According to the results, increasing trend in the numbers of APP over the years 2011 - 2013 was evident (Table 1). Raising the number of APP and the proportion of APP to all pediatric admissions may be due to the availability of drugs or medicines at homes (13). The constant ratio of APP to adult poisonings despite the increasing numbers of APP may bring this idea to the mind that other factors could be involved in the raising numbers of total poisoning, adult poisoning, and APP (14, 15). The sex ratio (53.1% male) of our cases did not change significantly over the period of the study, which was similar to the reports of Joghatae et al. (16) and Farnaghi et al. (17).
The number and pattern of APP have recently been changed in the region of the study. Similar changes have been reported from other regions (5). Socio-economic problems, lack of knowledge, introduction of new drugs and new formulations of pharmaceuticals, drug availability, demographic changes, and high rate of availability of drugs of abuse, and some new medical treatment programs e. g., Methadone Maintenance Therapy (MMT), may be the causes of these changes (1, 14, 18).
The mean age of poisoned children also resembles the mean age reported in some other studies (16, 19, 20). However, in our study, the mean age significantly increased over the years of the study from 2011 to 2013 (Table 2); this trend may be due to the increased numbers of older children poisoned by methadone or the other medicines.
The most common causes of children poisonings in our study were related to Methadone, Opium, and Benzodiazepine, whereas in the report of Joghataee et al. (2001) (16), the most common causes of APP included hydrocarbon, opium, and pharmaceuticals. However, the most common pharmaceutical cause of poisoning in children, was attributed to Benzodiazepine (16).
Based on our results, it seems that the mean age of opium poisoned children was lower (22.3 ± 2.2 months) than the mean age of children poisoned with other types of poisons. It may be due to the parents’ tendency to give opium to their children for treating diarrhea, cough, somnolence, and infantile colic, as well as due to accidentally ingestion of opium by children.
The mean age of methadone poisoned children in our study was similar to that reported from other hospitals in Iran (17, 21). Methadone is a synthetic µ-opioid-receptor agonist that is used both for treatment of chronic pain and as methadone maintenance therapy (MMT) for opioid dependency (22). This opiate not only allows patients to abstain from activities associated with procurement and administration of the abused opioid, but also eliminates much of the morbidity and mortality associated with illicit drug abuse (23). Due to the establishment of a large number of outpatient drug recovery clinics for MMT in Mashhad in recent years, that let patients taking drugs especially methadone syrup home, a larger amount of this opiate is available at homes (21, 24). In recent years, to prevent methadone abuse through illegal selling and to improve patients’ compliance, methadone provision has been changed from pills to syrup in this area; therefore, it might induce more pediatric poisoning. Lack of knowledge about methadone and its side effects may have affected the rate of pediatric poisoning. Also, high doses in syrup (5mg/mL) can be more toxic for children (18). Furthermore, home storage of drugs in inappropriate containers, such as juice containers or baby bottles, may be a cause of accidental methadone ingestion by children. Administration of methadone syrup instead of safe drugs such as acetaminophen or diphenhydramine syrup by parents to children may also cause over dosages (24). Such events can be anticipated because methadone is frequently formulated as a palatable liquid and may not be distributed in child resistant containers. Unfortunately, children death by methadone poisoning is frequent (24-26).
As the pattern of methadone pediatric poisoning has changed through 2011 - 2013 in this area, we focused on the geographic location of the patients in the city. There are 13 municipal divisions in Mashhad. We investigated the rate of pediatric poisoning with methadone in each municipal division per one million civilians. We found that the zone of high incidence of methadone intoxication changed from the first and second municipal divisions, which are recognized as high economic areas, to 7th municipal division, as a low economic area (Figure 1 and Table 5). This may show the variation of socioeconomic level in parents, the change in addiction pattern, the change in geographical distribution of abstinence therapy clinics, and possible other types of addiction. Also, it may be due to the variation in population pattern e.g. number of children.
5.1. Conclusion
Pediatric poisonings increased during 2011 - 2013 in Mashhad, Iran. The pattern of APP changed from traditional opium poisoning in 2011 to methadone poisoning in 2013. Also, the mean age of APP changed during this period. Methadone poisoning is now the most common type of pediatric poisoning (35%) in this area that may be due to the availability of unsafe form of the drug (syrup) for children. Methadone poisoning was more significant in the poor economic areas of the city. The changing pattern of pediatric poisoning over the years is probably due to the changing pattern of addiction from opium to its synthetic derivatives such as methadone and increasing its availability at the homes of addicted parents.
More investigations, particularly a prospective epidemiological study, are necessary to develop a health plan of action to control pediatric poisoning in this area.
5.2. Limitations
The exact population of children and fertility rates in each municipal division of Mashhad through 2011 - 2013 was not found, so the estimated 2012 population of every municipal division was used as denominator to calculate all the rates.
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