Journal of Pediatric Nursing (2015) 30, 395–401

Pick Your Poison: What's New in Poison Control for the Preschooler Lauren Glenn RN, CPNP ⁎ Columbia University School of Nursing, New York, NY Received 17 February 2014; revised 7 October 2014; accepted 9 October 2014

Key words: Poison; Poison control; Protection motivation; Health belief model; Laundry pods; Button battery; Nicotine; Syrup of ipecac; Mr. Yuk

Accidental childhood poisonings are a major public health concern despite many efforts to alleviate this problem. While the rate of pediatric fatalities due to poisonings have decreased over the last two decades, poison control centers around the US have collectively fielded over one million calls with regard to toxic exposures in the preschool age group. According to the American Association of Poison Control Centers nearly half of all human exposures reported last year involved children under six. By focusing poison prevention efforts on the preschooler, we can attempt to decrease morbidity and mortality in the most vulnerable age group affected. Although the subject is still prevalent, current discussion on this topic is limited. Newer literature discusses past initiatives such as child resistant packaging and sticker deterrent programs and addresses their efficacy. This article revisits older mechanisms of prevention as well as the science behind the human motivation to change one's own practice and behavior. © 2015 Elsevier Inc. All rights reserved.

AS DECADES OF research on this topic have uncovered, the modality of prevention of childhood accidents and specifically, poisoning, relies upon educating parents and other caregivers on how to keep dangerous products out of kids' hands. Whether this has been effective still remains a question. Although anticipatory guidance and specific instruction are provided, children still present to the emergency room every year with accidental contact with toxic substances (Franklin & Rodgers, 2008). Poisoning ranks as the fifth most common cause of fatality worldwide in children younger than five (Kendrick et al., 2008). The question now is, how can we as healthcare providers, be more effective in our instruction so that the outcomes of prevention are improved? Staying abreast of the latest literature of toxicities reported on pediatric patients and

⁎ Corresponding author: Lauren Glenn, RN, PNP. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.pedn.2014.10.009 0882-5963/© 2015 Elsevier Inc. All rights reserved.

educating caregivers is paramount. Questioning current methods and examining older literature should be a part of the process. One theory is to start by looking at parents' perception of harm and the motivation behind their decision-making (Beirens, van Beeck, Brug, den Hertog, & Raat, 2010; Rosenberg, Wood, Leeds, & Wicks, 2011).

Parents' Perceptions When delving into the topic of accidental poisoning, there are multiple components identified that contribute to the problem. Healthcare providers educate about prevention of accidental poisonings to parents as part of anticipatory guidance for the preschool age as part of primary care. Parents and other caregivers play an integral role along the continual approach to preventing accidental poisonings. However as research shows, well meaning parents do not necessarily incorporate all of the preventative measures that are advised (Beirens et al., 2010; Lee et al., 2012). It makes

396 sense then, to consider why parents do what they do when trying to protect their children. Two behavioral theories, the protection motivation theory and the health belief model, have been utilized to examine parental decision-making regarding this topic. The protection motivation theory is one behavioral theory that has been studied to ascertain the incentive for parent's decisions regarding how to safely protect their children from harmful substances around the home (Beirens et al., 2010). This theory investigates four components of motivation: severity of the perceived threat, personal vulnerability to that threat, perceived efficacy of the solution, and the self confidence in oneself to accomplish the solution (Beirens et al., 2010). One study applied this theory by asking parents of toddlers which products they perceived as most harmful and which they locked away safely. Parents' self-reported behaviors indicated that household cleaners and medications were the most dangerous toxins. Consequently, those items were more likely to be locked away or placed in a safe area. The parents that recognized medications and cleaning products as potentially harmful but did not properly store them, failed to identify them as harmful enough to lock away. Researchers found that the protection motivation theory, which bypasses race, gender, and socioeconomic status, was an effective model to portray this situation (Beirens et al., 2010). Low-income populations that pose socioeconomic challenges are a known risk factor, so this theory may be helpful in evaluating this group (Kendrick, Barlow, Hampshire, Polnay, & Stewart-Brown, 2009; Lee et al., 2012; Rodgers & Condurache, 2011). The health belief model is another behavioral theory discussed in the realm of this health concern. This model accounts for perceived susceptibility of disease, perceived threat of disease, and benefits versus barriers to an intervention. Perceived external factors such as education, socioeconomic status, and personal knowledge of the disease are all considered when looking at this model (Rosenberg et al., 2011). In short, how dangerous is this threat, how likely is it that it will affect me, and does the solution actually work? Australian researchers applied this theory to a study that asked parents of children up to 4 years old about their poison prevention practices. Similar to the previous study that evaluated protection motivation, parents were more likely to lock away household cleaners and chemicals and less likely to secure over the counter (OTC) medications because they saw the household cleaners as “fatally poisonous” but did not identify the medications as harmful (Rosenberg et al., 2011). This supports the theory that if parents do not believe OTC medications are dangerous and they do not believe their children are likely to be harmed by them, then they are not likely to take aggressive precautions against their child ingesting them (Rosenberg et al., 2011). Using these two theories, it is reasonable to suggest that parents may need to be further convinced of the harm certain toxins can cause. The study by Rosenberg et al. (2011) found that parents were well informed of the mechanisms used to

