FEASIBILITY AND ACCEPTABILITY


FEASIBILITY AND ACCEPTABILITY OF OBJECTIVE STRUCTURED CLINICAL EXAMINATION (OSCE) FOR A LARGE NUMBER OF CANDIDATES: EXPERIENCE AT A UNIVERSITY HOSPITAL

 

Gamal A. Khairy, FRCS, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia

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هدف الدارسة : تقييم إمكانية تحقيق وقبول تطبيق نظام الإختبار السريري الموضوعي ( أوسكي ) على مجموعة كبيرة من طلبة الطب .

طريقة الدارسة : تم اختيار ثلاثمائة من طلبة كلية الطب الذين أنهوا فترة التدريب الأساسية في الجراحة وذلك باتباع طريقة الاختبار السريري ( أوسكي ) للمرة الأولى في كلية الطب ، الرياض . هناك ورقة إستبيان تم ملؤها من قبل المختبرين في نهاية كل اختبار بالإضافة إلى ورقة إستبيان أخرى تم ملؤها من قبل الطلاب أنفسهم لإبداء رأيهم في كل جوانب الامتحان .

نتائج الدارسة : كل الطلاب أجمعوا على أن تنظيم الاختبار كان سلساً والوقت الذي أعطى لكل مرحلة كان كافياً . 86% من الطلاب وافقوا على أن الأسئلة كانت من ضمن المنهاج أثناء فترة التدريب . 82% من الطلاب أجمعوا على أن الاختبار منصف وهادف . 93% رغبوا في تطبيق هذا النمط من الاختبارات في السنوات القادمة بدلاً من الاختبار التقليدي ( الكتابي مع حالة سريرية واحدة طويلة ) كما أن المختبرين الذين شاركوا بالاختبار أعطوا نفس الانطباع .

الاستنتاج : الأوسكي طريقة عملية ومقبولة لتقييم المهارات الجراحية الأساسية لطلاب كلية الطب وحتى بالنسبة للعدد الكبير منهم إذا توفرت الإمكانيات المطلوبة في مركز الاختبار .

 

الكلمات المرجعية : أوسكي – كلية الطب – اختبارات الجراحة .

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Objective: To assess the feasibility and acceptability of using objective structured clinical examination (OSCE) for a large number of medical students.

Methods: All medical students (291) who had completed the basic surgical course were examined by objective structured clinical examination (OSCE) at the College of Medicine, Riyadh, for the first time.  A 5-scale questionnaire was filled by the examiners at the end of the examination each day.  Another questionnaire was filled by the students as a feedback.

Results:All students agreed that the organizational aspect of the examinations was smooth and the time for each station was adequate. 86% of the students agreed that the stations were within the content of the course, 82% agreed that the examination was fair and objective and 93% wanted this method to be followed in the assessment of third year medical students, instead of the traditional examination (written and single long case).  Similar responses were received from the examiners who were involved in the exams.

Conclusion: OSCE is a practical and acceptable method for assessing medical students' basic surgical skills, even for a large number of candidates, if facilities are available in the examination center. Replacing written exams with OSCE depends on the design of stations to test knowledge adequately in scope and depth probably at problem solving level.

 

Key Words: OSCE, medical students, surgery exams

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INTRODUCTION

In recent years, there has been growing dissatisfaction in medical schools with the traditional methods of student assessment based on written examinations and faculty ratings of performance in clinical training.  This is because of the limited skills assessed through written tests and psychometric problems associated with the rating


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Correspondence to:

Dr. Gamal A. Khairy, FRCS, MS,Assistant Professor & Consultant Surgeon, Department of Surgery, College of Medicine and King Khalid University Hospital, P.O. Box 7805, Riyadh 11472, Saudi Arabia

E-mail: gkhairy@ksu.edu.sa


of performance.1 Clinical competence refers to a complex set of skills that include the abilities to interview, perform a physical examination, make diagnostic and treatment decisions, and while demonstrating good interpersonal skills communicate with a patient and his or her family.2 The importance of the assessment of these skills, which are usually not systematically done in medical schools has been identified by many associations,3 addressed in several conferences and reports,4-5 and  already has been applied in some medical schools in many parts of the world.7-8

        The purpose of this prospective cross-sectional study is to examine the feasibility and acceptability of an objective structured clinical examination (OSCE) which was used to examine a large number of medical students for the first time at our institution.

 

MATERIAL AND METHODS

A total population (two hundred and ninety one) of medical students who had completed the basic surgical course (mainly history-taking and physical examination) at the College of Medicine, Riyadh, were examined by OSCE.

        Forty consultant surgeons (examiners) were involved in a two-day examination, in four surgical wards.  In addition, 8 surgical registrars organized the examinations. During the examination the students rotated round ten stations in each surgical ward at the same time, spending 4 - 5 minutes at each station.  On a bell signal, the student moved to the next station.  The time assigned was the same for all stations. A further 30 seconds was allowed for the student to move to the next station and for the examiner to finalize comments on the previous student’s performance.  Where the distance between two stations was long, a rest station was placed between them.

        The assessment at each station was limited to the techniques of history-taking, physical- examination and differential diagnosis. Stations were either manned, with real or simulated cases or unmanned with pictures of clinical cases. The examiners used checklists to record the performance of the students at the manned stations.  A 5-point scale answer questionnaire comprising 12 questions was completed (Appendix I).  This was completed each day by all examiners immediately after the examination. Another feedback questionnaire was constructed for the students examined.  Both questionnaires were in English.

 

RESULTS

The total number of students who were examined was 291 (208 male and 83 females). Almost all of the students agreed that the organization of the examinations was smooth and the time allotted for each station was adequate.  The exam was described as fair and objective by 86% of the students, and 93% wanted this to be the method of assessment for third year surgical course.

        All of the examiners agreed that the organization was smooth and the stations were within the scope of the course.  The vast majority of the examiners (90%) agreed that the examinations were fair and objective and 78% preferred this method of assessment to the traditional method (written and single long case examination).

        Forty clinical cases (real and simulated) were used on both days of examination.  Patients were cooperative despite being examined by a large number of students on the same day. Another group of clinical cases were used on Day 2.

 

DISCUSSION

In our institution, the method used in the assessment for the third year medical students who have completed the basic surgical course, are the traditional written and long case clinical examinations.  These methods have many shortcomings. Firstly, there is no guarantee that students would be able to use their knowledge in the care of patients or apply their clinical skills in the appropriate situations.  Several studies9,10 have shown that students’ clinical performances are rarely observed by faculty in written examinations.  Secondly, with regard to the long case clinical examination, there is great variability both in the patients assigned to students and in the criteria used by individual faculty members in rating students' performance. Therefore, the current methods tend to be mostly subjective and not standardized. These negative effects of traditional methods of assessment have often been reported.11-13

        In 1979, Harden14 described the first objective structured clinical examination (OSCE). This method has dramatically changed the assessment of clinical competence and had a significant impact on future doctors' training and practice.15 OSCE fulfills most of the criteria needed to assess clinical competence especially because of its greater objectivity and the fact that the areas tested are uniformly applied by the examiners.  It is envisaged that students' skills in history-taking and physical examination, the essential content of the basic surgical course for the third year medical students would be tested. This would leave investigations, diagnosis and treatment to be included in the final year surgical course.  In OSCE, the various components of clinical competence such as history-taking, examining the abdomen, commenting on a picture of a patient…etc are tested in phases; each component assessed in turn and dealt with at one of the stations in the examination.

