Plant poisoning is a common presentation in paediatric practice and an important cause of preventable mortality and morbidity in Sri Lanka. The burden of plant poisoning is largely underexplored. The current multicenter study based in rural Sri Lanka assessed clinical profiles, poison related factors, clinical management, complications, outcomes, and risk factors associated with plant poisoning in the paediatric age group. Among 325 children, 57% were male with 64% being below five years of age. 99.4% had ingested the poison. Transfer rate was 66.4%. Most had unintentional poisoning. Commonest poison plant was
Acute poisoning in the paediatric age group is an important cause of preventable mortality and morbidity. Globally, every year 3000 children who are less than 14 years of age die following acute poisoning [
Plants remain to be an important cause of mortality among adults in Sri Lanka. Two studies from Northern Sri Lanka reported
This multicenter prospective study included 36 hospitals in the North-Central province of Sri Lanka (Anuradhapura Teaching hospital (THA), Polonnaruwa District General hospital (THP), and 34 base/district/rural hospitals of the province under RDHS, Regional Director of Health Services). The study was conducted in four major arms: (1) a two-year prospective study (2012–2014) at Anuradhapura Teaching Hospital, (2) a two-year prospective study (2012–2014) at Polonnaruwa general hospital, (3) one-year prospective study involving 34 hospitals under RDHS of NCP (2013-2014), and (4) a five-year retrospective study at Anuradhapura Teaching Hospital (2007–2012). The major part of data collections was carried out at Anuradhapura hospital prospectively by the same investigator using a pretested, multistructured, interviewer administered questionnaire that comprehensively assessed clinical profiles, plant poison related factors, clinical management, complications, and outcome following acute paediatric poisoning.
Both children with intentional and unintentional poisoning were included in the assessment. Children aged 9 months to 12 years were considered for the analysis. Acute poisoning due to nonplant poisons (household poisons/medicines/pesticides), food poisons, snake envenomation, allergic reactions, and adverse drug reactions which can be considered in the purview of toxicology was omitted in the study. Also children with doubtful poisoning where there was no clear aetiology were excluded from the study. All three prospective studies identified clinical presentations, reasons for delayed management in addition to demographic data.
A prospective controlled risk factor study included all children who presented with plant poisoning to Anuradhapura Teaching Hospital over the two-year study period (2012–2014). The controls were selected from the same hospital and children who presented with acute medical illnesses were recruited as controls. The acute medical illnesses considered included viral fever, acute upper respiratory tract infection, and urticaria. All other acute conditions including nonspecific symptoms without a definitive diagnosis were excluded. All children were matched for age and gender on a case by case basis.
Data collections in all components of the current study were subjected to independent audit and close monitoring by South Asian Clinical Toxicology Research Collaboration (SACTRC) and the investigators of the study themselves. Ethical clearance for the study was issued by ethical review committees, faculty of medicine, University of Kelaniya, and Rajarata University of Sri Lanka.
There were 325 incidents of plant poisoning reported in all arms of the study. Male children outnumbered female children in all studies and amounted to 186 (57%). Sixty-seven percent of children were less than five years of age. However, plant poisoning was uncommon among children who were less than two years of age (4.6% of total) compared to older children. The majority of poisoning events were secondary to unintentional ingestion of the poison (314/325, 96.6%). Mortality rate was 1.2% (4 cases) and all four cases (100%) followed ingestion of lethal dose of Oleander. Sixty-six percent of children (216/325) were transferred from a local hospital (under RDHS) to a tertiary care hospital following the poisoning event. Table
Demographic characteristics, patterns of poisoning, and transfer rates of children with plant poisoning.
Variable | Retrospective study ( |
THA Study ( |
Polonnaruwa study ( |
Peripheral study ( |
Total |
---|---|---|---|---|---|
(1) Male : female | 90 : 59 |
38 : 27 |
38 : 20 |
20 : 17 |
186 : 139 |
(2) <5 years : >5 years | 99 : 66 |
52 : 13 |
26 : 32 |
31 : 6 |
208 : 117 |
(3) Unintentional : intentional | 162 : 3 |
60 : 5 |
57 : 1 |
35 : 2 |
314 : 11 |
(4) Mortality | 2 (1.2%) | 1 (1.5%) | 1 (1.7%) | — | 4 (1.2%) |
(5) Commonest poison |
|
|
|
|
|
(6) Transfer rate | 108 (65.4%) | 49 (75.3%) | 34 (58.2%) | 25 (67.6%) | 216 (66.4%) |
Patterns of poisoning with poisonous plants among children in North-Central province.
