SPECIAL ISSUE ARTICLE

Pediatric Poisonings: The Risk of

Over-the-Counter Pharmaceuticals
Elizabeth Quaal Hines, MD

The peak age of unsupervised in-

ABSTRACT
gestions is 1 to 2 years, and ingestion
Every week in the United States, 56% of children younger than age 18 years and 82% at this age is more likely to result in
of adults take at least one medication. Nonprescription medications, including acetamino- hospitalization.1,2 The peak age of care-
phen and ibuprofen, are among the most commonly used pharmaceuticals across all age giver-associated ingestions is younger
groups. Use of nonprescription medications, traditionally available over-the-counter, has (less than age 1 year) and less likely to
become ubiquitous. Unfortunately, with such abundant use there is an associated risk for result in hospitalization.2,4-6 Caregiver-
therapeutic misuse, intentional misuse, and even abuse. [Pediatr Ann. 2017;46(12):e454- associated ingestions are due to the
e458.] wrong dose (43.7%) or the wrong med-
ication (33.2%) provided to a child.1
Children are at particular risk for thera-

A
ccording to the National Elec- after caregiver administration. Unsuper- peutic dosing errors due to weight-
tronic Injury Surveillance Sys- vised ingestions are due to a complex based dosing of liquid preparations.
tem (NEISS), approximately interplay between the child and their Dosing errors include incorrect vol-
70,000 children younger than the age of environment. The child’s developmental ume unit (ie, teaspoon vs. tablespoon
18 years in the United States are seen in stage of exploration includes behavioral vs. kitchen spoon), 10-fold errors due
emergency departments every year for milestones such as crawling, cruising, to decimal point misplacement, double
unintentional medication exposures.1 and walking with typical hand-to-mouth dosing, and timing errors.1,4 Fortu-
The most frequently involved medica- behavior. But, the environment in which nately, most pediatric therapeutic er-
tions are acetaminophen, antidepres- they live carries the risk of pharmaceu- ror cases are associated with none or
sants, and nonsteroidal anti-inflammato- tical exposure and potential lack of su- only minor outcome.4 However, in an
ry drugs. Over-the-counter medications pervision by their parent or caregiver. evaluation of pediatric therapeutic error
are implicated in 34% of cases.1 Most Considering that approximately 82% cases that did result in major effect or
unintentional medication exposures oc- of adults and 56% of children in the US death, 27% involved over-the-counter
cur in children younger than age 5 years, take at least one medication per week,3 it medications such as analgesics, cough
with the highest prevalence between is not surprising that one-half of child- and cold preparations, antihistamines,
ages 1 and 2 years.1,2 hood unsupervised ingestions involve and imidazoles. The most common eti-
There are two main categories of over-the-counter medications. The most ology of these severe errors was 10-fold
young childhood exposures: (1) unsu- commonly implicated over-the-counter dosing errors.5
pervised ingestions when a child ac- medications include acetaminophen, The root cause of childhood over-
cesses medication without caregiver cough and cold remedies, ibuprofen, and the-counter medication errors lies ei-
oversight and (2) adverse drug events diphenhydramine.2,4 ther with the caregiver or the manufac-
turer. Studies have linked low caregiver
Elizabeth Quaal Hines, MD, is an Assistant Professor, Department of Pediatric Emergency Medicine, health literacy and numeracy to in-
University of Maryland School of Medicine. creased errors in interpretation of dos-
Address correspondence to Elizabeth Quaal Hines, MD, Department of Pediatric Emergency Medi- ing instructions and choice of dosing
cine, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201; email: device.7 Thus, the burden is left to the
ehines@peds.umaryland.edu. manufacturer to provide the simplest
Disclosure: The author has no relevant financial relationships to disclose. instructions and best device to ensure
doi:10.3928/19382359-20171120-02
safe medication delivery to children.