        All the examiners who participated in the study agreed that the stations were within the purview of the course.  For our students, this method of assessment was highly acceptable.  The faculty in turn could decide in advance the items to be examined (history-taking, physical examination and differential diagnosis) and design the stations accordingly. Furthermore, the content, structure and complexity of the examination (e.g. more straight-forward cases for junior students) are easily controlled.  Besides, the use of the checklists by the examiners resulted in a more objective assessment, and with ten stations, a larger sample of the student’ skills were tested.  For this reason, 78% of the teaching staff who responded to the questionnaire recommend this method for examining the third year medical students, even though OSCEs are time-consuming and labor-intensive.16

        The OSCE is considered a significant contribution to the improvement of the methods of testing students' clinical skills in medicine,17 and is known to be more valid in the assessment of clinical skills, both in undergraduate and postgraduate training.18 OSCEs combine the reality of live clinical interactions, the standardization of problems and the use of multiple observations of each student.  Consequently, it is rapidly replacing other forms of assessment at all levels of medical and health professional education, licensure and certification.19

        The organization of OSCE is complex and time consuming especially when many stations are to be used.20 These and other logistic limitations have restricted its application to smaller groups.18 Although this method of assessment was used for the first time at our institution, it was successful for a large number of candidates (291 medical students).

        Simulated cases which were well-controlled by checklists were used  in a few stations (e.g. asking the student to examine a normal abdomen or to take a history from the examiner himself).  Standardized patients (SPs) have been used before in the OSCE format.  SPs are individuals with or without actual disease, who have been trained to portray a medical condition in a consistent manner.21 SPs can also evaluate skills in interviewing interpersonal relationships, and communication.22 With the proper training, SPs were known to provide consistent and accurate simulations and recordings of performance by medical students and professionals.23 They are the gold standards for measuring the competence of students and the quality of the practice of physicians.24  Since the use of OSCE was the first in our surgical course, no SPs were used, but there are plans to use them in the coming exams.

        In conclusion, OSCEs are practical and acceptable methods for assessing medical students' basic surgical skills.  If facilities are available (manpower, surgical wards, clinical cases and an enthusiastic organizing committee), a large number of candidates can be accommodated. In our institution, the OSCE is now the method of assessment for the third year medical students who have completed the basic surgical course.

 

ACKNOWLEDGMENT

The author would like to thank the 3rd year medical students, the examiners and both Ms. Cora Rivera and Ms. Arlene Dasco for their expert secretarial assistance.

 

REFERENCES

1.     Van der Vleuten CPM, Swanson DB.  Assessment of clinical skills with standardized patients: State of the art.  Teach Learn Med 1990; 2:58-76.

2.     NU Veit Vu, Howard SB, Marcy ML, Steven JV, Jerry AC, Terry T.  Six years of comprehensive, clinical, performance based assessment using standardized patients at the Southern Illinois University School of Medicine.  Acad Med 1992; 67:42-50.

3.     Muller S. (Chairman).  Physicians for the Twenty-First Century: Report of the project panel on the general professional education of the physician and college preparation for medicine.  J Med Educ 1984; 59: Part 2.

4.     Gastel B and Rogers DE, eds.  Clinical education and the doctor of tomorrow.  New York: New York Academy of Medicine 1989. 

5.     Marini CJM. Evaluating the competence of health professionals.  JAMA 1988; 260:1057-8.

6.     Sibbald D, Regehr G.  Impact on the psychometric properties of a pharmacy OSCE: Using first-year students as standardized patients.  Teach learn Med 2003; 15:180-5.

7.     Hart J, Harden R (Eds).  Further development in assessing clinical competence.  Montreal: Can Heal 1987.

8.     Davis MH.  OSCE: The Dundee Experience: Montreal.  Med Teach 2003; 25:255-61.

9.     Engel GL.  Are medical schools neglecting clinical skills?  JAMA  1976; 236:861-3.

10.   Stillman P, Regan MB, Swanson DA. Diagnostic fourth-year performance assessment.  Arch Intern Med 1987; 19:1981-5.

11.   Sternburg JK, and Brokway BS.  Evaluation of clinical skills: An asset-oriented approach.  J Fam Pract 1979; 8:1243-1245.

12.   Shakun EN.  The clinical skills assessment form: A preliminary examination in paediatric examinations.  Eval Health Professions 1981; 4:330-7.

13.   Largerkvist B, Samuelsson B, Sjolin S.  Evaluation of the clinical performance and skill in paediatrics of medical students.  Med Educ 1976; 10:176-8.

14.   Harden RM, Gleeson FA.  Assessment of clinical competence using an objective, structured clinical examination (OSCE).  Med Educ 1979; 13:41-54.

15.   Hodges B.  OSCE! Variations on a theme by Harden.  Med Educ 2003; 37:1134-40.

16.   Zantman RR, McWhorter AG, Seale NS, Boone WJ. Using OSCE based evaluation: Curricular impact overtime.  J Dent Edu, 2002; 66:1323-30.

17.   Murto SH, MacFadyen JC. Standard setting: A comparison of case-author and modified borderline-group methods in a small scale OSCE.  Acad Med 2002; 77:729-32.

18.   Karmer AW, Jansen JM, Zuithoff P, Dusman H, Tan LH, Van der VLenten Cp.  Predictive validity of a written knowledge test of skills for an OSCE in postgraduate training for general practice.  Med Educ 2002; 36:812-9.

19.   Mellroy JH, Hodges B, McNaughton N, Reghr G.  The effect of candidate’s perceptions of the evaluation method on reliability of checklist and global rating scores in an objective structured clinical examination.  Acad Med 2002; 77:725-8.

20.   Carpenter JL.  Cost analysis of objective structure clinical examination.  Acad Med 1995; 70:828-33.

21.   Consensus statement of the researchers of clinical skills assessment (RCSA) on the use of standardized patients to evaluate clinical skills.  Acad Med 1993; 68:475-7.

22.   Stillman PL.  Session three: technical issues: Logistics.  Acad Med 1993; 68:464-70.

23.   Vu NV, Barrows HS.  Use of standardized patients in clinical assessments: Recent developments and measurement findings.  Edu Res 1994; 23:23-30.

24.   Peabody JW, Luck J, Glassman P.  Comparison of vignettes, standardized patients and chart abstraction: A prospective validation study of 3 methods for measuring quality.  JAMA 2000; 283: 1715-22.


 

      


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TEACHING TIPS


TEACHING TIPS - QUESTIONING

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Questioning is a fundamental method of teaching. Posing certain questions can help learners develop a greater degree of understanding. In fact, questioning "opens" the learner's thinking and checks misunderstanding.

