a psychiatric clinic. Case classified as suicidal attempt.

Results Case 4: An overweight 11 year old male (K.AA.) with a history of epilepsy and physical handicap on phenobarbital and baclofin was admitted to ED after intentionally ingesting 10 tablets of Amitriptyline and chlordiazepoxide (Triage level I). The intention of death was clearly admitted by the boy, and a referral to a psychiatric clinic was made after staying in the hospital for more than 48hr . Case classified as suicidal attempt.

Results Case 5: a 14 year old boy a case of G6PD complaining of moderate abdominal pain lasting 2 hours and abnormal vital signs (Triage level III). The parents informed the ED personnel that their son intentionally ingested 6 tablets of 500 mg acetaminophen tablets after an episode of crying and locking himself in the room alone. The boy was admitted to a pediatric ward for more than 48hr before being discharged. The boy confessed that the poisoning incident was intentional due to his chronic medical condition, so he was referred to a psychiatric consultation. Case classified as a suicidal attempt.

Results Case 6: A previously healthy 9 year old female named (M.AO.) was admitted to ED complaining of abdominal pain (Triage level IV). The parents notified health personnel that she has intentionally ingested 1/4 glass of Clorox before notifying her parents. The patient was discharged from ED 3 hours later after advising the parents to consult with a psychiatrist. Reason behind the incident was unknown.

Results Case 7: A 13 year old female (N.AH.) was admitted to the ED complaining of moderate abdominal pain and vomiting with suspected medication poisoning (Triage level III). The girl admitted to intentionally ingesting 4 tablets of acetaminophen before notifying her parents who rushed her to the hospital 2 hours later. The girl was admitted to the pediatric ward after receiving the required emergency treatments and later discharged home, spending 36 hours at the hospital. The reason of intentional poisoning was not fully disclosed to study investigators and the child was referred to a psychiatric clinic for consultation.

Results Case 8: A 10 year old boy (H.AH), arrived to the ED complaining of moderate to severe abdominal pain and vomiting (Triage level II). Although previously healthy but overweight, the boy admitted to intentionally ingesting 3 tablets of acetaminophen. The boy informed the health personnel that he intentionally ingested the tablets but wasn't aware it might lead to death. His father notified the study investigator that the intention was attention seeking. The boy was admitted to a pediatric ward where he was later discharged home after 1 day of observation, and referred to a psychiatric clinic. Case was classified as nonsuicidal self injurious.

Results Case 9: A 14 year old, previously healthy, female (S.AS.) was admitted (Triage level IV) to the ED complaining of mild to moderate abdominal pain. Conscious and oriented she admitted to orally ingesting an unknown amount of Clorox (bleach). The poisoned patient had stable vital signs and was overweight. Upon questioning the child's parents, the reason behind the intentional poisoning was a conflict with her stepmom. Her father informed the study investigator that their relationship was not going well after her biological mother passed away one month ago. The child confessed that the ingestion was intentional and that she was socially stressed out. The patient was stabilized and discharged home from ED after 28 hours, with a referral to the psychiatric clinic. Case classified as suicidal attempt.

Discussion…Continued  Of the 9 cases, four cases were positively confirmed as suicidal attempt that is the preadolescent admitted to having a suicidal ideation and implemented the act of ingesting a poison product with a clear intention of death.  Literature stated that in one school, 23/387 (5.9%) of preadolescent students who were assessed prospectively exhibited a suicidal ideation or self-harm behaviors9.  In Saudi Arabia, almost 3% of intentionally poisoned cases reported to a single poison center in a 4 year period study were aged below 12 years11.

Discussion…Continued 

Incident characteristics observed where the preadolescent being a male of the older age group



In literature some studies stated that the majority of intentional poisoning preadolescent cases were males12,13, whereas others stated that among there are very small or non-significant sex differences14. Furthermore, previous literature findings revealed that suicidal ideation and attempts in adolescence predict future suicidal behavior in adulthood for females but not for males15.

Discussion…Continued  In this study authors suspected that a child being overweight or obese might be at higher risk of committing intentional poisoning compared to those with normal weight.  In literature, an American study (sample 31,540 adolescents) found an association between being overweight and suicide risk among females only17.  Researchers believe that other confounding risk predictors are present with overweight children including depression, failed weight control attempts and peer pressures17,18. This study showed that half of the females admitted that being overweight was the main reason behind committing such an act.

Discussion…Continued 

A preadolescent suffering from a chronic previous health conditions could be at higher risk of committing intentional poisoning.



In this report, 4 cases suffered of epilepsy, G6PD and asthma which all require daily prescribed medications and routine lab tests beside other complains such as pain, fatigue, and activity intolerances. This finding was comparable with “The Truth About Suicide” UK study, where researchers found at least 10% of suicides are linked to terminal or chronic illnesses19. Also, another study stated that of 1,069 cases, 18.9 % gave the physical distress due to cancer, chronic pain, and heart diseases as the reason for committing a suicidal attempt20.

Conclusions  suicide is uncommon in preadolescence but becomes an extremely serious issue among adolescents.  The primary role of parents, schools and primary health care institutions would be to screen for risk factors, recognize them and act synergistically with other specialists to prevent and treat suicidal behaviors.  Primary care physicians and school nurses should also be able to identify the “warning signs” for suicide since their presence implies an attempted suicide may occur sooner than anticipated.  A number of intentionally poisoning cases by orally ingesting a potentially poisonous substance was observed among Saudi preadolescents, which might be an underreported figure in a culturally and religiously conservative community.  Suicidal attempts were more common than non-suicidal self injurious behavior incidents.  Incident characteristics observed were being a male of the older age group, and overweight

World Suicide Prevention Day has taken place on 10th September each year.

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