Salicylate poisoning in children and adolescents
- A Karl Barnett, MD
A Karl Barnett, MD
- Attending Physician
- Athens Regional Medical Center
- Edward W Boyer, MD, PhD
Edward W Boyer, MD, PhD
- Professor of Emergency Medicine, Director of Toxicology
- University of Massachusetts Medical School
- Section Editors
- Michele M Burns, MD, MPH
Michele M Burns, MD, MPH
- Section Editor — Pediatric Toxicology
- Assistant Professor of Pediatrics
- Harvard Medical School
- Stephen J Traub, MD
Stephen J Traub, MD
- Section Editor — Toxicology
- Associate Professor of Emergency Medicine
- Mayo Medical School
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
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 . 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 .
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 . 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 . The methyl salicylate concentration and the bioavailability of salicylate in methyl salicylate creams vary by preparation [8,11].
PHARMACOKINETICS AND TOXICOKINETICS
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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- PHARMACOKINETICS AND TOXICOKINETICS
- MECHANISM OF ACTION
- CLINICAL MANIFESTATIONS
- EVALUATION AND DIAGNOSIS
- - Plasma salicylate
- - Additional tests
- DIFFERENTIAL DIAGNOSIS
- Supportive care
- - Airway
- - Breathing
- - Circulation
- - Supplemental glucose
- - Potassium repletion
- Gastrointestinal decontamination
- Elimination enhancement
- - Urine alkalinization
- - Treatments to avoid
- - Hemodialysis
- - Multiple dose activated charcoal
- Laboratory monitoring
- Mental health referral
- ADDITIONAL RESOURCES
- SUMMARY AND RECOMMENDATIONS