e454 Copyright © SLACK Incorporated


In an evaluation of more than 200
over-the-counter products, only 148 in-
cluded a dosing device and 98.6% had
at least one inconsistency between the
instructions and the device.8 As a result
of such discrepancies, in 2011, the US
Food and Drug Administration (FDA)
released guidelines for liquid over-the-
counter pharmaceutical products out-
lining specific directions to align dos-
ing instructions and the accompanying
device.9 In 2014, Budnitz et al.10 found
that although 91% of products adhered
to FDA guidelines regarding dosing di-
rections and 62% of products adhered
to FDA guidelines regarding devices,
only 57% of products adhered to all
FDA guidelines for both directions and
devices.
In evaluating childhood intentional
exposures, there is a significant in-
crease as age increases. According to
the American Association of Poison
Control Centers’ (AAPCC) National
Poison Data System (NPDS), 60% of
exposures in children older than age 12
years are intentional.6 Additionally, a
single-center pediatric intensive care
unit study found all patients admitted
after intentional ingestions were older
than age 11 years.11 This shift is due to
an increased frequency of adolescent
substance use, abuse, and suicidal ex-
posures, and is associated with an in-
creased risk of morbidity and mortality.
Adolescent intentional ingestions are
associated with an increased severity of
illness and a higher rate of hospitaliza-
tion (63%) compared to younger chil-
dren (12.8%).6 Despite increased illicit
drug use among adolescents, over-the-
counter products continue to rank
among the NPDS’s 10 most-frequent
adolescent exposures. These products
include acetaminophen, ibuprofen,
cough and cold products, and antihista-
mines, most likely due to their ease of
accessibility.6
PEDIATRIC ANNALS • Vol. 46, No. 12, 2017
SPECIAL ISSUE ARTICLE
An intentional exposure that de-
serves special mention is that of mali-
cious intent to harm by poisoning, oth-
erwise known as medical child abuse.
Medical child abuse is considered physi-
cal abuse by poisoning either with phar-
maceuticals or nonpharmaceuticals. A
recent 9-year NPDS review of malicious
cases of pharmaceutical poisoning found
1,634 cases (18 deaths).12 Over-the-
counter pharmaceuticals were a frequent
agent and included analgesics (n = 176),
cough and cold products (n = 155), gas-
trointestinal preparations (n = 89), and
antihistamines (n = 85). Other non–over-
the-counter pharmaceuticals included
stimulants and street drugs (n = 173),
sedative/hypnotics (n = 158), and etha-
nol (n = 11).12
ACETAMINOPHEN
Acetaminophen is the most common-
ly used over-the-counter medication,
and is available both as a single ingredi-
ent product and as an active ingredient
within combination products. products. Therefore, providers should
The toxicity of acetaminophen is
closely linked to its metabolism. At
therapeutic doses, it is primarily me-
tabolized in the liver via glucuronida-
tion and sulfation to nontoxic metabo-
lites. Approximately 5% to 10% of
aceatminophen undergoes cytochrome
p450 (CYP450) 2E1 metabolism to N-
acetyl-p-benzoquinoneimine (NAPQI).
NAPQI is conjugated to glutathione
to form another nontoxic metabolite.
However, in overdose, an increased
concentration of aceatminophen over-
whelms the glucuronidation and sul-
fation pathways and results in an in-
creased production of NAPQI. When
NAPQI depletes glutathione stores it
covalently binds to hepatocytes and
produces direct hepatic cellular injury
and death.13
The hepatotoxicity of acetaminophen
is manifested as three phases of clini-
cal toxicity. First, anorexia, nausea, and
vomiting develop. If untreated, hepatic
dysfunction develops during phase two,
manifested by abnormal hepatic en-
zymes, and prothrombin time develops.
Increased creatinine is also seen during
this phase due to local production of
NAPQI by renal CYP450 2E1. Lastly,
fulminant hepatic necrotic failure with
jaundice, coagulopathy, encephalopathy,
and associated risk of death can occur.13
Acetaminophen-associated hepa-
totoxicity typically occurs after two
categories of ingestions: single acute
ingestions and chronic ingestions. The
Rumack-Mathew nomogram14 was de-
veloped to stratify the risk of single acute
ingestions based on acetaminophen con-
centration versus time and is not of use
in patients who present after chronic in-
gestions. Chronic ingestions commonly
occur after repeated supratherapeutic in-
gestions, therapeutic ingestions with in-
correct spacing, or ingestions of multiple
acetaminophen-containing combination
maintain a high level of suspicion for
acetaminophen toxicity in patients who
present with hepatic injury in the setting
of any acetaminophen ingestion even
when the concentrations are less than
the nomogram.