 

The Purpose of Questioning

1.   To arouse interest in the subject

2.   To test the previous knowledge of the subject

3.   To motivate the students through allowing them to demonstrate success

4.   To help understanding through getting the students to rephrase in their own words

5.   To promote discussion and help give new insights by challenging or guiding questions

6.   To strengthen (consolidate) learning by asking the students to summarize

7.   To stimulate critical thinking through encouraging making conclusions

8.   To facilitate diagnosis (or evaluation) of students strengths and weakness

 

Types of questions

There are two categories of questions: closed questions, which can be answered with a yes, or no, and open questions, which aim to elicit more expansive replies and encourage further discussion. While closed questions only check knowledge or understanding, open questions stimulate high order thinking (i.e. reasoning, judgment, problem-solving). Prefixing a question with How, Why, Explain, Compare, What if or Predict (provoking words) make it more likely to be an open-ended question.

 

Guidelines for Effective Questioning

1.   Focus on objectives (think about the purpose of the question)

2.   Ask only one question at a time

3.   Use interpretative and problem-solving questions rather than questions requiring recall

4.   Braden ideas by using questions that involve comparison or different viewpoints

5.   Wait for some time, between asking and expecting an answer, to allow students to think

6.   If students do not respond rephrase or clarify the question

7.   Use verbal encouragement (e.g. Go on) and non-verbal encouragement (e.g. Smiling) to get further response

8.   Give negative feedback to wrong answers by focusing on the response (not the student)

 

Professor Khalid Al-Umran

Chief, Directorate of Medical Education

College of Medicine, King Faisal University

Dammam, Saudi Arabia


   


-0001-11-30

ACUTE ABDOMEN


ACUTE ABDOMEN WITH PNEUMOPERITONEUM

 

Zafer S. Matar, FACHARTZ, ABS, Aseer Central Hospital, Abha, Saudi Arabia

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يعد التهاب الزائدة الدودية  الحاد  من أكثر الأسباب شيوعاً لآلام البطن ، لكنه يعد من الأسباب النادرة لوجود الهواء في الغشاء البريتوني .

في هذه الحالة الوصفية نعرض  حالة أحد المرضى الذين أحضروا إلى قسم الطوارئ وهو يشتكي من ألم حاد في البطن 

وتم عمل التحاليل والفحوصات الإشعاعية التي بينت أنه يعاني من التهاب حاد في الزائدة الدودية أدت إلى انفجارها وحدوث تجمع هوائي في الغشاء البريتوني ، كما نستعرض في هذا التقرير مراجعة أدبية للحالات المشابة .

 

الكلمات المرجعية: ألم البطن الحاد، الغشاء البريتوني..

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Acute appendicitis is a common cause of acute abdomen. However, it is a rare cause of pneumoperitonium.  In this report the surgical diagnoses and management will be discussed in detail.

 

Key Words: Acute abdomen, peritoneum.

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INTRODUCTION

Acute appendicitis is one of the most common surgical diagnoses in acute abdomen.1 Although, its clinical features are  straight forward, sometimes they could be confused, particularly, if history taking was difficult or plain X-ray of the abdomen showed rare relevant findings such as pneumoperitonium.

 

CASE REPORT

A 30-year-old Indian male was brought to the Accident and Emergency Department of  King Khalid Hospital in Al-Kharj with a history of abdominal pain which was steadily increasing with nausea but there was neither vomiting nor fever. There were no previous abdominal symptoms and no history of drug use. Initial examination showed normal vital signs as follows: temperature 370C, pulse 80/min, blood pressure  120/80mmHg.

        Physical examination revealed the following: The patient was ill and mildly dehydrated. There was generalized abdominal tenderness and guarding, bowel sounds were absent, but per-rectal examination  was normal. Chest and heart were unremarkable.

        On admission, investigations revealed the following results: CBC showed mild leukocytosis 14.300, serum bilirubin was 1.5mg/dl. X-ray chest showed gas under the right diaphragm (Figure 1). Based on  this  data, the diagnosis of perforated peptic ulcer was made.

        Management of the case started with the correction of dehydration with crystalloid solution, and patient was moved to the operating room for  exploratory laparotomy. The abdomen was opened by an upper mid line incision.  Turbid foul-smelling fluid in the pelvis was noted. Swab was taken for culture and sensitivity.  The appendix was found to be gangrenous and perforated at its tip and adherent to the sigmoid colon and ileum. The stomach, duodenum and all other structures were normal.  Appendicectomy was done, peritoneal toilet was carried out and the abdomen was closed. Postoperative period was uneventful.

        The pelvic fluid swab for culture and sensitivity showed E. Coli. Histopathology confirmed gangrenous perforated appendix.  Patient was discharged from the hospital on 6th  postoperative day.

 


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Correspondence to:

Dr. Zafer S. Matar, P.O. Box 11176, Abha, Saudi Arabia   E-mail: zafer_s_m@hotmail.com

 


 

 

Figure 1: Chest X-ray

 

DISCUSSION

Perforated appendix is a common complication of acute appendicitis with an estimated incidence of 20%.1 However, pneumoperitoneum is rarely found in association with perforated appendicitis.  Few  articles  have  been  published  in  medical

literature about this subject since first case was reported by Gulleurin in 1923 quoted by Sabeo.2 A study conducted  in Portland  to find the reasons  for pneumoperitonium  among patients with  intrabdominal ruptured or perforated viscus did not reveal a single case caused by perforated appendicitis.3 The reason for the low incidence includes inadequate reporting and the absence of X-ray studies as  emphasized by Farman et al and Harned.4,5

        Although most pneumoperitoneum occur as perforated peptic ulcer, it is important not to  miss the perforated appendix as a cause for this condition, particularly if exploratory laparotomy shows normal stomach and duodenum as seen in this case. The site of perforation of the appendix in this case was at the tip.  This finding was similar to that mentioned by Cannova et al.6

        The culture of peritoneal fluid revealed E.Coli, whereas Katz et al  mentioned a mixed growth of streptococcus bovi, type II, bacteroides species.7 To our best knowledge, this is the first case of appendicitis  with pneumoperitoneum reported in the Kingdom of Saudi Arabia.

 

ACKNOWLEDGMENT

My appreciation goes to  Dr. Mohammed Ashfaque Khan for his  help  in typing the draft of this report. 

 

REFERENCES

1.     Tierney LM, McPhee SJ, Papadakis MA. Current Medical Diagnosis & Treatment .37th edition ,1998; pp 600-601.  Appleton & Lange, Stamford (UK). 

2.     Saebo A.  pneumoperitonium  associated with perforated appendicitis. Acta Chir Scand 1978;144(2):115-7.

3.     Winek TG, Mosely HS, Grout G, Luallin D. Pneumoperitoneum and its association with ruptured abdominal viscus. Arch Surg 1988; 123(6):709-12.

4.     Farman J, Kassner EG, Dallemand S, Stein HD. Pneumoperitoneum and appendicitis. Gastrointest Radiol 1976; 1( 3): 277-9.

