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Predictors of Unintentional Poisoning among Children under 5 years of age in Karachi. A Matched Case Control study.

Author(s) Bilal Ahmed1, Zafar Fatmi2, Rehana Siddiqui3.
Affiliation(s) 1Department of Medicine , The Aga Khan Univesity , Karachi, Pakistan, 2Community Health Sciences, The Aga Khan University , Karachi, Pakistan, 3Community Health Sciences, The Aga Khan University , Karachi, Pakistan.
Country - ies of focus Pakistan
Relevant to the conference tracks Chronic Diseases
Summary Poisoning is one of the main causes of unintentional injury among children. It is the fourth leading cause of morbidity and mortality after road traffic accident, burns and drowning. Majority of these poisoning occur among preschool children under 5 years of age. There is a scarcity of evidence based analytical literature in the area of unintentional injuries, therefore there is need to identify the specific factors in our population in order to provide follow up action that reduces morbidity and mortality in young children and improves the handling of such emergencies by parents and health care workers.
Background Global estimates for childhood unintentional poisoning are not available and most of the existing information is from developed countries. There were an estimated 86,194 child poisoning incidents treated in United States hospital emergency departments in 2004, amounting to 429.4 poisoning per 100,000 children. Since morbidity is comparatively more associated with unintentional poisoning than mortality, non fatal incidents occur more among children of 1-4 years of age. Previous studies identified kerosene, petrol, medicines, insecticides, and household cleaning products as major hazards for poisoning incidents in children less than 5 years. Kerosene oil poisoning is commonly reported from developing countries. For cooking and lighting the main fuel use is paraffin (kerosene) and petrol for power generators, which is often stored under the beds in beverage or other empty containers. Unintentional ingestion of medicines both over the counter and prescription drugs, by young children and toddlers has been often reported. Similarly, household chemicals like bleach, toilet cleaners are also common substances involved in unintentional poisoning. Pakistan is a developing and low income country and, with more than 24 million children under 5 years of age, is highly vulnerable to such incidents.
Objectives There are few descriptive surveys available from Pakistan on unintentional childhood poisoning. However, there is a scarcity of analytical based epidemiological studies that has focused on factors within households that are associated with poisoning among young children. Epidemiological studies investigating the etiology of unintentional poisoning in children have been reported from the developed world or Malaysia and Greece.
As mentioned earlier, the majority of poisoning incidences occur inside home, however factors associated with household environment, behavioral issues of children and storage practices of caregivers have not been studied in our setting before. Monitoring of acute poisoning is important for health authorities because they can identify major factors involved in a particular population to prevent them. There is a scarcity of evidence based analytical literature in this area of unintentional injuries, therefore there is need to identify the specific factors in our population in order to enact follow up action that reduces morbidity and mortality in young children and improves handling of such emergencies by parents and health care workers. Moreover, it would help in designing appropriate strategies and interventions to create awareness in general population to reduce the burden of childhood poisoning.The key objectives are to determine the factors associated with poisoning among children under-5 years of age reporting to Emergency rooms of tertiary care hospitals in Karachi.
Methodology This study was conducted in the ERs of three large tertiary care hospitals in Karachi: the Aga Khan University Hospital (AKUH), the Civil Hospital Karachi (CHK), and the National Institute of Child Health (NICH). AKUH, a private hospital, caters
for 12 000 paediatric patients annually, whereas CHK and NICH are public hospitals, and receive approximately 150 paediatric patients in the ER daily. These hospitals provide services for the upper, middle and lower socioeconomic classes of the Karachi population. The study data were collected from August 2008 to March 2009. The investigation was a matched case control study. All consecutive poisoning cases were enrolled in the study, including gravely ill children or those who died either in the ER or before reaching the hospitals during the study period.The cases were defined as being children under 5 years of age with oral ingestion of any noxious substances. They were recruited into the study after a definite diagnosis of accidental intake of poisoning was made by the attending physician of the respective hospitals. The noxious agents considered for poisoning in this study were any substance that had the
potential for toxic effects and included medicines, insecticides, pesticides, petroleum products, household chemicals, and cosmetics. Children admitted for food poisoning, adverse drug reactions, and poisoning with animal venom were excluded. Controls were selected from the ER of the same hospitals and comprised of children with complaints other than poisoning. Controls were matched for age (66 months) and sex, as these were the known confounders. Three control children per case visiting the ER of the same hospital within 48 h of case identification were enrolled for the study. Children with symptoms of chronic illness such as known cases of cardiac disease, renal failure, chronic pulmonary disease, cancer patients, and road traffic accidents were excluded from the study sample. Children brought from nearby areas outside Karachi were not included in the study. Caregivers were interviewed using a structured questionnaire. Information on the sociodemographic characteristics of the child and caregiver, and the storage practices for medicines and chemicals in their household, were obtained.
