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1. Mr. Abhijit Bhoyar
COMMONHEALTH PROBEMS DURING
CHILDHOOD
POISONING, STINGS & BITES, FOREIGN BODIES

2. POISONING
• Poisoning is one of the important accidental
hazards among children.
• The children below five years of age are the
common victim of this problem.
• It may occur as acute exposure of poisonous
substance or may also occur due to chronic
exposure of poisons.
INGESTION
INHALATION
INJECTION
SKIN
CONTACT
It may occur
through

3. Common Poisoning
Agents
Poisonous seeds and plants are also ingested by
the children due to their curious nature leading
to poisoning.
Chemical products are swallowed
commonly by the children, which
include kerosene, medicines,
acids, insecticides, cosmetics,
paints, bleach, etc.

4. • Bites and stings of animals and insects also cause poisoning.
• Carbon monoxide poisoning can happen when fires, stoves, heaters or ovens are
used in rooms which do not have proper ventilation to let the gas out.
• Inhalation poisoning can also occur due to gas vapour, dust, fumes, spray, etc.
• Nearly 75% of poisoning episodes are due to ingestion of nontoxic substance
which requires reassurance to the children and parents.
• About 20% of poisoning episodes require urgent measures to remove the poison
and approximately 5% of poisoning need intensive treatment

5. Ecology of
Poisoning
• About 70% of all
cases of
accidental
poisoning in
children occur
within third years
of life.
• They have
tendency to put
objects into the
mouth without
knowing its
consequences.

6. • Large families,
• Small accommodation,
• Careless storage of potentially poisonous household substances,
• Easy availability of poisons,
• Lack of time for supervision of children,
• Lack of discipline
• Anticipatory guidance

7. Basic
Principles of
Management
Emergency
stabilization
measures
Identification of
poison
Removal of
poisonous
substance and
toxin
Specific antidote
therapy Promotion
of excretion of
toxin
Supportive therapy
Counselling to
parents and
children.
Management

8. Steps of Management
• Establish clear airway and provide ventilatory support, if the child is
unconscious and having respiratory failure.
• Positioning-Place the child in semiprone position, if possible to minimize the risk
of inhalation of gastric contents.
• Assessment-Assess the child's condition, level of consciousness, features of
complications like metabolic acidosis, hypoglycemia, hyperkalemia, shock, renal
failure, etc.

9. • Identify the poison by careful history and find supporting evidence from the
presenting features and physical signs.
• Remove the unabsorbed poison by vomiting or gastric lavage.
• Vomiting is induced by-
• Induction of vomiting is contraindicated in corrosive or kerosene poisoning,
unconscious child and child with absence of gag reflex.
• Precautions must be taken to prevent aspiration during vomiting.
(a) tickling the back
of the pharynx by
fingers or a spoon or
(b) give salt water or
warm water to drink
or
(c) give ipecac syrup.

10. • Gastric lavage should not be performed in
children with poor gag reflex or corrosive
poisoning.
• In kerosene poisoning, lavage may be
done very cautiously, when the child has
consumed a large amount of kerosene and
is brought quickly to the hospital,
otherwise it is better to avoid stomach
wash in case of ingestion of kerosene. Gastric lavage is given with warm water or
tap water and four or five washes to be
given.

11. • Removal of poison may be needed from the skin and clothing in case of organophosphorus and
related compounds which can prove as fatal as oral route absorption.
• All contaminated clothes to be removed and whole body including nail, skin-folds, groin to be
irrigated with water or saline as soon as possible after exposure and continue irrigating for at least
15 minutes.
• Eye contamination requires immediate local decontamination by copious irrigation with
neutralizing solution (normal saline or water) for at least 30 minutes.

12. The commonly used antidotes
• Atropine for organophosphate,
• Naloxone for opioid analgesics,
• Neostigmine for anticholinergic poisonous seed (dhatura),
• Pyridine-2-aldoxime-methiodide (PAM) for organophosphates,
• Diazepam for chloroquine,
• Flumazenil for benzodiazepines, etc.

13. • Allow increased fluid intake to promote renal clearance by excretion of poison through
the urine.
• Fluid diuresis by IV fluid therapy or diuretics like lasix or mannitol can be used to
enhance the elimination of toxin.
• Hemodialysis or peritoneal dialysis can also be done to remove the poison in some cases.
• Hemoperfusion is more effective than hemodialysis in some selective poisoning but
hemodialysis may be preferred for correction of acid-base and electrolyte imbalance
simultaneously.