5.     Harned RK.  Retrocecal appendicitis presenting with air in the subhepatic space. Am J Roentgenol 1976;126(2):416-8.

6.     Cannova JV, Krummen DM, Nicholson OO. Pneumoperitoneum in association with perforated appendicitis. Am Surg 1995; 61(4): 324-5.

7.     Katz E , Engelhard D, Kerem E, Eid A, Berlatzki Y. Coma in an unusual case of perforated appendicitis with pneumoperitoneum. J Pediatr Surg 1987;22(11) : 1017-8.


 

  


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PERCEPTIONS AND SATISFACTION


PATTERN OF CHILDHOOD POISONING IN ABHA CITY – SOUTHWESTERN SAUDI ARABIA

 

Mohammed A. Al-Shehri, FRCPC, College of Medicine and Medical Sciences, King Khalid University, Abha, Saudi Arabia

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هدف الدراسة: وصف النموذج النمطي لتسممات الأطفال في قسم الأطفال وقسم الإسعاف في مستشفى عسير المركزي، وذلك من أجل الوصول إلى معرفة الأسباب الكامنة خلفها وبالتالي اقتراح طرق الوقاية.

طريقة الدراسة: هذه دراسة استرجاعية للأطفال المصابين بالتسمم والذين راجعوا قسم الإسعاف في مستشفى عسير المركزي أو الذين تم قبولهم في قسم الأطفال في نفس المستشفى في مدينة أبها، المملكة العربية السعودية، وذلك خلال الفترة من كانون الثاني عام 2000 ميلادية وحتى كانون الأول عام 2003 ميلادية. تمت هذه الدراسة على الأطفال الذين تقل أعمارهم عن 12 سنة. تمت مراجعة السجلات الطبية من أجل جمع المعلومات السريرية التالية مثل العمر والجنس ونوع التسمم والحالة السريرية وقت الإدخال للمستشفى، وكذلك تاريخ ومكان ووقت التعرض للعامل السمي.

نتائج الدراسة: تم دراسة 114 طفلاً في حالة تسمم ممن تقل أعمارهم عن 12 سنة. وقد وجد أن الأطفال من عمر 2- 4 سنوات كانوا أكثر عرضة للتسممات ( نسبة 81% ). وكانت نسبة الذكور ( 68% ) والإناث ( 32% ) وذلك بنسبة 2: 2.1. معظم العوامل المسممة كانت الأدوية الطبية ( 72% ). وبإعتبار الحالة السريرية وقت الإدخال للمستشفى فإن الأعراض والعلامات التالية مثل التهويم ( النعاس ) والغثيان والإقياء وكذلك الألم البطني، كانت موجودة في 82% من الحالات. 80% من الحالات التسممية المدخلة للمستشفى كانت في وقت النهار، و 71% من الحالات التسممية كانت خلال الفترة من شهر حزيران إلى شهر آب. وبالنسبة لمكان التعرض للمادة السامة، فإن غرف المعيشة والنوم كانت هي المكان في 58% من الحالات.

الخلاصة: حصلت معظم التسممات عند الأطفال قبل عمر الأربع سنوات وكانت معظمها نهارية الحدوث وأكثرها في فصل الصيف. كانت الأدوية الطبية هي معظم العوامل المسببة للتسمم وغرف المعيشة والنوم هي من أكثر الأماكن التي يتعرض فيها الأطفال للتسمم.

إن المراقبة الجيدة والمستمرة من قبل الأهل هي أساسية ولاسيما خلال العمر من 1 – 5 سنوات. وكذلك استخدام العبوات المقاومة للفتح من قبل الأطفال لتخزين الأدوية والمواد المستعملة في المنزل.

 

الكلمات المرجعية: التسمم ، مستشفى عسير المركزي ، طوارئ المستشفى.

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Objective: To describe the pattern of  childhood poisoning in the Emergency Room (ER) of the Pediatrics Department in Aseer Central Hospital (ACH), in order to suggest possible causes and preventive measures.

Methods: This is a retrospective study of cases of childhood poisoning or ingestions attending the pediatric emergency room of Aseer Central Hospital or those admitted to the Pediatric Department of same hospital in Abha, Kingdom of Saudi Arabia, during the period of January 2000 to December 2003.  Children aged 12 years and below were included.  Review of records was done to collect data on clinical information such as age, sex, type of poison, clinical condition on admission as well as the time, place and date of exposure to the offending agent.

Results: In this study, 114 poisoned children aged 12 years and below were studied.  It was found that children from 2-4 years were more liable to poisoning (81%, p<0.001).  Males were (68%) while females were (32%), with a sex ratio of 2.2:1.  Medical drugs offended the most (72%, p<0.001). As regards clinical condition on admission, drowsiness, nausea and vomiting as well as abdominal pain represented (82%) of the cases.  Daytime was when 80% of poisoned cases were admitted (p<0.001).  The peak months were from June to August (71%, p<0.01).  As regard the place of exposure to offending agent, living rooms and bedrooms accounted for 58% of the cases(p<001).

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Correspondence to:

Dr. Mohammed A. Al-Shehri, FRCPC, Department of Pediatrics, College of Medicine & Medical Sciences, King Khalid University, P.O. Box 641, Abha, Saudi Arabia   E-mail: fariss2000@yahoo.com

Conclusion: The peak age for poisonings in children is before the age of four with significantly high diurnal frequency, significant seasonal variation in favor of summer. Medical drugs were the most common agents of poisoning, and living rooms and bedrooms the places where most poisoning occurred. Good and continuous supervision by parents is essential, especially from the age 1-5 years.  There should also be legislation for the use of child resistant containers for home medicines and household agents.

 

Key Words:  Poisoning, Aseer Central Hospital (ACH) and Emergency room (ER).

_______________________________________________________________________________________

 


INTRODUCTION

Accidental ingestion of poisons and household substances, a potential source of morbidity and mortality in children all over the world,1,2 is a significant public health problem.  While this may be accidental, non accidental or iatrogenic in young children, it is usually deliberate among older children especially in industrialized countries.3  Most frequently, however, the ingested substances are taken accidentally.  The ingested poisons can be classified into drugs (prescribed or non-prescribed), household products and plants.  Their degree of toxicity may be low, intermediate or highly toxic.

The Pharmacy Services Department of ACH and  College of Medicine and Medical Sciences (CMMS) at King Khalid University (KKU) has established a poison control service in conjunction with drug information center. The primary goal of the poison information service is to offer expert advice from well-trained clinical pharmacists in the management of poisoning cases throughout the Southwestern region, Kingdom of Saudi Arabia (KSA).  The service is available 24 hours a day (calls received from 7:30 a.m. to 4:00 p.m.) are managed by the Drug and Poison Information Center, while after hours consultations were managed by on-call clinical pharmacologists and pharmacists.  Information on poisoning management targeted physicians, even though advice is also available to other paramedical personnel and the lay public.4

There are publications on accidental poisoning in children in different parts of KSA,5,6  but as far as we know, no study has been done on accidental poisoning of children in the city of Abha, Southwestern Saudi Arabia

Therefore, this retrospective survey aims to study the patterns of childhood poisoning in ACH, Abha, KSA.