Sample size: a total number of 120 cases and 360 controls were required to achieve the objectives of the study. Multivariable conditional logistic regression analysis was done and adjusted matched odds ratios (mORs) were calculated.
Results The data included 120 cases and 360 matched controls. Incidental uptake of medicines was the most common type of poisoning, followed by kerosene oil ingestion. Similarly, the majority of the incidents of poisoning occurred in the bedroom followed by the drawing/dining room, courtyard and kitchen. Among all the subjects enrolled during the study period, only one cased who had ingested medicine (warfarin) died. The majority of poisoning incidents occurred among children 1-2 years of age. Among the cases medicinal users at home, history of previous poisoning incident, and child behaviour reported as aggressive were more prevalent than among controls. Similarly, the proportion of parents living apart and living in a nuclear family system was more in cases than controls. The storage practices of medicines and chemicals showed that the proportion of unsafe storage of chemicals that is not at a height >2 m is greater among cases than controls (30.8% vs 16.7%). Similarly, more households of cases (80%) stored unlocked chemicals compared to controls (56.1%). Among the cases the safe storage of medicine at a height >2 m was 64.2% compared with 75.3% for the controls. Only 8.3% of the caregivers of cases reported that they kept medicines locked, compared to 23.6% of the controls. However, when these variables were combined to make a composite variable it showed that 14.2% of the caregivers of cases reported storing both chemicals and medicine unsafely, compared to 5.8% of controls. Adjusted analysis shows that, accessibility to hazardous chemicals and medicines was significantly associated with poisoning. Unsafe storage of either chemicals or medicines occurred 1.5 times more in cases compared to controls. Similarly, unsafe storage of both chemicals and medicines occurred 5.6 times more in cases compared to controls (mORadj 5.6, 95% 95% CI 1.9 to 16.7). Storage of kerosene and petroleum in soft drink bottles occurred 3.8 times more in cases compared to controls (mORadj=3.8, 95% CI 2.0 to 7.3). Cases were 8.2 times more likely to be aggressive compared to controls (mORadj=8.2, 95% CI 4.2 to 16.1). Similarly, the reporting of a previous poisoning incidence was 8.6 times more in cases compared to controls (mORadj=8.6, 95% CI 1.7 to 43.5). The low level of mother’s education was strongly associated with poisoning in children.
Conclusion In conclusion, we found that accessibility of hazardous chemicals and medicines due to unsafe storage, reported child behavior as aggressiveness, history of previous poisoning, low maternal education, storing of kerosene and petroleum in soft drink bottles, and low socio economic status were associated with increased risk of unintentional poisoning among children under-5 years of age living in Karachi. Some of these factors, particularly storage practices, are potentially modifiable and efforts to reduce the prevalence of unsafe storage could have the benefit of reducing the incidence of unintentional poisoning in this population. To curtail the number of childhood poisoning incidents understanding its related preceding factors in particular settings are necessary. Future directions in the field of childhood poisoning involves a number of strategies including the incorporation of better-tested and more refined educational, legislative, and environmental intervention strategies. As mentioned earlier, there is a scarcity of literature in the area of childhood injuries. The large community base studies, emergency room surveillance system for overall unintentional childhood injuries including poisoning, and population base follow-up studies helps to determine the predictors. Studies of risk factors have to be conducted and analyzed with due regard to possible confounding variables and interaction between factors. Similarly, cost effective and sustainable intervention needs to be launched, to see if it decreases the burden. Qualitative focus group discussions with parents of young children about real and perceived barriers to calling the local poison information center, resources for poison prevention messages, and ideas about public awareness campaigns should also be done.
Intervention and longitudinal studies can further provide the necessary evidence in understanding the behavioral issues of children, parents and other care givers that could lead to unintentional ingestion of harmful substances to further establish temporality and causal association.

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