According to data from the Pediatric
Acute Liver Failure registry, patients
with single acute exposure were older
(median age 15.2 years) and more likely
to present after suicidal ingestion than
those with chronic exposure (median age
3.5 years).15 Patients with chronic expo-
sure had significantly worse outcomes at
21 days and were more likely to die or
undergo hepatic transplantation.15
ASPIRIN
In the late 1950s, childhood aspirin
fatalities were responsible for two-
thirds of all drug-related pediatric poi-
soning deaths.16 In an effort to protect
e455

children from these poisoning deaths,
the Poison Prevention Act of 1970
authorized the US Consumer Product
Safety Commission to require child-
resistant packaging on pharmaceuti-
cal products. Although there has been
a dramatic decline in the incidence of
childhood salicylate poisonings due to
a combination effect of both regula-
tory changes and decreased therapeu-
tic use of aspirin in children, aspirin
continues to be used by adolescents in
suicide attempts.16
The major toxic effects of salicylate
poisoning include (1) direct stimulation
of the respiratory center causing a re-
spiratory alkalosis and (2) uncoupling
of oxidative phosphorylation inhibiting
mitochondrial respiration and causing
severe metabolic acidosis.17 Mild poi-
soning presents with tinnitus, tachy-
pnea, and vomiting. Severe poisoning is
a life-threatening combination of meta-
bolic derangements, coma, seizures,
hyperthermia, and cardiovascular col-
lapse.17 The primary goals of therapeu-
tic interventions are to prevent further
salicylate absorption, correct any fluid
imbalance, and decrease tissue salicy-
late concentration.18 By alkalinizing
the patient’s serum and urine, the acidic
salicylate is trapped in its ionic form
and unable to cross into the tissue, en-
hancing urinary excretion. However, in
some instances, severity of poisoning
necessitates hemodialysis for enhance-
ment of elimination.
NONSTEROIDAL ANTI-
INFLAMMATORY DRUGS
Ibuprofen belongs to the proprionic
acid class of over-the-counter nonste-
roidal anti-inflammatory drugs. Initial-
ly available by prescription, ibuprofen
was approved for over-the-counter use
in 1984. Therapeutically, ibuprofen
inhibits cyclooxygenase to prevent
the production of prostaglandin to re-
e456
SPECIAL ISSUE ARTICLE
duce pain, fever, and inflammation. In
general, ibuprofen is considered safe
with a large therapeutic window. Most
overdoses cause mild gastritis due to
decrease in prostaglandin-associated
gastric mucosal protection. Massive
overdose can cause coma, seizures, an-
ion gap metabolic acidosis, renal dys-
function, hypoglycemia, and possibly
death.19
COUGH AND COLD COMBINATION
PRODUCTS
Over-the-counter cough and cold
preparations are sold as combination
products containing antihistamines,
decongestants, antitussives, and expec-
torants. Over the past several decades,
studies have failed to find significant
clinical efficacy over placebo in treating
cold symptoms in children.20 Despite a
lack of effectiveness, cough and cold
products continue to be marketed and
used in the pediatric population with se-
vere consequences. Every year, an esti-
mated 7,091 children younger than age
12 years visit an emergency department
due to an adverse drug event caused by a
cough and cold product,21 with addition-
al case reports of infant deaths.22 A re-
view of childhood cough and cold prod-
uct risk identified 118 fatal cases.23 The
most common active ingredients were
pseudoephedrine, diphenhydramine,
and dextromethorphan. Most children
were younger than age 2 years (75%).
Twenty-six of the evaluated cases had
a nontherapeutic intent concerning for
medical child abuse.23
In October 2007, a joint meeting of
the FDA Pediatric Committee and Non-
prescription Drug Advisory committee
recommended against the use of cough
and cold products in all children under
the age of 6 years due to lack of efficacy
studies.24 At that time, manufacturers
voluntarily withdrew products marketed
for children younger than age 2 years.