L. Glenn keep poisonous substances away from their kids, and less informed of common items that were “fatally poisonous.” If action typically arises from motivation and the motivation is measured by the level of danger that common household items present, parents may carry out the changes needed. As evidence shows, dangerous items lying around the house do not necessarily raise a red flag to parents as harmful (Lee et al., 2012). By taking a look at some newer culprits involved in accidental ingestions, it may be easier to see why.

New Pediatric Poisoning Problems As nurses, it is our job to keep abreast on the latest information so we can provide the right guidance to our patients and families. Potential poisons tend not to cause concern until after enough significant events are reported to make it onto the radar. In the annual report by the Centers for Disease Control, the newest items causing accidental poisonings are making news. Emergency departments are reporting poisonings due to ingestion of laundry pods, lithium ion “button” batteries, and nicotine pellets across the country in high numbers (Connolly et al., 2009; Forrester, 2012; Litovitz, Whitaker, & Clark, 2010). These items are highlighted due to their likelihood to be underestimated by caregivers regarding their potential harm.

Laundry Pods In 2010, individual laundry detergent packets or “pods” were introduced to the U.S. market as a more compact, convenient method to package soap intended for washing machines. Over the next couple of years the product became more mainstream, but this addition to the American household eventually posed a threat. By the summer of 2012, the Center for Disease Control (CDC) began following reports of children ingesting the pods. The statistics were concerning: more than one thousand cases of poisoning by detergents were reported in 1 month and nearly half of those reported involved laundry pods (CDC, 2012). Children less than 5 years old were found to be at highest risk for poisoning, as they comprised ninety-four percent of the group affected by laundry pods (CDC, 2012). These data support the notion that these new products while convenient, are a growing national health concern (Scharman, 2012). A 2012 Morbidity and Mortality report by the Center for Disease Control and Prevention described two separate incidences in North Carolina involving ingestion of laundry pods (CDC, 2012). A 20-month-old boy and a 15-month-old boy were both brought to the emergency department after ingesting the liquid portion of the packet. The 20-month-old experienced profuse vomiting, respiratory distress and a seizure. He was intubated and placed on a ventilator but subsequently improved and made a full recovery. The 15-month-old boy also