 

METHODS

The study collected information from  the Department of Pediatrics and its Emergency Room at ACH, which is the only referral hospital in this region of KSA (population: 1.3 million). It lies about 8500 feet above sea level. As an urban population, the people have many modern facilities but retain the basic dietary and social habits of rural communities.

Cases of poisonings were studied during the period, January 2000 to October 2003. All cases of unintentional poisoning during this period in children aged 12 or less were included. For each case, seven parameters were studied. These were: age, sex, type of poison, clinical condition during admission, time of exposure, date of exposure, and place of exposure. Every effort was made to get the optimum benefit from the available data in the patient's files. There was however, no socio-demographic information of the children and their families in the files. All data obtained from the emergency and pediatric departments' medical records of children diagnosed with poisoning, were coded and entered into IBM compatible computer of Family and Community Medicine Department at the CMMS, KKU, using the Statistical Package for Social Science software (SPSS-Version 10).  The data entered was then checked for accuracy.  For each item, the frequency and percentage of assessment items were presented.

 

RESULTS

There were 114 cases in this study, 97(85%) patients  needed hospital admission and 17 (15%) patients were observed in the Pediatric ER .

Table 1 shows the distribution of 114 cases of poisoning in children in Abha.  Most of these cases were of children aged 2 to 4 years (?2 = 57.6, p<0.001). Boys were significantly more represented than girls (?2= 15.47, p<0.001), with sex ratio of 2.2:1.

Table 2 shows the distribution of cases according to some characteristics. Medicinal drugs significantly ranked first (p<0.001) as a cause of poisoning (82%), followed by household products (13.2%), and petroleum products (9.6%). Most cases occurred in the child’s own home, in the living room or bed room (57.9%), or in the kitchen (36.8%). Most of the cases occurred during the day, either in the morning (35.1%) or in the afternoon (44.7%), while cases that occurred at night constituted only 20.2% (?2=37.17, p<0.001). As regards the time of poisonings, about one-half of all cases (49.1%) occurred during the summer months, with a statistically significant seasonal variation (?2= 12.42, p<0.01).

 

Table 1: Distribution of 114 poisoned children by age and sex

 

 

Characteristics

Cases

No. (%)

 

 

Age (year)

X2=57.6, df=2, p<0.001

1-2

14 (12.3)

2-4

92 (80.7)

Sex

Male: Female=2.2:1

Boys

78 (68.4)

Girls

36 (31.6)

 

 

 

Table 2: Distribution of 114 children with poisoning by some characteristics

 

 

Characteristics

No. (%)

 

 

Type of poisonous agent

X2=43.8, df=3, p<0.001

Medications

82 (71.9)

Household products

15 (13.2)

Petroleum products

11 (9.6)

Others

6 (5.3)

Place of poisoning

X2=30.9, df=3, p<0.001

Living room or bedroom

66 (57.9)

Kitchen

42 (36.8)

School

2 (1.8)

Other places

4 (3.5)

Time of exposure

X2=37.2, df=1, p<0.001

Morning

40 (35.1)

Afternoon

51 (44.7)

Evening

23 (20.2)

Seasonal variation

X2=12.4, df=3, p<0.01)

December-February

13 (11.1)

March-May

23 (20.2)

June-August

56 (49.1)

September-November

22 (19.3)

 

 

 

Table 3: Clinical presentation of symptomatic poisoned children (percentages and confidence intervals)

 

 

 

Clinical presentation

No. (%)

95% CI

 

 

 

Drowsiness

39 (34.2)

2.5-43.3

Nausea and vomiting

46 (40.4)

31.6-49.6

Abdominal pain

19 (16.7)

10.7-24.4

Coma

5 (4.4)

1.6-9.5

Dyspnea

10 (8.8)

4.5-15.1

Sore throat

6 (5.3)

2.2-10.6

 

 

 

 

Ibuprofen was the most common (16%) of the drugs ingested , followed by Acetaminophen 14%, Acetylsalitic acid 10% and folic acid 9%, and unknown medications  in 51%. Toilet bowel cleaners were the most commonly incriminated product in  67% of cases,  followed by fingernail polish remover in 20% , soap powder in one child and clorox (Chlorine bleach) in another  child.

In this study, children who had ingested an offending agent, but had not developed symptoms represented 18% of the total number of cases as compared to symptomatic children.

Table 3 shows the distribution of symptomatic cases of poisoning according to various clinical manifestations. Nausea and vomiting (40.4%) and drowsiness (34.2%) came first, followed by abdominal pain (16.7%), and coma (4.4%) was the last.

 

DISCUSSION

The present retrospective study, highlights poisoning in children, which is a major health problem.  The preponderance of male to female patients in this study is in line with most studies.5-7  Similarly, the involvement of children in the 2-4 year age group in this study agrees with worldwide findings.3,7 In this age range, children are curious and explorative in behavior.  In some older children, hyperactivity predisposes them to poisoning at home where almost every substance is thrown into the mouth.

Medicinal products were the main cause of poisoning in the present study. Many reports particularly from other parts of Saudi Arabia, support this finding, highlighting the problem of medicine in self-poisoning.8-11 However, this finding was not in agreement with the findings in some developing countries, where ingestion of household  products like chlorine bleach (Clorox), pesticides, disinfectants and unidentified products ranked first.12,13  Some of the reasons for this finding in the present study, and those of other studies in other parts of Saudi Arabia, include the dispensing of drugs in envelopes instead of child-resistant containers, increased affluence, free medical treatment and easy access to drugs. However, it is important to note that careless storage of household products and drugs is a very important factor in the poisoning of children. The types of poisoning in the present study and substances involved were similar to those reported by other studies in Saudi Arabia and the Gulf countries.14-17

Regarding the type of drugs ingested by children in this study, Ibuprofen was the most common followed by Acetaminophen, Acetylsalitic acid  and folic acid 9%; 51% were unknown. Some other studies showed that acetaminophen was the most common drug poison in children.18-20 One of the explanations for our findings in this study is that Ibuprofen is similar to acetaminophen and can be obtained off the counter from a pharmacy. It is used by adult patients more commonly than acetaminophen as an anti-inflammatory and pain killer. Another explanation is that most of the ingested drugs were not known and few drugs were identified. Toilet bowel cleaners were the most common household products swallowed accidentally, followed by fingernail polish remover, soap powder and clorox .

The most common presenting symptoms of poisoning in this study were drowsiness, nausea, vomiting and abdominal pain (Table 3).  The high prevalence of poisoning in children during summer months (June to August) in our study may be due to the influx of people into the Aseer area, especially Abha which is a popular summer resort for Saudi nationals and people from all over Gulf region. Also, poisonings have a diurnal peak of frequency, occurring most frequently in the afternoon followed by morning. The majority of children must have been out of the sight of their carers who were performing some household chores when the poisoning occurred.