The next year, product labels were fur-
ther revised to exclude use in children
younger than age 4 years.25 Despite the
ongoing recommendations of the Advi-
sory committee, manufacturers continue
to market cough and cold products for
children with labeling that fails to reflect
the lack of efficacy and the associated
risk.24 Often, manufacturers use “pedi-
atrician-recommended” terminology,
when in fact the American Academy
of Pediatrics has been clearly warning
against cough and cold product use for
decades.25
Decongestant medications are pri-
marily alpha-adrenergic receptor ago-
nists. This sympathetic stimulation
causes vasoconstriction of the nasal
mucosa and decreases rhinorrhea. De-
congestants on the market today include
psuedoephedrine and phenylephrine.
Side effects and symptoms result from
the therapeutic mechanism of action
and include sympathomimetic effect at
the alpha-adrenergic receptors, includ-
ing tachycardia and hypertension. Mild
central nervous system stimulation can
cause anxiety, psychosis, and seizure.26
Phenylpropanolamine, another alpha-
agonist decongestant, was removed
from the market due increased risk of
hemorrhagic stroke.27
Antitussives act primarily on cen-
tral cough receptors and include dex-
tromethorphan and codeine. Dextro-
methorphan is an N-methyl-D-agonist
receptor antagonist and a sigma receptor
agonist. It is metabolized via CYP450
2D6 to dextrorphan. In high concen-
trations, dextrorphan causes effects
similar to phencyclidine and ketamine,
predominantly dissociative symptoms
such as disorientation, depersonaliza-
tion, somnolence, and hallucinations.28
However, when metabolism is delayed
or blocked via CYP450 inhibition, high
concentrations of the parent compound
dextromethorphan cause symptoms of
Copyright © SLACK Incorporated

serotonergic toxicity, such as tachycar-
dia, hyperthermia, altered mental status,
and hyperreflexia.28
Because of the hallucinogenic effect
of its metabolite, dextromethorphan is
being used as a substance of abuse, with
the highest prevalence in the adolescent
male population.29 Typical slang terms
include “DXM,” “robo-tripping” (de-
rived from the brand name Robitussin
[Pfizer, New York, NY]), “triple-Cs” for
the inscription on the Coricidin cough
and cold tablets [Schering-Plough, Ke-
nilworth, NJ], or “Skittles” [Wrigley
Company, Chicago, IL] because of the
small candy-like look of the Coricidin
tablets. The typical “high” from dextro-
methorphan requires doses up to 2 mg/kg
and if taken in the form of combination
cough and cold products, the patient can
easily become poisoned with other active
ingredients including acetaminophen, di-
phenhydramine, or phenylephrine.
In a recent NPDS review of all cases
of adolescent intentional abuse, the most
commonly reported substance of abuse
was an antihistamine or decongestant
with dextromethorphan (13.3%).30 The
following four substances of adolescent
abuse were ethanol (9.9%), benzodiaz-
epines (8.6%), dextromethorphan not
otherwise specified (6.9%), and mari-
juana (4.5%).30 This study carries the
limitations of all poison control studies,
in that it required a health care provider
to report the exposure. Therefore, the
data are not reflective of true prevalence
of adolescent substance abuse (ie, etha-
nol and marijuana), but is reflective of
prevalence of abuse that required health
care intervention and likelihood of poi-
son control center reporting.
ANTIHISTAMINES
The FDA first approved diphenhydr-
amine in 1946. In 2015, the AAPCC re-
ported 23,362 pediatric exposures to di-
phenhydramine with 73% of exposures
PEDIATRIC ANNALS • Vol. 46, No. 12, 2017
SPECIAL ISSUE ARTICLE
in children younger than age 6 years.6
Rarely, infant deaths have also been at-
tributed to diphenhydramine.31
Therapeutically, diphenhydramine
acts as a histamine H1 receptor antago-
nist with beneficial effect for patients
with allergic symptoms, nausea, and
mild insomnia.