Pick Your Poison presented to the emergency department with profuse vomiting and developed respiratory distress requiring intubation. He was extubated 6 hours later, making a full recovery (CDC, 2012). Similar to the above examples, most children who experience accidental poisoning do so by ingestion (Bronstein, Spyker, Cantilena, Rumack, & Dart, 2012). Dermatological contact, eye irritation, and conjunctivitis were also associated with the pods (CDC, 2012; Williams et al., 2012). The CDC reported that compared with traditional household detergents, children who ingested the pods were more likely to have serious medical outcomes. In addition to those already mentioned, symptoms of poisoning via detergents include coughing, choking, drowsiness, and lethargy. According to the report, emesis, lethargy, coughing, and choking were found to be more significant in the pod group than their liquid counterparts (CDC, 2012). The preschoolers' fascination to the laundry pod is not difficult to discern; the bright colored gel, soft texture, and palm-sized packet could easily be mistaken for a toy or food. Given that the mean age of children in the reported cases was two, one could speculate that the developmental stage of the toddler makes them more prone to ingestion or eye contact because of their exploratory interest in the senses, particularly oral discovery (Forrester, 2012). Parents and other caregivers of young children should be warned about specific age-related hazards and provided instructions about how to keep them safely out of reach. In addition, hazardous items should be kept in their original packages and not transferred to separate containers because past studies have shown that this increases the risk of accidental poisonings (Dancho, Thompson, & Rhoades, 2008; Kendrick et al., 2008). Soaps and cleaning supplies of any kind should be high on the safety list of anyone caring for a small child.

Battery Ingestions Batteries of various kinds are not just one of the inanimate objects children are curious enough to explore, but one of the most dangerous. Accidental battery ingestion rates have remained steady, with the occasional rise and fall over the past few decades (Litovitz et al., 2010). This fact necessitates the need for further exploration into better preventative measures regarding accidental battery ingestion. The rate of pediatric battery ingestion cases is not the only concerning element surrounding this subject: the severity of the cases is growing. Litovitz et al. (2010) attribute this increase in severity to the introduction of the 22-mm lithium ion battery, or “button battery.” As technology advances, so do the risks. The 22-mm lithium ion cell's slim size and shape, which is roughly the size of a quarter, make it much easier to swallow. The battery is more efficient than previous alkaline batteries and thus, are ever more popular in the market. The lithium ion cell is now used to operate remote controls, kid's toys, calculators, watches, and games as well as obscure objects such as electric toothbrushes or lighted shoes (Litovitz et al., 2010).

397 In an 18-year study conducted at Georgetown University using the National Battery Ingestion Hotline, researchers found that children under four were the most affected group and that the majority (61.8%) of those children obtained the batteries directly from the electronic product that contained them (Litovitz et al., 2010). This poses an increased threat to preventative measures; this culprit cannot be locked in a cabinet and placed out of reach when they are inside of numerous items around the home. One third of the previous group found the batteries outside of an appliance, and small majority (8%) removed them from original packaging (Litovitz et al., 2010). Any battery that gets caught in the esophagus can cause acute tissue injury within 2 hours (Marom, Goldfarb, Russo, & Roth, 2010). The damage is caused by a combination of three mechanisms: necrosis of tissue from pressure on the esophagus, leaking of alkaline materials, and the creation of an electrical charge that is triggered from the battery's outer pole with hydroxide in the fluids of the body (Marom et al., 2010). Button batteries have twice the voltage of the traditional battery, carrying with it a much higher capability of generating an electrical current. The sequelae that result from this type of injury include tracheosophageal perforation or fistula, blood loss secondary to fistula of a blood vessel, vocal cord paralysis, and tracheostenosis (Marom et al., 2010). As with any consumed foreign body, pneumonia and lung abscess have been reported (Marom et al., 2010). Due to the limited capacity of effective treatment for ingestion of this type of battery, the best treatment is prevention (Marom et al., 2010). Reversing this trend will need to be multi-faceted. Awareness of the potential danger that this battery imposes should be made to manufacturers and major electronic companies, which the AAP has previously outlined (Litovitz et al., 2010). Parents should be cautioned about accidental ingestion possibilities specific to the lithium ion batteries and other newer technologies of its kind as they arise.