14. • Oxygen, IV fluid and medications like anticonvulsive, antipyretics, analgesics,
antibiotics may be needed.
• Patent airway, removal of oropharyngeal secretions, position change, care of eyes,
mouth and skin, care of bladder and bowel should be emphasized.
• Oral feeding should be allowed when condition permits.
• Continuous monitoring of child's condition and intake output should be recorded

15. • Keep all relevant documents and records accurately
• Arrange for counseling of the parents and children and guide the parents for
regular psychological followup.
• Teach the parents and family members about the prevention of accidental
poisoning and need for parental supervision.

16. BITES AND
STINGS

17. Bites and stings are one form of poisoning and common
in infants and children.
Animal bites and insects' stings may lead to minor
symptoms like pain and swelling to a life-threatening
shock requiring immediate and urgent attention.
Common bites are dog bites and snake bites.
Common stings are scorpion stings and stings by bees,
ants, wasps, etc.

18. • Dog bite can result to a viral disease known as rabies or hydrophobia, especially
due to bite of a rabid dog. There is possibility of contracting rabies from other
animals (cat, monkey, horse, sheep, goat).
• Rabies in man is characterized by long incubation period, striking clinical
presentation of hydrophobia and an almost invariably fatal outcome. Rabies in
dogs takes two forms namely the furious and the dumb rabies. Once the dog
manifests clinical signs of rabies, it generally dies within a week.

19. • The virus-laden saliva (Lyssavirus type 1) of the infected animal comes in contact
with the subcutaneous and muscular tissues of the host as a result of the bite,
causing the picture of viral encephalitis.
• Transmission may occur through licks or aerosol or man-to-man (a case of a child
biting its parents).
• The incubation period of rabies ranges between 20 and 90 days in 90% of cases,
although it may vary from 10 days to over a year.

20. Clinical Manifestations
Fever, Myalgia, Headache,
Easy
fatigability,
Sore throat
and
changes in
mood.
Paresthesias
or
fasciculation
s at the site
of bite
During the initial 1 to 4 days, the patient suffers from
prodromal symptoms of

21. The prodromal stage is followed by widespread excitation and
stimulation of all parts of nervous system.
The patient is intolerant to noise, bright light or a cold draught of air.
Aerophobia or fear of air may present.
Examination may show increased reflexes and muscle spasms along
with dilatation of the pupils and increased perspiration, salivation and
lacrimation.
Mental changes include fear of death, anger, irritability and
depression.

22. • The symptoms are progressively aggravated and all attempts of swallowing liquid
become unsuccessful.
• The characteristic symptom of hydrophobia may found even at the sight or sound
of water due to spasm of muscles of deglutition.
• The patient may die abruptly during convulsion stage may pass to the stage of
paralysis and coma.

23. Diagnosis
• The diagnosis of rabies can be made with the history of dog bite, the
presence of paresthesias at the site of bite and hydrophobia.
• Confirmatory diagnosis of rabies can be made on postmorterm as
well as antemorterm by a variety of tests.
• The eosinophilic cytoplasmic inclusions, the 'Negri bodies' are
pathogenic of rabies.

24. Management
Managem
ent of
the
wound
The
rabies
prophyla
xis.
Antirabies treatment consists of two important
aspects, i.e.

25. Management of the wound
• It is done by cleaning and washing the wound with soap and running water and
then applying alcohol or tincture iodine or aqueous solution of iodine.
• Antirabies serum should be infiltrated around the wound, if the bite is less than 24
hours old.
• Tetanus toxoid should be given and antibiotics may be administered, if wound
appears unhealthy.
• There is no need of cauterization or stitching or application of oil or turmeric

26. • Passive immunization with antirabies serum combined with local treatment of the
wound and active immunization provides best-protection to the exposed
individual.
• Rabies immunoglobulin should be given for all category III exposures (single or
multiple transdermal bites or scratches and contamination of mucous membrane
with saliva).

27. • Active immunization by rabies vaccine can be provided even after exposure to the
infection due to long incubation period of rabies.
• Presently available rabies vaccines are nervous tissue vaccines and tissue culture
vaccines.
• The nervous tissue rabies vaccines are given by 7 or 14 daily doses
subcutaneously depending upon the nature of exposure.

28. • The tissue culture vaccines are scheduled on days 0, 3, 7, 14 and 30 in
intramuscular route for post-exposure and on 0, 7, 28 days for pre-exposure rabies
prophylaxis.
• Intramuscular injection should be given in anterolateral aspect of thigh and never
use gluteal region.
• An additional 6th dose on the day 90 is considered optional for post-exposure
prophylaxis.

