Paediatric Urine Toxicology - Operational Pathway for

Publication: 01/06/2009  --
Last review: 05/07/2018  
Next review: 05/07/2021  
Care Pathway
CURRENT 
ID: 1709 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Care Pathway is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Operational Pathway for Paediatric Urine Toxicology

This Pathway covers the following

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Target Group

This Guideline applies to Paediatric patients (up to 16th birthday). It is aimed at Doctors and Nurses on Paediatric wards and units and in the Emergency Department. The aim of this guideline is to improve patient care where poisoning has been considered, through a process where a quick toxicology result is achieved.

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Poisoning - when to consider it

Poison is defined as a substance causing illness or death when eaten, drunk or absorbed into the body by other means.
Poisoning may be:

  • Accidental
  • Neglectful or due to single acts of omission
  • Deliberate - clearly a form of child abuse.

Gray & Bentovim (1996) described 11 cases with children ranging from 4 weeks to 12 years and 3 months where a carer had ‘actively administered substances which were harmful to the child or where a parent had been actively interfering with the child's medical treatment’.

Repeated poisoning may be due to negligence but the consequences for the child may be equally as catastrophic as poisoning by intent or in order to fabricate illness and should be assessed as possible abuse.

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Accidental poisoning

Accidental poisoning: seldom fatal, 15% of children symptomatic related to the ingestion. The peak age 2–3 years, adult supervision was faulty and ingestions took place at home. In 60% of cases the substance ingested was not in its usual storage place and 60% of substances were not in child-resistant containers; 22% of children were admitted to hospital, < 10% needed intensive care and there were no fatalities.

Accidents may occur even in well-regulated homes but repeated ingestion should be looked at as neglectful, and deliberate poisoning considered. It is also appropriate to look at parental behaviour: is the mother depressed, or impaired by the use of drugs or alcohol? Are there other signs of neglect within the family?

The drugs ingested include analgesics, anxiolytics, the contraceptive pill, cough medicine and iron. Bleach, detergents and petroleum products account for most of the household substances ingested.

If symptoms are severe – for example seizures, coma, intractable vomiting – consider whether an unusual substance such as salt, insulin or anti-convulsants has been administered. Laxatives, easily available, are also often used.

The age of the child is also important. Toddlers aged 18 months to 3 years explore, test and taste whatever they find; by 4–5 years most children will know not to eat pills. When a young infant (not yet at the crawling stage) is brought, the facts of the story need to be very carefully obtained and a vigilant stance adopted.

Parents may misread instructions on a bottle and overdose a child but then the history is clear, whereas if parents deliberately overdose their child they will conceal the history. Children from 3 years are able to give a history and tell if they ‘ate grandpa's sweeties’ or if mummy gave them herself. Children as young as 6 years do deliberately overdose, but this is rare under 10 years. If any child or adolescent overdoses the reasons why must be explored.

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Intentional poisoning

See Table 1 for features of poisoning, whether due to accident, neglect or willful intent by care giver.

  • Gray & Bentovim describe a case of a 2.5-year-old child with the highest ever reported salt levels in her system for which ‘only active administration of salt could account for this finding’.
  • Rogers et al (1976) described deliberate poisoning of infants by salt, barbiturates, and other drugs. Two of the children in that study died of salt poisoning. There is considerable overlap, but the more bizarre the clinical situation the greater the likelihood of intentional poisoning, whether as an attempt to kill the child or factitious illness.
  • Meadow's (1993) study of deliberate salt poisoning described 12 children with this condition. The children in this study presented below the age of 6 months. Ten children did well in alternative care; several of them additionally suffered from fabricated symptoms. Two of the children died. Meadow (1993) described 12 children who were diagnosed as having non-accidental salt poisoning: seven out of the 12 mothers admitted to the poisonings and explained how they had done this and two of the children died as a result.
  • Drugs are also used to keep children quiet, for example the use of sedatives at night, or to make the child compliant, with high doses of anxiolytics.
  • Drugs have been used to allow sexual abuse to occur.
  • Adults who abuse drugs may also involve even very young children in their habit, and a child may present to hospital stuporous on the parent's heroin or methadone.
  • There are many examples of children of all ages dangerously intoxicated with alcohol. This may be deliberate poisoning, or unsupervised drinking, often in a house where heavy drinking occurs.