In overdose, diphenhydramine has
additional activity as a muscarinic re-
ceptor antagonist causing symptoms of
anticholinergic toxicity such as mydria-
sis, dry mucous membranes, tachycar-
dia, hypertension, urinary retention, and
delirium. More severe toxicity can cause
unresponsiveness, seizure, apnea, and
wide complex cardiac dysrhythmia.32
The wide complex tachycardia derives
from Na-channel blockade and associ-
ated QRS prolongation, similar to that
seen with tricyclic antidepressant tox-
icity. Treatment of such dysrhythmias
should focus on sodium bicarbonate ad-
ministration.33
CONCLUSIONS
Pediatric poisonings with over-the-
counter medications are a preventable
problem that was first addressed by
the Poison Prevention Act of 1970 and
most recently by the Centers for Dis-
ease Control and Prevention PROTECT
Initiative (Preventing Overdoses and
Treatment Exposures Task Force).34 The
PROTECT initiative was created in 2008
as a public-private collaboration be-
tween over-the-counter medication pro-
viders and pediatric safety experts. The
primary goal of the PROTECT Initiative
is to prevent unintentional medication
overdoses in children and reduce emer-
gency department visits.34
The forefront of poison prevention
includes education and engineering ad-
vancements. The PROTECT Initiative
has focused its educational campaign on
safe medication storage. Although 87%
of parents believe unintentional injuries
and poisonings are preventable, only
10% take any action toward removing
or securing poisons.35 Unfortunately, a
primary motivator to prompt safe stor-
age practices occurs only after a child-
poisoning event or a “near miss” has
occurred.36
“Up and Away and Out of Sight”
is the educational program of the
PROTECT initiative to promote safe use
and storage of all pharmaceuticals, in-
cluding over-the-counter medicines. The
program advocates for the safe return of
child-resistant caps immediately after
use and the storage of medicine out of
reach and out of sight of the children.
Although child-resistant packag-
ing was first mandated by the Poison
Prevention Act of 1970, little advance-
ment to the technology of the typical
click-and-twist or push-down-and-turn
engineering of most bottles has oc-
curred. Problems with traditional child-
resistant containers include the dispens-
ing of pharmaceuticals into nonresistant
containers, not properly closing child-
resistant containers, and transferring
products to a different nonresistant con-
tainer. The PROTECT Initiative has
fostered the development of innovative
packaging. In 2011, a number of lead-
ing liquid acetaminophen manufactur-
ers committed to incorporating a flow
restrictor valve, which decreases the vol-
ume of liquid dispensed should a child
breach the child-resistant closure.3
Progress toward eliminating pediatric
over-the-counter medication exposures
could focus on further unifying dosing
guidelines and devices across all liquid
products. The milliliter-only initiative
advocates for the use of the milliliter as
the sole volumetric unit in the outpatient
setting, as is used in the inpatient setting.
Use of the milliliter as the unit of mea-
sure would potentially remove teaspoon/
tablespoon/kitchen spoon confusion. Ad-
ditionally, it would support standardiza-
e457

tion toward use of oral syringe or drop-
per, which are associated with fewer
dosing errors compared to dosing cups.37
REFERENCES
1. Schillie SF, Shehab N, Thomas KE, Budnitz
DS. Medication overdoses leading to emer-
gency department visits among children.
Am J Prevent Med. 2009;37(3):181-187.
doi:10.1016/j.amepre.2009.05.018.
2. Lovegrove MC, Weidle NJ, Budnitz DS.
Trends in emergency department visits for
unsupervised pediatric medication exposures,
2004-2013. Pediatrics. 2015;136(4):e821-
e829. doi:10.1542/peds.2015-2092.
3. Slone Epidemiology Center. Patterns of Med-
ication Use in the United States 2006. http://
www.bu.edu/slone/files/2012/11/SloneSur-
veyReport2006.pdf. Accessed on November
20, 2017.