29. • Treatment of rabies in man should be done at
intensive care unit in the form of respiratory and
cardiac support with strict isolation technique and
intensive therapy.
• Rabies in humans almost inevitably ends in death;
a few instances of recovery have been recorded.
Immunization of
the animals also
helps in
prevention of
rabies.

30. Snake Bites
• Snake bites continue to be an important public health problem in India and other
countries
• The venoms produced by snake are primarily neurotoxic.
• They act by blocking neuronal transmission at the neuromuscular junction causing
death due to respiratory depression.
• The venoms produced by the vipers are primarily cytolytic causing cellular
necrosis, vascular leak, hemolysis and coagulopathy leading to death due to
hemorrhage, shock or renal failure.

31. Clinical Features
• Clinical features depend upon the type of snakes and presented as local effects and
systemic effects.
• Elapids (cobra, krait) bites produce local pain followed by swelling within 2 to 3
hours and rapid necrosis sets in as wet gangrene.
• Systemic manifestations occur within 15 minutes to 10 hours after the bites, as
neurotoxic and cardiotoxic features.

32. • Paralysis begins with ptosis and ophthalmoplegia followed by involvement of
muscles of palate, jaws, tongue, larynx, neck, deglutition and respiratory.
• Cardiotoxic effects include tachycardia, hypotension and ECG changes.
Hemolysis may also occur.

33. • Vipers' bites produce severe burning pain with dramatic appearance of edema, swelling,
cellulitis, bullae and ecchymoses at the site of the bite.
• Continuous oozing or bleeding may occur.
• Local necrosis is slow in onset and resembles dry gangrene.
• Systemic manifestations may occur within 15 minutes or may be delayed by several
hours and presented with bleeding from puncture sites, purpura, hematemesis, melena,
epistaxis, hematuria, gum bleeding, intracranial hemorrhage,
• etc. Circulatory collapse, delirium and renal failure may occur.

34. First Aid Management
• First aid management of snake bites includes reassurance, rest and moral support
with immobilization of patient and bitten part in horizontal position.
• Manipulation of the bitten part, exertion and exercise must be avoided.
• Do not give alcoholic drinks or stimulants to the patient.
• Incision and suction of the wound is no longer recommended.

35. • A wide tourniquet or crepe bandage to be applied proximal to the bite site to
occlude the lymphatics only, therefore it should not be too tight.
• It should be released and moved proximally as the advancing swelling augments
the tightness of the bandage.
• The level of swelling should be marked.
• The patient should be transferred promptly for definitive medical treatment.

36. Hospital Management
• Immediate hospital management should include management of shock, respiratory
failure by mechanical ventilation and antivenom therapy.
• Neostigmine-atropine regimen can be effectively used in case of Elapids venom.
• Supportive care includes fresh whole blood transfusion for blood loss, appropriate
antibiotic therapy for secondary infection, wound care and hemodialysis in renal
failure.

37. • The overall mortality due to snake bite is about 10%.
• The major reason of poor outcome is the delay to reach to hospital for definitive
treatment and non-availability of antivenin in most hospitals.
• Awareness to be promoted to prevent snake bites and to avail medical facilities as
early as possible, in case of snake bites.

38. Insects Stings
• Insects' stings are commonly found in rural and coastal areas.
• Scorpion stings are second only to snake bites as a cause of fatal envenomation.
• It occurs mainly in wet and summer months.
• The red scorpion is extremely dangerous.
• Insects' stings also include bees, wasps, ants and beetles.

39. • Scorpion stings may be fatal because scorpion venom is neurotoxic, cardiotoxic,
hematotoxic and myotoxic and having wide range of local and systemic
manifestations.
• The child may present following the scorpion stings with intense local pain,
swelling and ecchymosis.

40. Clinical manifestation
• Profuse perspiration, tachypnea,
vomiting, hypersalivation, lacrimation,
frequent passage of urine and stool are
the most prominent features of
autonomic storm.
• The children usually have convulsions,
hemiplegia and other neurological
deficits with shock, respiratory
distress, acute renal failure,
coagulopathy and cardiomyopathy.

41. Management
• Management of scorpion stings should be done promptly as no first aid measures
are of particular value.
• A tourniquet should be applied immediately with precautions.
• The wound should be washed with plain water and the part should be
immobilized.
• Local anesthetics to be used (lignocaine) to reduce pain.
• Oxygen therapy, drugs and IV infusion to be started to manage shock.

42. • Symptomatic treatment to be given promptly with adrenergic blocking agent
(prazosin), diuretic, bronchodilators and insulin which may be useful.
• The antivenom therapy and lytic cocktail regimen for scorpion stings are
controversial.
• Tetanus prophylaxis should be given.
• Prevention of scorpion stings should be promoted.