Nicotine Tobacco and nicotine products are universally known as noxious, disease-causing substances, but they are also a potential danger to young children who ingest them. In addition to cigarettes and chewable forms of tobacco, newer products on the market now exist presenting a greater potential of accidentally falling into the hands of children. Examples include nicotine-containing gums and dissolvable pellets. These two forms of nicotine are small, smokeless, and marketed either as cessation tools or nicotine substitutes. Camel Orbs pellets were introduced to the market in 2009 as a flavored alternative to cigarettes. Dissolvable pellets come in a small container, which the AAP has since warned to look and taste too much like Tic Tac candies (Connolly et al., 2009). Dissolvable strips and sticks are sold in similar packaging. The potential for poisoning involving these types of products is clear. Although the makers of Camel Orbs insist

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that the packaging is consistent with the Consumer Product Safety Commission's standards, the nature of the product still poses a major risk (Connolly et al., 2009). Unlike cleaning products, batteries, or medication that parents think to lock up and keep out of reach, these items are designed to conveniently fit in a pocket or purse. Additionally, as many kids attempt to mimic adult behaviors, watching an adult eating the pellets or gum will only tempt a child to do the same (Vilke et al., 2011). The potential for harm that cigarettes and other products like them pose is easily determined by measuring the amount of nicotine contained in each product. One milligram of nicotine per kilogram is considered the lethal amount of nicotine for a child (Connolly et al., 2009). The pellets contain roughly 3 mg per item; a young child could easily reach a toxic level if they consumed more than one. According to Connolly et al. (2009), as little as 1 mg of nicotine can cause nausea and vomiting. More severe physical reactions to nicotine include respiratory depression, convulsions and weakness. Table 1 is a summary of the major and minor toxic effects of nicotine, as well as battery and laundry pods.

The ‘Typical’ Poisons Much concern and attention are warranted regarding the newer items on the radar in poison control, but the older perpetrators still exist. Common cleaning solutions, cosmetics, personal care products, and medications remain the top categories of poisons affecting children under 5 years old (Bronstein et al., 2012). In 2011, the American Association of Poison Control Centers found that analgesics were the most common cause of accidental ingestions in children of all ages and had the largest rate of increase in previous years (Bronstein et al., 2012; Burghardt et al., 2013). Sedatives and hypnotics were next on the list as number two and three, respectively (Bronstein et al., 2012). There are more of these

Table 1 Summary of toxic effects of laundry pods, button batteries, nicotine products. Laundry pods

Button battery

Dissolvable nicotine products

• Minor symptoms: nausea, vomiting, respiratory distress, conjunctivitis, lethargy, drowsiness • Severe symptoms: respiratory failure, choking, seizure • Minor symptoms: tissue necrosis, pneumonia • Severe symptoms: tracheoesophogeal fistula, vocal cord paralysis, tracheostenosis • Minor symptoms: nausea and vomiting •Severe symptoms: respiratory depression, weakness, convulsions

types of drugs on the market than ever before and they are prescribed more frequently (Burghardt et al., 2013). Fortified packaging is standard for these meds, yet accidents still occur. Healthcare providers should always educate caregivers on the practice of keeping medication in its original container so that child-resistant packaging can remain a deterrent for children (Truitt, Brooks, Dommer, & LoVecchio, 2012). Over the counter medications, specifically cough and cold medications continue to comprise a large amount of poisonings (Bronstein et al., 2012). This may be due to caregiver knowledge deficit. Multiple studies have cited that OTC medications are not perceived as a very high threat, or at least not as dangerous as some other harmful substances around the house. Household cleaning products, cosmetics, batteries, prescription drugs, and illegal drugs are the broad categories listed of common poisonous agents kept in the home according to the National Poison Data System annual report in 2012 (Bronstein et al., 2012). An additional reason cold and cough medications rank in the top categories of drug poisonings is because a large portion of cases is due to off-label use. The comprehensive study by Dart et al. in 2008 reviewed every case of poisoning by non-prescription cough and cold medications in children under twelve including both intentional and unintentional causes (Dart et al., 2008). Of the medication cases investigated, the majority of the deaths were associated with non-therapeutic administration by an adult (Dart et al., 2008). Figure 1 depicts the breakdown of medications causing toxic effects in children less than 5 years old as reported by the American Association of Poison Control Centers' s National Poison Data System (2012). The largest group affected by overdose due to cold medication administration by parents, were infants. The rates declined as age increased, so the younger the child, the greater the risk of overdose (Dart et al., 2008). This is considered an unintentional poisoning by the parent rather Cosmetics/personal care items 2% Miscellaneous 5% Fumes/gases/vapors Batteries 6% 2%

Medications 48%

Household cleaning detergents 7%

Stimulants & Street drugs 11% Household chemicals (non detergents) 19%

Medications Stimulants & Streetdrugs Fumes/gases/vapors

Household chemicals (non detergents) Household cleaning detergents Miscellaneous

Batteries

Cosmetics/personal care items

Figure 1 Distribution of medications affecting children less than 5 years old. Data from Bronstein et al. (2012).

