Child poisonings are more common in households experiencing psychosocial stressors
- Correspondence to: Dr Alan David Woolf
Department of Pediatrics, Harvard Medical School, 1 Shattuck Street, Boston, MA 02111, USA;
Commentary on Tyrrell EG, Orton E, Tata LJ, et al. Children at risk of medicinal and non-medicinal poisoning: a population-based case-control study in general practice. Br J Gen Pract 2012;62:e827–33.
For more than 50 years, clinicians have understood that there is often more to a childhood poisoning event than can be summed up as a random ‘accident’ or an unavoidable ‘act of God’. Indeed many studies have pointed to a disproportionate number of such incidents occurring in single-parent families or those under the stress of recent moves or financial hardships.1–3 Poisoned children, sometimes, have parents who are socially isolated or have issues of mental or physical illness.1 ,2 Poisonings involving toddlers most often occur in their homes, when hazardous products or potent medicines may be easily available.4 These events are more likely when parents are distracted (eg, during mealtimes or when they are outside of their usual routines, such as during holidays).
The dynamic of childhood poisoning is that of the intersection of a vulnerable host exposed to a toxic agent in a conducive environment. While clinicians have focused on defining the toxic agent and what therapies will avert serious medical consequences, more energy might be devoted to investigating what ‘conducive’ environment constitutes the hazard and what characteristics of the ‘vulnerable’ parent–child dyad warrant attention in designing effective strategies for prevention.
Tyrrell and colleagues’ recent case–control study compared two groups of children, one poisoned by medicinals (N=1316) and the other non-medicinals (N=503) with more than 17 700 non-poisoned, similarly aged children who were followed in primary care. The study used The Health Improvement Network database, an accumulation of data taken from the health records of families followed in general practice in Britain between 1988 and 2004. The purpose was to see in what ways these groups might differ, if at all, in family structure or circumstances, allowing poisoning prevention outreach strategies to be tailored to family needs.
The results showed a higher rate of poisoning among children in single-parent households, those with younger mothers and those in families experiencing circumstances of social and economic deprivation. There was a disproportionately higher risk of medicinal poisoning among 2-year-olds (adjusted OR 9.61, 95% CI 7.73 to 11.95)—this is the age when ambulation, climbing, fine motor skills and curiosity all coalesce and the need for supervision by adults is maximal. Children aged 1–2 years were at a higher risk of poisoning with non-medicinal agents (adjusted OR 5.44, 95% CI 4.07 to 7.26), possibly because such products are frequently stored in low, easily accessible cabinets. Poisoned children were more likely to have mothers with histories of clinical depression and/or alcohol misuse. These results confirm and extend the findings of previous studies.1–4
While storage practices of both medicinals and non-medicinals may remain static (eg, in a cupboard under the bathroom or kitchen sink), the use of child-resistant containers is an effective prevention measure. Parental behaviours governing which products are bought and brought into the home, how and when they are used and stored and how well children are supervised are complex, dynamic and ever-changing. Multiple studies, including the present study, confirm the relationship between children's developmental attainments and their risk of poisoning.4 ,5 However, this study also suggests that, during health care visits, practitioners must identify parents living in circumstances of severe deprivation and those with mental health problems and/or alcohol misuse issues, and target them for action. Practitioners can and should provide access to resources to help these families become healthier and better organised, forestalling poisoning incidents by better supervision and safer storage practices. Such a counselling has been shown to change parental knowledge in a variety of settings,6 though its ultimate effect on poisoning rates remains unclear. One thing is clear: those prevention strategies that fail to recognise the importance of factors such as the behaviour of the child, his or her interactions with, and supervision by, parents and others, the family's level of stress and its access to financial and other resources have little chance of success.