Previous studies have shown that accidental poisoning in children is related to the lifestyle of the household, and some environmental factors.21,22 The present study showed that 95% of poisoning occurred in the child’s own home where a collection of drugs, household cleaning agents and personal products are very often improperly stored. The importance of parental supervision, control and prevention of poisoning  of children mentioned by other investigators22  is reinforced by our study.

In conclusion, the peak age of poisonings in children occurs before four years of age, with a significantly high diurnal frequency, significant seasonal variation in favor of summer season. Medical drugs were the most frequent  agents of poisoning and living rooms and bedrooms, the more frequent places of poisoning. Ibuprofen was the most common known drug accidentally ingested followed by acetaminophen, and toilet bowel cleaners were the most common household products followed by fingernail polish remover.

Finally, it is evident that lack of safe storage of poisonous drugs and  household products is an essential risk factor for the poisoning of children.  As a preventive strategy, we recommend that parents must ensure that all medicates, household chemicals and toxic products are kept in a safe place out of the reach of children.  There should be legislation for the use of  child resistant containers for household agents  and dispensed medications.  Finally, good parental supervision is always necessary.  The establishment and operation of drug and poisoning information centers in every region through a network is highly  recommended.  All these measures are absolutely vital for the prevention of poisoning in children.

 

ACKNOWLEDGMENT

The author would like to thank the Clinical Pharmacist, Dr. Mostafa Mohsen  and the staff  at the Poison Information Center at ACH, Abha and the Department of Clinical Pharmacology, Faculty of Medicine, KKU, Abha, KSA.  I am also grateful to Prof. Anwar Hamdi for his valuable suggestions and invaluable assistance in translating the abstract of the manuscript into Arabic.

 

REFERENCES

1.        Walton WW. An Evaluation of Poisoning Prevention Packing.  Acta Paed 1982;69:363-70.

2.        Lawson GR, Craft AW, Jackson RH.  Changing Patterns of Poisoning in Children in Newcastle.  1974-1981.  BMJ 1983;37:291-5.

3.        Sibert J, Davies PA.  Poisoning, Accidents and Sudden Infant Death Syndrome.  In: Campbell AGM, McIntosh M, editors. Forfar and Arneil’s Textbook of Pediatrics.  4th edition.  London: Churchill Livingstone, 1992:1777-1800.

4.        Saddique A. Poisoning in Saudi Arabia: Ten-year experience in King Khalid University Hospital. Ann Saudi Med 201;21:88-91.

5.        Mahdi AH, Taha SA, Al-Rifaie MR.  Epidemiology of Accidental Home Poisoning in Riyadh, Saudi Arabia.  J Epidemiol Community Health 1983;37-291-5.

6.        El-Mouzan MI, Elageb A, Ali NK.  Accidental Poisoning of Children in the Eastern Province.  Saudi Med J 1986;7:231-6.

7.        Al-Sekait MA.  Epidemiology of Accidental Poisoning of Children in Riyadh, Saudi Arabia.  Ann Saudi Med 1990;10:276-9..

8.        Repetto MR. Epidemiology of poisoning due to pharmaceutical products, poison control centre, Seville, Spain. European Journal of Epidemiology 1997; 13:353-6.

9.        Chan TY, Crithley JA. Hospital admission due to acute poisoning in the new territories, Hong Kong. Southeast  Asian  Journal  of Tropical Medicine and Public Health 1994;25:579-5.

10.     Blanc PD, Kearney TE, Olsen R. Under-reporting  of fatal cases to a regional poison control center. Western Journal of Medicine 1995;152:505-9.

11.     Khan LA, Khan SA, Al-Hateeti HS. Clinical profile and outcome of poisoning in Jajrana. Annals of Saudi Medicine 2003;23: 205-7.

12.     Basavaraj DS, Forster DP.  Accidental  Poisoning in Young Children.  J Epidemiol Community Health 1982;36:31-4.

13.     Al Sadoom I, Yacoub A, Abdul-Karim M.  Accidental Poisoning Among Children in Basrah.  J Fac Med 1988;30:105-12.

14.     Izuora GI, Adeoye A. A seven-year review of accidental poisoning in children at a Military Hospital in Hafr Al-Batin, Saudi Arabia. Annals of Saudi Medicine 2001; 21(1-2): 13-15.

15.     Litavitz TL, Klein-Swartz W, Dyer KS, et al.  1997 Annual Report of the American Association of Poison Control Centers Toxic Exposure.  Surveillance System.  Am J Emerg Med 1998;16:443-97.

16.     Falaki NN, Fernando NP.  Acute Poisoning in Children. One Year One Hospital Experience.  J Kwt Med Assoc 1986;20:3-11.

17.     Litavitz TL, Manoguerra A.  Comparison of Pediatric Poisoning Hazards: An Analysis of 3.6 Million Exposure Incidents.  Pediatrics 1992;89:999-1006.

18.     Boe GH, Haga C, Andrew E, Berg KJ. Paracetamol poisonings in Norway 1990-2001. Tidsskr Nor Laegeforen 2004;124(12):1624-8.

19.   Moller LR, Nielsen GL, Olsen ML, Thulstrup AM, Mortensen JT, Sorensen H. Hospital discharges and 30-day case fatality for drug poisoning: a Danish population-based study from 1979 to 2002 with special emphasis on paracetamol. Eur J Clin Pharmacol. 2004;59(12):911-5:

20.   Ott P, Dalhoff K, Hansen PB, Loft S,   Kisely SR, Lawrence D, Preston NJ.  The effect of recalling paracetamol on hospital admissions for poisoning in Western Australia.  Med J Aust 2003;178(2):72-4.

21.   Aziz BH, Zulkifli HI, Kasim MS.  Risk Factors for Unintentional Poisoning in Urban Malaysian Children.  Am Trop Paediatr 1993;13:183-8.

22.   Towner E, Dowswell T, Jarirs S.  Reducing Childhood Accidents.  The Effectiveness of Health Promotion Interventions:  A Literature Review.  London: Health Education Authority; 1993.


 

  


-0001-11-30

PATTERN OF CHILDHOOD


PATTERN OF CHILDHOOD POISONING IN ABHA CITY – SOUTHWESTERN SAUDI ARABIA

 

Mohammed A. Al-Shehri, FRCPC, College of Medicine and Medical Sciences, King Khalid University, Abha, Saudi Arabia

_______________________________________________________________________________________

 

هدف الدراسة: وصف النموذج النمطي لتسممات الأطفال في قسم الأطفال وقسم الإسعاف في مستشفى عسير المركزي، وذلك من أجل الوصول إلى معرفة الأسباب الكامنة خلفها وبالتالي اقتراح طرق الوقاية.

طريقة الدراسة: هذه دراسة استرجاعية للأطفال المصابين بالتسمم والذين راجعوا قسم الإسعاف في مستشفى عسير المركزي أو الذين تم قبولهم في قسم الأطفال في نفس المستشفى في مدينة أبها، المملكة العربية السعودية، وذلك خلال الفترة من كانون الثاني عام 2000 ميلادية وحتى كانون الأول عام 2003 ميلادية. تمت هذه الدراسة على الأطفال الذين تقل أعمارهم عن 12 سنة. تمت مراجعة السجلات الطبية من أجل جمع المعلومات السريرية التالية مثل العمر والجنس ونوع التسمم والحالة السريرية وقت الإدخال للمستشفى، وكذلك تاريخ ومكان ووقت التعرض للعامل السمي.