Pick Your Poison

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than a child directed poisoning. Overmedicating or giving an anti-histamine for sedative effects could easily escape the usual poison prevention guidance provided by healthcare providers because it is not the typical mechanism of injury. Awareness of this issue should be brought to the attention of parents because many of the mentioned studies have shown that a large percentage of parents do not consider cough and cold medications to be dangerous. Aside from medications, other major injury causing agents such as household cleaners and personal cosmetics rank high on the list of any poisoning study in children under five. The various preparations of household products allow for a varied route of accidental contact. Ingestion is the most common pathway, but ocular exposure, inhalation, skin contact, or any number of combinations is frequently reported (Bronstein et al., 2012). Figure 2 is the dissection of the major categories of toxins causing harm in pediatric patients according to the American Association of Poison Control Centers' data system in 2011. Child resistant packaging is a mandated precaution that pharmaceutical companies must comply with as a barrier to medications according the Poison Prevention Packaging Act of 1970. Since this law has come into effect, fatal and non-fatal medication poisonings have decreased by forty percent (Franklin & Rodgers, 2008). However, the shift to child resistant packaging has its limitations. Many people find this packaging so difficult to open that they remove the contents and place them in a separate container, rendering the packaging futile. Furthermore, the parameters of this law do

Analgesics 22% Topicals 15% Asthma meds 3% Sedatives/Antidepressents 5% Vitamins & Minerals 14%

Homeopathic/Herbals 4% Hormonal medications 5% Cardiovascular meds 5%

not guarantee that any child that attempts to open the packaging will find it impenetrable. When designing and testing a container, a resistance rate of 80% is sufficient to pass quality standards; meaning 20% of children under five could succeed in removing the contents of the container and still pass inspection (Franklin & Rodgers, 2008). Over-dosage and misuse of medications are common and therefore may not affect this practice. Even with its limits, the introduction of childproof packaging has led to a decrease in accident prevention over the past 30 years.

Methods of Preventing Harm from Poisonings Syrup of Ipecac Syrup of ipecac is a medication made of diluted extract of ipecac, a naturally occurring poisonous root. The syrup induces vomiting and was used in previous years as an antidote to poisonous substances after an accidental ingestion. In the 1980s it was highly recommended by the AAP for parents to keep stored in their home in case of emergency (Bond, 2003). In 2003, the position of the AAP changed, no longer recommending storage of the syrup at all (Gutierrez, Negron, & Garcia-Fragoso, 2011). The American Association of Poison Control centers agree and advise against the use of ipecac. Bond (2003) reported that syrup of ipecac did not decrease emergency room visits or improve the child outcomes, rendering the medication ineffective. The push against ipecac has been so effective that it is essentially unavailable on the market; a recent Internet search to purchase ipecac syrup was unsuccessful. Syrup of ipecac was found to have too many negative side effects such as lethargy, diarrhea, or continued vomiting (Bond, 2003). Furthermore, the medication's use could prevent some caretakers from contacting emergency services or the poison control hotline, trying to manage the episode on their own. Activated charcoal and other more specific antidotes have since replaced syrup of ipecac as a common antidote after poisonous ingestion. Charcoal is only administered in an acute care setting and is not available to parents at home. Therefore, anticipatory guidance for parents of infants and young children should be more focused on preventative measures instead of a home remedy.

Antihistamines/Cough & Cold Antimicrobials 15% 6% GI meds 6%

Mr. Yuk Analgesics

Topicals

Vitamins & Minerals

Antihistamines/Cough & Cold

GI meds

Antimicrobials

Cardiovascular meds

Hormonal medications

Homeopathic/Herbals

Sedatives/Antidepressents

Asthma meds

Figure 2 Substances involved in pediatric fatalities in 2011. Data from Bronstein et al. (2012).