Poisonous Plant | Retrospective study |
Prospective study |
Polonnaruwa |
Peripheral |
Total |
---|---|---|---|---|---|
(1) |
81 (49.1%) | 22 (33.8%) | 24 (41.3%) | 16 (43.2 %) | 143 (44%) |
(2) |
36 (21.8%) | 10 (15.4%) | 14 (24.1%) | 8 (21.6%) | 68 (20.9%) |
(3) |
27 (16.4%) | 15 (23%) | 11 (19%) | 7 (18.9%) | 60 (18.5%) |
(4) |
9 (5.4%) | 5 (7.7%) | 1 (1.7%) | 2 (5.4%) | 17 (5.2%) |
(5) |
6 (3.6%) | 4 (6.2%) | 2 (3.3%) | — (0%) | 12 (3.7%) |
(6) |
1 (0.6%) | 3 (4.6%) | 2 (3.3%) | 2 (5.4%) | 8 (2.5%) |
(7) |
1 (0.6%) | 2 (3.1 %) | 1 (1.7%) | 1 (2.7%) | 5 (1.5%) |
(8) |
1 (0.6%) | 2 (3.1%) | 1 (1.7%) | — (0%) | 4 (1.2%) |
(9) |
3 (1.8%) | 2 (3.1%) | 2 (3.3%) | 1 (2.7%) | 8 (2.4 %) |
Commonest route of poisoning was ingestion (323/325, 99.4%). One child had symptoms following contact of the poison with mucus membranes. Another child indirectly ingested the poison indirectly through breast milk following her mother intentionally ingesting Oleander.
160 children recruited to studies at THA, THP, and RDHS were available for the analysis. Gastrointestinal symptoms (125 children, 78.1%) were the predominant symptoms following plant toxin ingestion and they were consistently seen in all three studies. Most gastrointestinal symptoms occurred following
Clinical manifestations of plant poisoning among children in rural Sri Lanka.
Reasons for delayed presentation | THA | THP | RDHS | Total |
---|---|---|---|---|
(1) Gastrointestinal symptoms | 59 (90.1%) | 41 (70.6%) | 25 (67.5%) | 125 (78.1%) |
(2) Respiratory symptoms | 25 (38.4%) | 22 (37.9%) | 16 (43.2%) | 63 (39.3%) |
(3) Cardiovascular symptoms | 3 (4.6%) | 6 (10.3%) | 2 (6.4%) | 11 (6.8%) |
(4) Neurological symptoms | 2 (3%) | 1 (1.7%) | — | 3 (1.8%) |
Fifty-two children (32.5%) presented to primary care hospital at least two hours after the ingestion of the poison. Commonest reason for delayed presentation was lack of concern regarding urgency of the situation, 33 children (20.6%). Detailed analysis of reasons for delayed presentation to primary care unit is presented in Table
Reasons for delayed presentation to primary care unit among children in rural Sri Lanka.
Reasons for delayed presentation | THA | THP | RDHS | Total |
---|---|---|---|---|
(1) Lack of concern regarding need for urgent care | 12 (18.4%) | 11 (18.9%) | 10 (27%) | 33 (20.6%) |
(2) Lack of transport facilities for emergency management | 8 (12.3%) | 7 (12%) | 12 (32.4%) | 25 (15.6%) |
(3) Lack of knowledge regarding possible complications | 6 (9.2%) | 6 (10.3%) | 4 (10.8%) | 16 (10%) |
(4) Lack of financial resources | 6 (9.2%) | 4 (6.8%) | 2 (5.4%) | 12 (7.5%) |
(5) Poisoning event unrevealed until symptoms occurred | 2 (3.1%) | 1 (1.7%) | 1 (2.7%) | 4 (2.5%) |
(6) Delayed attention by medical team | 1 (1.5%) | — | — | 1 (0.6%) |
Sixty-five children presented to THA following plant poisoning over the two-year study period. Mean age of children was 4.3 years (range: 11 months–12 years). Most parents had received secondary education, 50 fathers (77%) and 54 mothers (83.1%). The majority of fathers were engaged in farming (21, 32.3%), defense service (11, 16.9%), and manual labour (11, 16.9%). Most mothers were housewives (45, 69.2%). Most of the poisoning events occurred in home garden (43, 66.1%) followed by cultivation area (12, 18.4%) and inside of home (5, 7.7%).
Harmful first-aid measures were practiced in 19 children (29.2%). The commonest measure was forceful ingestion of water (8, 12.3%) and it was followed by forceful finger insertion (3, 4.6%), forceful milk (2, 3.1%), and coconut milk ingestion (2, 3.1%).