 

Table1 Poisoning: is it accident, neglect or deliberate? (from Hobbs, Hanks & Wynne 1999)

 

Accident

Neglect

Deliberate

Age

2–3 years

2–3 years

Infancy–3 years

 

Rarely older child

Rarely older child

May be any age

History

Usually clear, makes sense

Variable, due to social chaos

None, but ill child

     

History of accidental ingestion

     

Recurrent symptoms

Symptoms

Uncommon

Uncommon

Common

 

< 15%

< 15%

Seizures, drowsy, vomiting diarrhoea

 

< 1% need intensive care

< 1% need intensive care

Dead

Outcome

Rarely fatal

Rarely fatal

 

Substance

     

Drugs

Analgesics, anxiolytics, cough medicine, oral contraceptive, iron

 

Analgesics, antidepressants, anxiolytics, anticonvulsants, insulin, etc.

Household or other

Bleach, detergent, petroleum product

 

Salt, bicarbonate of soda, corrosives, etc.

Past history

Nil

Repeated ingestions

Other unexplained child deaths in family including SIDS

   

Increased incidence of SIDS

 
   

Known to social services

Other abuses

Diagnosis

History equates with clinical signs

As accidental

History usually at variance with clinical signs

 

Confirm if necessary by toxicological investigation

 

Ask advice of toxicologist: blood, urine samples

     

Think of possibility: parents' behaviour may be bizarre although they present as caring and concerned

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Urine Toxicology Pathway

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Contact Information

It is essential that the toxicology section is made aware as soon as possible that the sample is coming and that the result is needed urgently.  Failure to inform the lab or deliver the sample directly will lead to delayed sample processing.

Toxicology is based at Specialist Laboratory Medicine, Block 46 , St James Hospital, Beckett Street, LS9 7TF
Laboratory 66063 (main number), 64256, 66679, 64851
Sample reception 64195
Advanced Biomedical Scientists: James Booth & Bryan Hill 64204
Clinical Scientists: Dr Carys Lippiatt 67174 Dr Elizabeth Fox 64860
If toxicology section cannot be contacted, please contact the Duty Biochemist on 26922 (Option 2) or bleep 80-2607.
General Paediatrics Registrar phone 23927 or bleep 2111
Specialities Registrar bleep 1904
PICU Registrar via ward 27447
Paeds ED 25549

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Provenance

Record: 1709
Objective:

The aim of this guideline is to improve patient care where poisoning has been considered, through a process where a quick toxicology result is achieved.

Clinical condition: Poisoning
Target patient group: This guideline applies to paediatric patients (up to 16th birthday).
Target professional group(s): Secondary Care Doctors
All Secondary Healthcare Professionals
Adapted from:

Evidence base

  • Meadow R M 1993 Non-accidental salt poisoning. Archives of Diseases in Childhood 68:448-452
  • Rogers D, Tripp J, Bentovim A, Berry D, Goulding R 1976 Non‑accidental poisoning: an extended syndrome of child abuse. British Medical Journal i: 793-796
  • Gray J and Bentovim A (1996) Illness Induction Syndrome: Paper 1 A series of 41 Children from 37 Families Identified at The Great Ormond Street Hospital for Children NHS Trust. Child Abuse and Neglect. 20 8: 655-673
  • Moeller K,  Kelly C, Kissack J. Urine drug screening; Practical guide for clinicians. Mayo Clinic Proceedings. 2008. 83(1) 66-76

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Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Appendix

Drugs/Medications routinely checked on urine toxicology screen

Morphine, 6-monoacetylmorphine, codeine, dihydrocodeine,
Amphetamine
Benzoylecgonine (cocaine metabolite)
Nordiazepam and oxazepam (Diazepam metabolites)
Cannabis,.
Methadone and EDDP (metabolite)
Buprenorphine and norbuprenorphine (metabolite),

Drugs/medications that will need a specific request and liaison

Ethanol, Ketamine, MDMA, Oxycodone, Pholcodine, Diazepam, Temazepam, Nitrazepam,Pregabalin, Tramadol. : available in-house.
Any other substance: sent away for analysis.

Common drugs/medications that can interact with the assays

Codeine – Morphine may be detected at a lower, similar or greater concentration than codeine.  Relative proportions depend upon CYP2D6 genotype of the individual.
Poppy seed ingestion – morphine and codeine positive
Pholcodine – Possible trace of morphine

Other sources of positive results (not exhaustive list):

ALCOHOL
Urine contaminated with sugars and microorganisms may contain detectable ethanol due to fermentation. (Cobas Roche/Hitachi Ethyl alcohol assay product insert 2010-06, V7)

AMPHETAMINE
Dextroamphetamine
Methamphetamine
l-Methamphetamine (Vick’s inhaler)d
Selegiline

CANNABIS
Hemp-containing foods

COCAINE
Coca leaf tea
Topical anaesthetics containing cocaine

OPIATES / OPIOIDS
Heroin
Opiates (codeine, hydromorphone, hydrocodone, morphine)
Poppy seeds

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Equity and Diversity

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.