4. Smith MD, Spiller HA, Casavant MJ,
Chounthirath T, Brophy TJ, Xiang H. Out-
of-hospital medication errors among young
children in the United States, 2002-2012. Pe-
diatrics. 2014;134(5):867-876. doi:10.1542/
peds.2014-0309.
5. Tzimenatos L, Bond GR; Pediatric Thera-
peutic Error Study Group. Severe injury or
death in young children from therapeutic er-
rors: a summary of 238 cases from the Ameri-
can Association of Poison Control Centers.
Clin Toxicol (Phila). 2009;47(4):348-354.
doi:10.1080/15563650902897650.
6. Mowry JB, Spyker DA, Brooks DE, Zimmer-
man A, Schauben JL. 2015 Annual Report
of the American Association of Poison Con-
trol Centers’ National Poison Data System
(NPDS): 33rd annual report. Clin Toxicol
(Phila). 2016;54(10):924-1109. doi:10.1080/
15563650.2016.1245421.
7. Yin HS, Dreyer BP, Foltin G, van Schaick
L, Mendelsohn AL. Association of low care-
giver health literacy with reported use of non-
standardized dosing instruments and lack of
knowledge of weight-based dosing. Ambul
Pediatr. 2007;7(4):292-298. doi:10.1016/j.
ambp.2007.04.004.
8. Yin HS, Wolf MS, Dreyer BP, Sanders LM,
Parker RM. Evaluation of consistency in
dosing directions and measuring devices
for pediatric nonprescription liquid medi-
cations. JAMA. 2010;304(23):2595-2602.
doi:10.1001/jama.2010.1797.
9. US Food and Drug Administration. Guidance
for industry: dosage delivery devices for orally
ingested OTC liquid drug products. https://
www.fda.gov/downloads/Drugs/Guidances/
UCM188992.pdf. Accessed November 29,
2017.
10. Budnitz DS, Lovegrove MC, Rose KO. Ad-
herence to label and device recommendations
e458
SPECIAL ISSUE ARTICLE
for over-the-counter pediatric liquid medica-
tions. Pediatrics. 2014;133(2):e283-e290.
doi:10.1542/peds.2013-2362.
11. Even KM, Armsby CC, Bateman ST. Poison-
ings requiring admission to the pediatric in-
tensive care unit: a 5-year review. Clin Toxicol
(Phila). 2014;52(5):519-524. doi:10.3109/
15563650.2014.909601.
12. Yin S. Malicious use of nonpharmaceuticals in
children. Child Abuse Negl. 2011;35(11):924-
929. doi:10.1016/j.chiabu.2011.05.019.
13. Kearns GL, Leeder JS, Wasserman GS.
Acetaminophen intoxication during treat-
ment: what you don’t know can hurt you.
Clin Pediatr (Phila). 2000;39(3):133-144.
doi:10.1177/000992280003900301.
14. Rumack BH, Matthew H. Acetamino-
phen poisoning and toxicity. Pediatrics.
1975;55(6):871-876.
15. Leonis MA, Alonso EM, Im K, Belle SH,
Squires RH; Pediatric Acute Liver Failure
Study Group. Chronic acetaminophen expo-
sure in pediatric acute liver failure. Pediat-
rics. 2013;131(3):e740-e746. doi:10.1542/
peds.2011-3035.
16. Rodgers GB. The effectiveness of child-resis-
tant packaging for aspirin. Arch Pediatr Ado-
lesc Med. 2002;156(9):929-933. doi:10.1001/
archpedi.156.9.929
17. Hill JB. Salicylate intoxication. N Engl J
Med. 1973;288(21):1110-1113. doi:10.1056/
NEJM197305242882107.
18. Pierce AW. Salicylate poisoning. Pediatrics.
1974;54(3):342-347.
19. Seifert SA, Bronstein AC, McGuire T. Mas-
sive ibuprofen ingestion with survival. J Toxi-
col Clin Toxicol. 2000;38(1):55-57.
20. Smith MB, Feldman W. Over-the-counter
cold medications: a critical review of clini-
cal trials between 1950 and 1991. JAMA.
1993;269(17):2258-2263.