نتائج الدراسة: تم دراسة 114 طفلاً في حالة تسمم ممن تقل أعمارهم عن 12 سنة. وقد وجد أن الأطفال من عمر 2- 4 سنوات كانوا أكثر عرضة للتسممات ( نسبة 81% ). وكانت نسبة الذكور ( 68% ) والإناث ( 32% ) وذلك بنسبة 2: 2.1. معظم العوامل المسممة كانت الأدوية الطبية ( 72% ). وبإعتبار الحالة السريرية وقت الإدخال للمستشفى فإن الأعراض والعلامات التالية مثل التهويم ( النعاس ) والغثيان والإقياء وكذلك الألم البطني، كانت موجودة في 82% من الحالات. 80% من الحالات التسممية المدخلة للمستشفى كانت في وقت النهار، و 71% من الحالات التسممية كانت خلال الفترة من شهر حزيران إلى شهر آب. وبالنسبة لمكان التعرض للمادة السامة، فإن غرف المعيشة والنوم كانت هي المكان في 58% من الحالات.

الخلاصة: حصلت معظم التسممات عند الأطفال قبل عمر الأربع سنوات وكانت معظمها نهارية الحدوث وأكثرها في فصل الصيف. كانت الأدوية الطبية هي معظم العوامل المسببة للتسمم وغرف المعيشة والنوم هي من أكثر الأماكن التي يتعرض فيها الأطفال للتسمم.

إن المراقبة الجيدة والمستمرة من قبل الأهل هي أساسية ولاسيما خلال العمر من 1 – 5 سنوات. وكذلك استخدام العبوات المقاومة للفتح من قبل الأطفال لتخزين الأدوية والمواد المستعملة في المنزل.

 

الكلمات المرجعية:التسمم ، مستشفى عسير المركزي ، طوارئ المستشفى.

___________________________________________________________________

Objective: To describe the pattern of  childhood poisoning in the Emergency Room (ER) of the Pediatrics Department in Aseer Central Hospital (ACH), in order to suggest possible causes and preventive measures.

Methods: This is a retrospective study of cases of childhood poisoning or ingestions attending the pediatric emergency room of Aseer Central Hospital or those admitted to the Pediatric Department of same hospital in Abha, Kingdom of Saudi Arabia, during the period of January 2000 to December 2003.  Children aged 12 years and below were included.  Review of records was done to collect data on clinical information such as age, sex, type of poison, clinical condition on admission as well as the time, place and date of exposure to the offending agent.

Results: In this study, 114 poisoned children aged 12 years and below were studied.  It was found that children from 2-4 years were more liable to poisoning (81%, p<0.001).  Males were (68%) while females were (32%), with a sex ratio of 2.2:1.  Medical drugs offended the most (72%, p<0.001). As regards clinical condition on admission, drowsiness, nausea and vomiting as well as abdominal pain represented (82%) of the cases.  Daytime was when 80% of poisoned cases were admitted (p<0.001).  The peak months were from June to August (71%, p<0.01).  As regard the place of exposure to offending agent, living rooms and bedrooms accounted for 58% of the cases(p<001).

_______________________________________________________________________________________

Correspondence to:

Dr. Mohammed A. Al-Shehri, FRCPC, Department of Pediatrics, College of Medicine & Medical Sciences, King Khalid University, P.O. Box 641, Abha, Saudi Arabia   E-mail: fariss2000@yahoo.com

Conclusion: The peak age for poisonings in children is before the age of four with significantly high diurnal frequency, significant seasonal variation in favor of summer. Medical drugs were the most common agents of poisoning, and living rooms and bedrooms the places where most poisoning occurred. Good and continuous supervision by parents is essential, especially from the age 1-5 years.  There should also be legislation for the use of child resistant containers for home medicines and household agents.

 

        Key Words:  Poisoning, Aseer Central Hospital (ACH) and Emergency room (ER).

_______________________________________________________________________________________

 


INTRODUCTION

Accidental ingestion of poisons and household substances, a potential source of morbidity and mortality in children all over the world,1,2 is a significant public health problem.  While this may be accidental, non accidental or iatrogenic in young children, it is usually deliberate among older children especially in industrialized countries.3  Most frequently, however, the ingested substances are taken accidentally.  The ingested poisons can be classified into drugs (prescribed or non-prescribed), household products and plants.  Their degree of toxicity may be low, intermediate or highly toxic.

        The Pharmacy Services Department of ACH and  College of Medicine and Medical Sciences (CMMS) at King Khalid University (KKU) has established a poison control service in conjunction with drug information center. The primary goal of the poison information service is to offer expert advice from well-trained clinical pharmacists in the management of poisoning cases throughout the Southwestern region, Kingdom of Saudi Arabia (KSA).  The service is available 24 hours a day (calls received from 7:30 a.m. to 4:00 p.m.) are managed by the Drug and Poison Information Center, while after hours consultations were managed by on-call clinical pharmacologists and pharmacists.  Information on poisoning management targeted physicians, even though advice is also available to other paramedical personnel and the lay public.4

        There are publications on accidental poisoning in children in different parts of KSA,5,6  but as far as we know, no study has been done on accidental poisoning of children in the city of Abha, Southwestern Saudi Arabia

        Therefore, this retrospective survey aims to study the patterns of childhood poisoning in ACH, Abha, KSA.

 

METHODS

The study collected information from  the Department of Pediatrics and its Emergency Room at ACH, which is the only referral hospital in this region of KSA (population: 1.3 million). It lies about 8500 feet above sea level. As an urban population, the people have many modern facilities but retain the basic dietary and social habits of rural communities.

        Cases of poisonings were studied during the period, January 2000 to October 2003. All cases of unintentional poisoning during this period in children aged 12 or less were included. For each case, seven parameters were studied. These were: age, sex, type of poison, clinical condition during admission, time of exposure, date of exposure, and place of exposure. Every effort was made to get the optimum benefit from the available data in the patient's files. There was however, no socio-demographic information of the children and their families in the files. All data obtained from the emergency and pediatric departments' medical records of children diagnosed with poisoning, were coded and entered into IBM compatible computer of Family and Community Medicine Department at the CMMS, KKU, using the Statistical Package for Social Science software (SPSS-Version 10).  The data entered was then checked for accuracy.  For each item, the frequency and percentage of assessment items were presented. 

 

RESULTS

There were 114 cases in this study, 97(85%) patients  needed hospital admission and 17 (15%) patients were observed in the Pediatric ER .

        Table 1 shows the distribution of 114 cases of poisoning in children in Abha.  Most of these cases were of children aged 2 to 4 years (?2 = 57.6, p<0.001). Boys were significantly more represented than girls (?2= 15.47, p<0.001), with sex ratio of 2.2:1.