The majority of children had onset of symptoms within one hour from the time of poisoning event (35, 53.8%). Though most children (45, 69.2%) were brought to primary care unit within two hours from the poisoning event, twenty children (31.8%) presented at least 2 hours after the poison was ingested (range: 2 to 8 hours). Emesis induction was offered to 32 children (49.2%). Two children (3.1%) required prescription of antidotes and management in an intensive care unit. Reported medical complications included cardiac arrhythmia (2) (3.1%), severe dehydration (1) (1.5%), hematemesis (1) (1.5%), and seizures (1) (1.5%).
Risk factor evaluation showed four proposed risk factors which were associated with significantly elevated risk (
Analysis of proposed risk factors in case-control study.
Proposed risk factor | Cases | Controls | Chi square value |
|
---|---|---|---|---|
(1) Poisonous plants in home garden | 54 | 6 | 71.31 | <0.001 |
(2) Inadequate supervision of the child | 49 | 13 | 39.96 | <0.001 |
(3) Past history of poisoning | 24 | 2 | 23.26 | <0.001 |
(4) Lack of family support | 33 | 12 | 14.98 | <0.001 |
(5) Mother working during the daytime | 17 | 15 | 0.16 | 0.68 |
(6) Lack of schooling/education in mother | 2 | 1 | 0.34 | 0.55 |
(7) Young mother (<19 years) | 7 | 9 | 0.28 | 0.59 |
(8) Primary level education in mother | 10 | 7 | 0.60 | 0.43 |
(9) Parents from farming community | 22 | 19 | 0.32 | 0.57 |
(10) Economic problems | 21 | 20 | 0.03 | 0.85 |
Plant poisoning in children is one of the common presentations to emergency departments. However, the risk factors and circumstances of these poisoning events are largely underexplored in international literature [
The current study identified male children more vulnerable than female children for plant poisoning. Furthermore, it also revealed that the majority of children were between 2 and 5 years of age. Unintentional poisoning accounted for more than 90% of poisoning events and almost all cases had taken the poison through ingestion. Similar observations are made in previously published studies from Sri Lanka [
A key observation in the current study was the higher transfer rate of children. The study identified that 66.4% of total population were transferred between two hospitals and 67.2% of children who attended local hospitals under RDHS were subsequently transferred to a tertiary hospital for further management. Previously published adult studies in the same region of Sri Lanka observed a transfer rate of 50% [
We observed a higher percentage of deliberate ingestions compared to a previously published study in urban Sri Lanka [
It was also revealed that 78.5% of children had ingested plant poisons within their own home gardens or neighborhoods. This figure of 78.5% is much higher compared to previous Sri Lankan studies conducted in more urban areas [
Home garden was the commonest place for poisoning with plant seeds in current study. A study from urban Sri Lanka observed
Patterns of poisoning and as well as subsequent outcome are always related to the underlying sociocultural circumstances. Observation of scientifically unproven yet culturally based first-aid practices by some parents as observed in this study can be associated with detrimental effects. Therefore providing knowledge to at-risk communities regarding such issues is helpful in bringing down childhood poisoning related morbidity and mortality.
Delayed presentation to primary care hospital following the poisoning event has a potentially strong negative impact on effective management and patient outcomes [
The current study identified four factors including presence of poisoning plants in home garden, inadequate supervision, past history of poisoning, and parents’ subjective feeling of lack of family support to look after children as being associated specifically with significantly elevated risk of plant poisoning in children. Schmertmann et al. reported inadequate supervision as a risk factor for unintentional poisoning in the paediatric age group [
The study revealed harmful effects of traditional first-aid practices which are detrimental to health of the child. Children become victims of plant poisoning mostly secondary to presence of poisoning plants in home garden, inadequate supervision by care givers, and previous poisoning. As these risk factors are significantly associated with plant poisoning, the effect of community education to enhance vigilance and assurance of safe environment should be evaluated. The study also identified the importance of awareness among healthcare workers regarding the mostly benign nature of plant poisoning in children in view of reducing expenditure on patient management.
The study was granted ethical approval by ethical review committees of Faculties of Medicine, University of Kelaniya, and Rajarata University of Sri Lanka.
Parents of all participants gave written consent for participation of their children in the study and publication of results.
The authors declare that they have no conflicts of interest.
M. B. Kavinda Chandimal Dayasiri designed the study, carried out data collection following appropriate methodology, analysed data, and wrote the manuscript. Shaluka F. Jayamanne and Chamilka Y. Jayasinghe designed the study, analysed data, and supervised manuscript writing process.
No external funding was obtained for this study.
The authors of this study acknowledge Dr. Suneth Agampodi, Head of Department of Community Medicine, and Dr. Lalith Senarathna, Senior Lecturer, Faculty of Applied Sciences, Rajarata University of Sri Lanka, for providing technical advice in data analysis, and Dr. Thilini Hemachandra and Dr. Chamila Dissanayaka of Anuradhapura Teaching Hospital, Sri Lanka, for providing support in entering data into statistical databases.