43. • Bees and wasps' stings to be managed by local cooling, removal of visible sting,
application of soothing lotion (calamine) or anesthetic cream, oral analgesic and
antihistamine.
• Adrenaline may be needed in anaphylactic manifestations along with other
supportive management.

44. • Ants' stings may be managed by application of cold compresses, washing of sites
with soap and water, applying local antiseptics, oral or topical antihistamines, oral
corticosteroids and analgesics.
• Severe reactions necessitate immediate subcutaneous injection of 0.3 to 0.5 mL of
1:1000 solution of epinephrine and repeated at ten minute intervals, if necessary.

45. Nursing responsibility
• Nursing responsibility in relation to bites and stings are mainly promoting
awareness about the prevention of this problem.
• Prompt management at hospitalization should be initiated to prevent complications
and fatal outcome.
• Parental support and providing information about the probable outcome are
important aspects of nursing liability.

46. • Children are fond of putting objects into various orifices either their own or others
due to curiosity or innocence, during the oral phase of psychosocial development
and thereafter.
• Objects inserted into the nose, ears, anus, vagina are usually easy to manage but
foreign bodies in the mouth can be difficult and often life-threatening because they
may track down into the respiratory tract or in the alimentary tract.
FOREIGN BODIES

47. • Foreign bodies in the eyes may also create serious problem but in the soft tissue
may be managed easily.
• Foreign Bodies in the Respiratory Tract
• Aspiration of foreign bodies into the respiratory tract is quite common in children.
About 75% cases seeds, nuts and other vegetable matters are inhaled in the
airways.

48. • Inert materials like glass bead, plastic piece (from toy, ball pen), stone, screw, etc.
can also aspirate in respiratory passage.
• This problem is common in male toddlers.
• A definite history of foreign body inhalation is not always available.
• The child may present with acute airway obstruction.

49. Clinical features
• Sneezing,
• Discomfort
• Serosanguinous discharge.
• Sudden choking,
• Aphonia
• Even death,
• Wheezing,
• Hoarseness,
• Hemoptysis,
• Cyanosis and dyspnea.
• Tachypnea,
• Pneumonitis and bronchiectasis
• Lung abscess, atelectasis and
emphysema

50. Diagnosis
• Plain chest X-ray (including neck and diaphragm).
• Bronchoscopy.

51. Emergency Management
• Emergency management of foreign body inhalation at
home can be done with precautions by hanging the
child upside down, thumping over the back, groping
with fingers in the pharynx, back blows, chest thrusts,
Heimlich maneuver, etc.
• In hospital, once the diagnosis is established or
strongly suspected, bronchoscopy should be done as
soon as possible. After bronchoscopy, some children
may need humidification, parenteral steroids,
antibiotics and chest physiotherapy.

53. • Tracheotomy may be needed when large vegetable foreign body swells up and
difficult to remove through larynx or in case of laryngeal obstruction.
• Thoracotomy and bronchotomy may be required in case of impacted long-standing
foreign bodies in the bronchus.

54. Foreign Bodies in the Alimentary Tract
• Ingestion of foreign bodies is also common like inhalation.
• The majority of swallowed foreign bodies are spontaneously passed in the stool;
some may require endoscopic or operative removal.
• The commonly ingested foreign bodies are coins, button, cell, key, safety pin,
rings, pencil sharper and sometime trichobezoar (bolus of hair) or cotton from
clothes.

55. • Initial features of foreign body ingestion may be same as foreign body inhalation
but the coughing is not severe and there is minimal choking and gagging.
• This is usually followed by dysphagia, drooling of saliva and retrosternal or
epigastric discomfort, if the foreign body gets impacted in the esophagus.

56. • When the foreign body passed beyond the esophagus, it remains asymptomatic
and spontaneously removed in the stool within 4 to 5 days.
• Impaction of foreign body in the gastrointestinal tract may present with features of
intestinal obstruction, peritonitis, etc.

57. Preventive measures
• Children must be supervised and watched carefully by the caretakers.
• Harmful small articles and toys with detachable small parts should not be allowed
to the child or to be kept out of their reach.
• A foreign body in any parts of the body should be managed immediately with
special attention.

58. • Foreign bodies in the aero-digestive tract can be a life-threatening emergency
requiring immediate management.
• It is, therefore, important that public awareness should be increased by health
education about the different preventive approaches.
• Nurses are the key person to educate the people and make them aware about the
prevention of these hazards.