21. Schaefer MK, Shehab N, Cohen AL, Bud-
nitz DS. Adverse events from cough and
cold medications in children. Pediat-
rics. 2008;121(4):783-787. doi:10.1542/
peds.2007-3638.
22. Centers for Disease Control and Preven-
tion (CDC). Infant deaths associated with
cough and cold medications—two states,
2005. MMWR Morb Mortal Wkly Rep.
2007;56(1):1-4.
23. Dart RC, Paul IM, Bond GR, et al. Pediatric
fatalities associated with over the counter
(nonprescription) cough and cold medica-
tions. Ann Emerg Med. 2009;53(4):411-417.
doi:10.1016/j.annemergmed.2008.09.015.
24. Sharfstein JM, North M, Serwint JR. Over
the counter but no longer under the radar—
pediatric cough and cold medications. N
Engl J Med. 2007;357(23):2321-2324.
doi:10.1056/NEJMp0707400.
25. Consumer Healthcare Products Association.
Statement from the CHPA on the voluntary
label updates to oral OTC children’s cough
and cold medicines. https://www.chpa.org/1
0_07_08labelupdatecoughmedicine.aspx. Ac-
cessed November 29, 2017.
26. Pentel P. Toxicity of over-the-counter stimu-
lants. JAMA. 1984;252(14):1898-1903.
27. Kernan WN, Viscoli CM, Brass LM, et
al. Phenylpropanolamine and the risk
of hemorrhagic stroke. N Engl J Med.
2000;343(25):1826-1832. doi:10.1056/
NEJM200012213432501.
28. Schwartz AR, Pizon AF, Brooks DE. Dex-
tromethorphan-induced serotonin syn-
drome. Clin Toxicol. 2008;46(8):771-773.
doi:10.1080/15563650701668625.
29. Wilson MD, Ferguson RW, Mazer ME, Lito-
vitz TL. Monitoring trends in dextrometho-
rphan abuse using the National Poison Data
System: 2000-2010. Clin Toxicol (Phila).
2011;49(5):409-415. doi:10.3109/15563650.
2011.585429.
30. Sheridan DC, Hendrickson RG, Beauchamp
G, Laurie A, Fu R, Horowitz BZ. Adolescent
intentional abuse ingestions: overall 10-year
trends and regional variation. Pediatr Emerg
Care. 2016 Oct 4. [Epub ahead of print].
doi:10.1097/PEC.0000000000000866.
31. Baker AM, Johnson DG, Levisky JA, et al.
Fatal diphenhydramine intoxication in in-
fants. J Forensic Sci. 2003;48(2):425-428.
32. Nine JS, Rund CR. Fatality from diphen-
hydramine monointoxication: a case re-
port and review of the infant, pediatric,
and adult literature. Am J Forensic Med
Pathol. 2006;27(1):36-41. doi:10.1097/01.
paf.0000188093.45675.ee.
33. Cole JB, Stellpflug SJ, Gross EA, Smith
SW. Wide complex tachycardia in a pedi-
atric diphenhydramine overdose treated
with sodium bicarbonate. Pediatr Emerg
Care. 2011;27(12):1175-1177. doi:10.1097/
PEC.0b013e31823b0e47.
34. Budnitz DS, Salis S. Preventing medica-
tion overdoses in young children: an op-
portunity for harm elimination. Pediatrics.
2011;127(6):e1597-e1599. doi:10.1542/
peds.2011-0926.
35. Eichelberger MR, Gotschall CS, Feely HB,
Harstad P, Bowman LM. Parental attitudes
and knowledge of child safety. A national sur-
vey. Am J Dis Child. 1990;144(6):714-720.
36. Gibbs L, Waters E, Sherrard J, et al. Under-
standing parental motivators and barriers to
uptake of child poison safety strategies: a
qualitative study. Inj Prev. 2005;11(6):373-
377. doi:10.1136/ip.2004.007211.
37. Yin HS, Mendelsohn AL, Wolf MS, et al. Par-
ents’ medication administration errors: role of
dosing instruments and health literacy. Arch
Pediatr Adolesc Med. 2010;164(2):181-186.
doi:10.1001/archpediatrics.2009.269.
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