The Washington PostDemocracy Dies in Darkness

A surprising number of children are accidentally poisoned. Simple steps can prevent that.

A toddler plays with pills — a situation that can prove deadly. Experts say you need to always put medicine up and away — and out of sight — of children. (iStock)

It only took a few seconds. During a family trip, a woman took out an Ambien and put the prescription sleep aid on her bathroom counter. Then, she turned to grab a bottle of water. In an instant, her toddler grandson grabbed the pill and ate it.

“She was standing right there, not even moving away, just reaching with her hands,” says Maneesha Agarwal, a pediatric emergency medicine doctor at the Emory University School of Medicine in Atlanta and Children’s Healthcare of Atlanta, who treated the child in the ER. “It was that fast.”

U.S. hospitals treated nearly 52,000 children under age 6 for medicine poisonings in 2017, says Safe Kids Worldwide, an injury-prevention nonprofit group. That’s down from almost 76,000 in 2010, suggesting that safety measures are helping. But it’s still too many, says Dan Budnitz, an internal medicine physician who directs the Medication Safety Program at the Centers for Disease Control and Prevention in Atlanta.

Experts advise adults to protect kids from accidental poisoning with simple steps that can make a big difference. They are also working behind the scenes to protect children with better dosing guidelines, safer packaging and other solutions.

“We have been building a better mousetrap or, in this case, a better bottle cap,” Budnitz says. “And we are trying to remind parents and other caregivers to put that cap on completely after every time they use it, and to put the medicine up and away and out of sight every time after they use it, even though they might need the medicine again in four to six hours.”

Every year, U.S. poison control centers receive more than 2 million calls about human exposures to potentially toxic substances. In 2017, nearly half of those calls concerned children ages 6 and younger. And while many incidents involved ingestion of batteries, cleaning products and other substances, medications remain a persistent concern — with a peak at age 2. More than 80 percent of kids poisoned by medications are between 1 and 3.

Although hospital visits for medicine poisonings among children younger than 6 have dropped, certain drugs have become increasingly problematic for kids — especially opioids, which cause harm in young people through both accidental and intentional ingestion.

Between 1999 and 2016, deaths from opioids increased among children and adolescents, a 2018 study found, rising from 2.2 to 8.1 per 1 million children, a total of nearly 9,000 deaths in young people up to age 19 over the 17-year period. The sharpest increases have been among teens, with heroin in particular, but there has been a steady rise for kids up to age 9, as well.

Living with an adult who has a prescription raises risks for kids. One 2017 study found that young children of mothers with opioid prescriptions had a much higher risk of going to the hospital or dying of an opioid overdose compared with kids whose mothers did not have a prescription. Diabetes medications and blood-pressure drugs show similar associations, according to other research.

One reason opioids, including fentanyl and oxycodone, are so concerning is that they belong to a category of medications that can be fatal for kids in a single dose. Designed for adults, these drugs can be disastrous in a small body. Other deadly single pills include antimalarials, tricyclic antidepressants, beta blockers and calcium channel blockers.

Other potentially deadly substances include liquid nicotine and oil of wintergreen, which is like concentrated aspirin and can be fatal to children with just a teaspoon. High doses of vitamins, such as iron and vitamin D, are also dangerous.

One way to prevent kids from accidentally ingesting medications is with policy changes, Budnitz says.

That has been clear since 1970, when the Poison Prevention Packaging Act mandated ­child-resistant packaging on a variety of household substances. After that, there was a dramatic decline in the number of kids who died each year from poisonings.

More recently, companies voluntarily participating in the CDC’s Prevention of Overdoses and Treatment Errors in Children Taskforce (PROTECT) Initiative added special tops, called flow restrictors, which limit how much liquid can come out of infant acetaminophen products, even when shaken or turned upside down. In turn, the Food and Drug Administration recommended that manufactures add flow restrictors to all pediatric products with acetaminophen.

The switch has made it harder for kids to get into bottles of acetaminophen, suggests a 2013 study in which Budnitz and colleagues challenged 110 preschoolers to open bottles that were filled with a safe liquid.

Within two minutes, the children, ages 3 and 4, drained the vast majority of bottles that lacked flow-restrictor tops, even when those bottles were partially closed with a cap. But only 6 percent of uncapped bottles with flow restrictors were emptied completely during a 10-minute test period, and it took more than six minutes for even the fastest child to get all the liquid out.

The PROTECT Initiative is now working to identify other medications that would be good candidates for improved packaging with flow restrictors, such as children’s liquid diphenhydramine (also known as Benadryl). To help caregivers avoid unintentional dosing confusion, the CDC supports using milliliters as standard units on all liquid prescriptions. Consistent units can help adults avoid confusion about how much of each medication to measure out.

And they encourage caregivers to use precise dosing instruments, such as oral syringes or dosing cups, instead of kitchen measuring spoons.

Education about medication safety remains important, and not just for parents. Multiple studies show that medication intended for grandparents are responsible for 10 to 20 percent of accidental ingestions by children. For some of the most dangerous medications, preliminary data by Agarwal’s group suggests that grandparents’ medication accounts for more than 50 percent of cases.

Don’t be afraid to ask visitors in your home — or people whose homes you visit — to store their medication safely, says Agarwal, whose daughter is 5. “I research this and I constantly have to yell at my parents when they come to visit,” she says.

Some organizations advocate locking up medications. Others, including the PROTECT Initiative’s Up and Away campaign, advise putting medicines out of sight and out of reach of children (even if the drugs are in a bag or purse), and making sure the cap is put on completely after use. Agarwal also recommends not taking medication in front of small children and not giving them medicine bottles to hold.

She remembers a 1-year-old who was allowed to shake a pill bottle like a rattle. He managed to open it and swallowed a pill. It was buprenorphine, which is used to treat opioid addiction, and it killed him.

“Parents are sometimes complacent and as an adult, you can struggle to sometimes get into these containers,” Agarwal says. “But the reality is that mechanisms can wear down with time, and if you give a kid enough time with it, they can open it up.”

If you are concerned about an exposure or suspected exposure, call the Poison Control Center (800-222-1222). Around the clock, the independent, nonprofit organization offers specialists who can offer advice. Information and assessments are also available through the organization’s website, which offers articles about the toxicity of substances such as sprouted potatoes, tulip bulbs and centipede stings.

“They are incredible, amazing professionals,” says Agarwal, adding that anyone who takes care of kids should program the Poison Control number into their cellphones. “They have heard it all. There is no judgment.”

If you need to go to the hospital, Agarwal adds, bring as many specifics as possible about what the child ingested, the dosages and a list of other medications in the home. Depending on the situation, children might need infusions of antidotes or supportive medications, and admission to the pediatric intensive care unit or general ward. Or they might just need some time for observation.

The experience can be scary. Friends have made panicked calls and hospital visits after their kids swallowed toothpaste, Tums, house plants, ibuprofen, a cat’s thyroid medication and more. Most often, everything ends up okay, which was true for the toddler who swallowed the Ambien. He was observed and discharged without problems.

“These are almost always very loving, well-intentioned family members and caregivers involved when this happens,” Agarwal says. “Fortunately, most kids are fine. That’s the reason I take care of only kids — they tend to be fine.”

Poison control centers receive 32 calls a day about children exposed to opioids

Many people fail to get rid of unneeded and expired drugs

An overdose victim had an extraordinary level of fentanyl. She was 18 months old.