Epidemiologic Notes and Reports Unintentional Ingestions of Prescription Drugs in Children Under Five Years Old

In 1985, the American Association of Poison Control Centers (AAPCC) received more than 60,000 reports of unintentional prescription drug ingestions involving children under the age of five (Consumer Product Safety Commission (CPSC), unpublished data). In addressing this problem, the CPSC initiated a study of the circumstances surrounding oral prescription drug ingestions by children under 5 years of age and of the efficacy of the closures used on the containers involved.

A non-random sample of oral prescription drug ingestions by children was obtained from reports received from February to May 1986 by nine poison control centers representing each of the U.S. Census regions*. Incidents were eligible for the study if the ingestion had been unintentional and had involved a child under 5 years of age. Incidents were excluded if they involved dosing errors or ingestion of veterinary drugs, non-oral prescription drugs, or over-the-counter medications, even if dispensed by prescription. Each center completed 225 investigations. The sample group represented 90% of the eligible reports for the time period.

Trained interviewers administered a telephone questionnaire to parents or other adults present when the ingestion took place. The data collected included 1) the age and sex of the child, 2) the demographics of the child's household, 3) the type of container, 4) who the medicine belonged to and how that person was related to the child, 5) where the child found the medicine, and 6) where the child was when the medicine was consumed. The respondents were also asked to mail the containers to the CPSC so the closures could be examined. Exposures to 1,982 drugs involving 2,015 children met the study criteria.

Seventy-six percent of the ingestions involved children from 1-1/2 to 3-1/2 years of age; 9% were 1 year or 4 years old (Table 2). Fifty-six percent of the children were male. The ingested drugs were more frequently owned by female, non-sibling relatives (mother, grandmother, great grandmother, aunt, or cousin) (44%) than by male, non-sibling relatives (12%). Grandparents' medications accounted for a substantial number of episodes (17%).

Of the 382 containers CPSC received for testing, 80% were child-resistant (Table 3). During follow-up telephone interviews, respondents who had not sent in the containers involved were asked to examine them; 76% of these had child-resistant closures. Sixty-seven percent of respondents who had to base their descriptions on recollection alone reported that the containers had child-resistant closures. Tests proved that 200 (65%) of the 306 child-resistant containers received were ineffective.

Two types of child-resistant containers were commonly used. Two hundred and twenty-nine containers used for liquid medications had continuous-thread closures. Sixty-nine percent of these were ineffective; 87% of these failures were associated with a buildup of liquid residue on the threads. Wear of the closure mechanism had caused failure in 52% of the 73 lug-type containers**.

In 65% of the cases, the medication was in the original container when the ingestion occurred. Problems not related to failure of the child-resistant closure included 1) not resecuring the closure in a child-resistant manner (18% of the incidents), 2) not keeping medicines in any container (i.e., loose), and 3) keeping medicine in some container other than the original (25%). Eighty-two of the ingestions took place in the child's home, and 14%, in a relative's home. The four categories of drugs most frequently ingested were antimicrobials (23.4%), birth control pills and hormones (14.9%), analgesics (9.6%), and cardiovascular drugs (9.2%). The four areas in the home where the ingested medicines were most frequently stored were kitchens (48%), bedrooms (24%), living rooms (10%), and bathrooms (8%). Reported by American Assn of Poison Control Centers; Div of Poison Prevention and Scientific Coordination, Directorate of Health Sciences, U.S. Consumer Product Safety Commission; Div of Injury Epidemiology and Control, Center for Environmental Health, CDC.

Editorial Note

Editorial Note: The week of March 15-21, 1987, is designated National Poison Prevention Week (NPPW) by the Poison Prevention Week Council. NPPW was established by federal legislation and has been observed since 1962 (1). The death rate from poisoning in children under five has steadily declined since the enactment of the Poison Prevention Packaging Act (PPPA) of 1970. Since then, deaths from poisoning by solids and liquids (E850-E866))S), the group of substances most affected by the PPPA, have declined by 70%. An 8-year analysis of the impact of the PPPA estimated that 86,000 ingestions of poisons were prevented between 1974 and 1981 (2). The potential for poisoning remains significant, however; in 1985, AAPCC centers received more than 500,000 reports of exposures of children under 5 years old to potential poisons (CPSC, unpublished data). In 1983, there were 55 deaths from ingested poisons, 39 of which were from poisoning by drugs, medicinals, and biologicals (E850-E858) (National Center for Health Statistics, unpublished data) (1). The age-specific death rate for external causes (E850-E858) in this age group was 0.22/100,000 in 1983 (National Center for Health Statistics, unpublished data) (3).

The results of the AAPCC study should be interpreted cautiously since the data were taken from a sample that may not be representative of the entire population under 5 years of age and at risk for poisoning. Furthermore, the purpose of the study was only to determine factors associated with unintended ingestion of oral prescription drugs. In addition, seasonal variation could introduce bias since the data were collected only from February to May.

The findings show that multiple factors contribute to the risk of unintentional ingestion of prescription medications. These include the inability of young children to recognize potential hazards, their tendency to explore the world and to put things in their mouths, and the availability of medicine in the kitchen and bedrooms. Other factors include ineffective child-resistant closures, closures that do not continue to function as designed, and the misuse of these closures.

Public education and awareness efforts should be targeted at persons who have frequent contact with children, including those who may not live in a household where children reside (e.g., grandparents). Unless there are specific reasons to avoid child-resistant containers, consumers who have contact with children should insist on child-resistant packaging regardless of whether they have small children in their own household. Child-resistant containers should always be capped tightly and should never be either modified to eliminate the safety feature or substituted with a non-child-resistant container. Medications should never be kept where children have ready access to them and especially should never be kept in the kitchen or bedrooms.

This study demonstrates the need to use National Poison Prevention Week to make pharmacists, physicians, manufacturers, and the public aware of the importance of the PPPA requirements. While the present technology for child-resistant packaging may provide incomplete protection from prescription drug poisoning, the use of child-resistant packaging should be strongly encouraged whenever possible. Development of improved child-resistant closures with increased reliability should be a priority for the safety-packaging industry. CPSC has made poison prevention a priority project for 1987.

References

1. CDC. National poison prevention week: 25th anniversary observance. MMWR 1986:35;149-52.

2. National Safety Council. Accidental deaths from poisoning. Accident Facts 1982:82-3.

3. Bureau of the Census. Resident population in thousands by age, sex, and race. Washington, DC: U.S. Department of Commerce, Bureau of the Census, 1984. (Table 2; series P-25; no. 949). *Shreveport, Louisiana; Detroit, Michigan; Pittsburgh, Pennsylvania; Louisville, Kentucky; Minneapolis, Minnesota; District of Columbia; San Diego, California; Boston, Massachusetts; and Salt Lake City, Utah. **The majority of the containers received by CPSC were screw-type closures operated by "push and turn" or similar action. SNinth revision, International Classification of Diseases. The group of external causes E850-E866 excludes gases distributed by pipeline, other utility gases and carbon monoxide, and other gases and vapors since it is not likely that poisoning by these substances would be prevented by the PPPA.

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