        Table 2 shows the distribution of cases according to some characteristics. Medicinal drugs significantly ranked first (p<0.001) as a cause of poisoning (82%), followed by household products (13.2%), and petroleum products (9.6%). Most cases occurred in the child’s own home, in the living room or bed room (57.9%), or in the kitchen (36.8%). Most of the cases occurred during the day, either in the morning (35.1%) or in the afternoon (44.7%), while cases that occurred at night constituted only 20.2% (?2=37.17, p<0.001). As regards the time of poisonings, about one-half of all cases (49.1%) occurred during the summer months, with a statistically significant seasonal variation (?2= 12.42, p<0.01).

 

Table 1: Distribution of 114 poisoned children by age and sex

 

 

Characteristics

Cases

No. (%)

 

 

Age (year)

X2=57.6, df=2, p<0.001

1-2

14 (12.3)

2-4

92 (80.7)

Sex

Male: Female=2.2:1

Boys

78 (68.4)

Girls

36 (31.6)

 

 

 

Table 2: Distribution of 114 children with poisoning by some characteristics

 

 

Characteristics

No. (%)

 

 

Type of poisonous agent

X2=43.8, df=3, p<0.001

Medications

82 (71.9)

Household products

15 (13.2)

Petroleum products

11 (9.6)

Others

6 (5.3)

Place of poisoning

X2=30.9, df=3, p<0.001

Living room or bedroom

66 (57.9)

Kitchen

42 (36.8)

School

2 (1.8)

Other places

4 (3.5)

Time of exposure

X2=37.2, df=1, p<0.001

Morning

40 (35.1)

Afternoon

51 (44.7)

Evening

23 (20.2)

Seasonal variation

X2=12.4, df=3, p<0.01)

December-February

13 (11.1)

March-May

23 (20.2)

June-August

56 (49.1)

September-November

22 (19.3)

 

 

 

Table 3: Clinical presentation of symptomatic poisoned children (percentages and confidence intervals)

 

 

 

Clinical presentation

No. (%)

95% CI

 

 

 

Drowsiness

39 (34.2)

2.5-43.3

Nausea and vomiting

46 (40.4)

31.6-49.6

Abdominal pain

19 (16.7)

10.7-24.4

Coma

5 (4.4)

    1.6-9.5

Dyspnea

10 (8.8)

  4.5-15.1

Sore throat

6 (5.3)

2.2-10.6

 

 

 

 

        Ibuprofen was the most common (16%) of the drugs ingested , followed by Acetaminophen 14%, Acetylsalitic acid 10% and folic acid 9%, and unknown medications  in 51%. Toilet bowel cleaners were the most commonly incriminated product in  67% of cases,  followed by fingernail polish remover in 20% , soap powder in one child and clorox (Chlorine bleach) in another  child.

        In this study, children who had ingested an offending agent, but had not developed symptoms represented 18% of the total number of cases as compared to symptomatic children.

        Table 3 shows the distribution of symptomatic cases of poisoning according to various clinical manifestations. Nausea and vomiting (40.4%) and drowsiness (34.2%) came first, followed by abdominal pain (16.7%), and coma (4.4%) was the last.

 

DISCUSSION

The present retrospective study, highlights poisoning in children, which is a major health problem.  The preponderance of male to female patients in this study is in line with most studies.5-7  Similarly, the involvement of children in the 2-4 year age group in this study agrees with worldwide findings.3,7 In this age range, children are curious and explorative in behavior.  In some older children, hyperactivity predisposes them to poisoning at home where almost every substance is thrown into the mouth.

        Medicinal products were the main cause of poisoning in the present study. Many reports particularly from other parts of Saudi Arabia, support this finding, highlighting the problem of medicine in self-poisoning.8-11 However, this finding was not in agreement with the findings in some developing countries, where ingestion of household  products like chlorine bleach (Clorox), pesticides, disinfectants and unidentified products ranked first.12,13  Some of the reasons for this finding in the present study, and those of other studies in other parts of Saudi Arabia, include the dispensing of drugs in envelopes instead of child-resistant containers, increased affluence, free medical treatment and easy access to drugs. However, it is important to note that careless storage of household products and drugs is a very important factor in the poisoning of children. The types of poisoning in the present study and substances involved were similar to those reported by other studies in Saudi Arabia and the Gulf countries.14-17

        Regarding the type of drugs ingested by children in this study, Ibuprofen was the most common followed by Acetaminophen, Acetylsalitic acid  and folic acid 9%; 51% were unknown. Some other studies showed that acetaminophen was the most common drug poison in children.18-20 One of the explanations for our findings in this study is that Ibuprofen is similar to acetaminophen and can be obtained off the counter from a pharmacy. It is used by adult patients more commonly than acetaminophen as an anti-inflammatory and pain killer. Another explanation is that most of the ingested drugs were not known and few drugs were identified. Toilet bowel cleaners were the most common household products swallowed accidentally, followed by fingernail polish remover, soap powder and clorox .

        The most common presenting symptoms of poisoning in this study were drowsiness, nausea, vomiting and abdominal pain (Table 3).  The high prevalence of poisoning in children during summer months (June to August) in our study may be due to the influx of people into the Aseer area, especially Abha which is a popular summer resort for Saudi nationals and people from all over Gulf region. Also, poisonings have a diurnal peak of frequency, occurring most frequently in the afternoon followed by morning. The majority of children must have been out of the sight of their carers who were performing some household chores when the poisoning occurred. 

        Previous studies have shown that accidental poisoning in children is related to the lifestyle of the household, and some environmental factors.21,22 The present study showed that 95% of poisoning occurred in the child’s own home where a collection of drugs, household cleaning agents and personal products are very often improperly stored. The importance of parental supervision, control and prevention of poisoning  of children mentioned by other investigators22  is reinforced by our study.

        In conclusion, the peak age of poisonings in children occurs before four years of age, with a significantly high diurnal frequency, significant seasonal variation in favor of summer season. Medical drugs were the most frequent  agents of poisoning and living rooms and bedrooms, the more frequent places of poisoning. Ibuprofen was the most common known drug accidentally ingested followed by acetaminophen, and toilet bowel cleaners were the most common household products followed by fingernail polish remover.

        Finally, it is evident that lack of safe storage of poisonous drugs and  household products is an essential risk factor for the poisoning of children.  As a preventive strategy, we recommend that parents must ensure that all medicates, household chemicals and toxic products are kept in a safe place out of the reach of children.  There should be legislation for the use of  child resistant containers for household agents  and dispensed medications.  Finally, good parental supervision is always necessary.  The establishment and operation of drug and poisoning information centers in every region through a network is highly  recommended.  All these measures are absolutely vital for the prevention of poisoning in children.

 

ACKNOWLEDGMENT

The author would like to thank the Clinical Pharmacist, Dr. Mostafa Mohsen  and the staff  at the Poison Information Center at ACH, Abha and the Department of Clinical Pharmacology, Faculty of Medicine, KKU, Abha, KSA.  I am also grateful to Prof. Anwar Hamdi for his valuable suggestions and invaluable assistance in translating the abstract of the manuscript into Arabic.

 

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