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Abstract

Among injuries caused by child maltreatment, poisoning and other causes of death have the most dire consequences. Head injuries account for 90% or more of fatal child abuse cases, but it is important to remember that neglect by itself or in combination with abuse actually causes or contributes to more deaths than abuse alone. When the neglect involves inadequate supervision leading to accidental ingestions, or worse, when the poisoning is actually intentional, the consequences can be deadly given the smaller size of children and their immature metabolism when compared with adults, which can lead to drug effects far out of proportion to those seen in adults. This paper briefly reviews keys elements of poisoning and child maltreatment fatality, highlighting important steps in recognition and management, with differentiation from accidental and other causes.

Keywords: Child abuse, child maltreatment, poisoning, fatal abuse

Introduction

Poisoning as a pattern of abuse has been a less understood and reported form of child maltreatment. Early reports of intentional poisoning noted the use of common substances such as salt, water, acetaminophen, iron, and mental health medications. Infants and teens are more likely to have been intentionally poisoned (1). Intentional or abusive poisoning is more deadly than accidental ingestion, with higher fatality estimates due to delays in seeking medical care and nonspecific symptoms on presentation for medical care.

Historically, commonly used drugs in reported cases of intentional poisoning included iron, alcohol, caffeine, benzodiazepines, glutethimide, insulin, ipecac, laxatives, marijuana/THC, oral hypoglycemics, pepper, salt, and a variety of other prescription and illicit substances (2). In a large national dataset of cough and cold medication ingestions, Halmo et al. (3) found 40 fatalities, the majority of which occurred in children <2 years old and involved nontherapeutic intent. Medicine was sometimes administered to murder the child; in other cases, death followed intentional use to sedate the child. Among older children in the National Violence Death Reporting System, Hunter et al. (4) reported 122 poisoning-related deaths, and half of these were attributed to opioids. Next were benzodiazepines (8%), amphetamines (7%), and antidepressants (5%); 25% involved homicidesuicide. Following qualitative analysis, three unique categories of fatal poisoning emerged: "intentional administration without documented benign intent," "intentional administration with benign intent," and "unclear administration."

In addition, the health care provider must...

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