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Salicylate poisoning in children and adolescents

A Karl Barnett, MD
Edward W Boyer, MD, PhD
Section Editors
Michele M Burns, MD, MPH
Stephen J Traub, MD
Deputy Editor
James F Wiley, II, MD, MPH


The clinical manifestations and management of all salicylate intoxications are similar. An overview of salicylate intoxication in children and adolescents will be presented here. General issues relating to the clinical management of drug intoxication are presented separately. (See "Approach to the child with occult toxic exposure" and "Gastrointestinal decontamination of the poisoned patient".)


The number of pediatric exposures to salicylates reported to the American Association of Poison Control Centers Toxic Exposure Surveillance System (AAPCC TESS) has declined since the 1980s [1]. The use of aspirin (acetylsalicylic acid, ASA) in children has declined since it was associated with Reye syndrome. The incidence of unintentional salicylate intoxication among toddlers also has declined with limitation of the dose of aspirin in chewable, flavored tablets (to 81 mg), restriction of the number of tablets per bottle (to 36), and child-resistant packaging [1-3]. Among children there are approximately 20,000 salicylate exposures reported to United States regional poison control centers annually [4].

Deaths from exploratory salicylate overdose in children are rare. Most pediatric cases of severe salicylate poisoning or death occur among adolescents with intentional ingestion.


Aspirin (acetylsalicylic acid) is available in chewable form, regular tablets, and enteric-coated pills. Other salicylates, such as salicylic acid, bismuth subsalicylate, and methyl salicylate, can cause intoxication when ingested or absorbed through the skin [5,6]. Salicylic acid is a topical keratolytic agent and wart remover. Bismuth salicylate is a common ingredient in over-the-counter antidiarrheal agents (eg, Pepto-Bismol, Kaopectate). Magnesium subsalicylate in combination with caffeine, a combination product known as Diurex, is used as an “antibloat” medicine, but has been reported to cause salicylate toxicity in overdose [7]. Methyl salicylate (oil of wintergreen) is a common ingredient of Chinese herbal medications as well as liniments and ointments used in the management of musculoskeletal pain; it also is used as a flavoring agent [8-10]. One teaspoon (5 mL) of oil of wintergreen contains approximately 7 g of salicylate, the equivalent of 22 adult aspirin tablets; ingestion of just 4 mL can be fatal in a child [9]. The methyl salicylate concentration and the bioavailability of salicylate in methyl salicylate creams vary by preparation [8,11].


After ingestion, salicylate is rapidly absorbed from the gastrointestinal tract, primarily from the jejunum and to a lesser extent, from the stomach and duodenum [12,13]. The type of formulation (eg, liquid, effervescent, extended-release, enteric-coated) affects the degree of absorption [14-16].


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Literature review current through: Sep 2016. | This topic last updated: Nov 5, 2015.
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