Mr. Yuk is a campaign started at Children's Hospital of Pittsburgh in the 1970s, as an effort to deter children from harmful substances (Demorest & Osterhoudt, 2002). The effort revolves around stickers that portray a cartoon face of disgust which parents are instructed to place on dangerous items around the home. The Mr. Yuk logo, as pictured in Figure 3, is an initiative is still commonly used today as a

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Figure 3 Mr. Yuk image, retrieved from Children's Hospital of Pittsburgh, 2013.

take-home method for parents to prevent poisoning (Pooley & Fiddick, 2010). An advantage of using stickers such as these is that they communicate with a child directly. In the event that a child reaches a harmful substance in the house, the child will theoretically see the sticker and recognize the item as repugnant. But does this work? Mr. Yuk is intended as an adjunct effort to the guidance and instruction that healthcare providers give parents, but has faced criticism in the past couple of decades. Critics of the sticker argue that it could possibly attract kids to it with its bright, cartoon picture or that it simply would not work. The latter is supported by the fact that toddlers, the most common age group affected by poisoning, lack the cognition to identify a facial emotion from a sticker (Pooley & Fiddick, 2010). Therefore, facial emotions would not change their behavior. Most studies that have investigated this notion were performed in the 1980s, so there is a lack of recent evidence to suggest whether Mr. Yuk actually prevents poisonings either way. Table 2 reviews the benefits and disadvantages of the Mr. Yuk campaign. An Australian study conducted by Pooley and Fiddick (2010) attempted to dig deeper in to the emotional reasoning

Table 2

Components of Mr. Yuk stickers.

Advantages

Disadvantages

• Communicates directly • Cannot be trusted as a deterrent with the child • Teaching tool for parents • Bright colors and cartoon face may entice children • Provides poison control • May be using the wrong emotion center hotline number to deter children from the product • Infants and toddlers lack the social referencing cues needed for understanding the icon

of children, to assess the validity of the “disgust” emotion that Mr. Yuk tries to convey. The idea behind this psychology is termed “social referencing.” This occurs when an infant sees an adult convey an emotion and uses that expression to interpret a situation. The findings of the study concluded that both the children and their parents found the emotion of fear as a better predictor of deterrence than disgust (Pooley & Fiddick, 2010). Proponents of Mr. Yuk continue to hand out stickers to parents as an educational tool instead of a potential deterrent tool. They point out that even if it has no bearing on a child, it is a vehicle that propels parents to think about poisoning risks and to be proactive (Pooley & Fiddick, 2010). The sticker should be given in conjunction with the phone number to the nearest poison control center to provide fast access to help in case of an emergency (Demorest & Osterhoudt, 2002). In the event of an emergency, new guidelines on how to intervene have also been replaced in recent decades, as discussed below.

Role of the Nurse The goal of healthcare providers, in any capacity, is to promote a state of good health and empower individuals with knowledge to do so. Prevention of childhood accidents is no exception; providers have the opportunity to motivate and encourage parents to foster a safe environment for children. Nurses and nurse practitioners are at the forefront of this conversation because we are the link between the information needed and the anticipatory guidance to implement. This issue is a public health concern and nurses are fully equipped and mobilized to deliver this information to the public due to our sheer numbers and access to children and families. In addition to providing anticipatory guidance to parents, it is important to include other major caregivers involved with the child, such as grandparents, neighbors, or extended family, as accidents can also occur outside of the primary home. The extended network of caregivers should be kept in mind when providing information, which extends beyond the pediatrician's office. Clinical settings are ideal for advising caregivers on the techniques and rationales for poison prevention measures, but it can also be mentioned on any platform we have the opportunity to make an impact. Community settings, especially school environments, are a great place to relay information to parents, as it is a consistent setting for parents to get information from school nurses they are familiar with.

Conclusion By staying up to date on current literature, healthcare providers can gain new perspectives on an old problem. Along with progressive new products and technological advances that come into the public market, new threats arise

Pick Your Poison to our young patients. As health care advocates, it is our responsibility to provide anticipatory guidance that is both effective and accurate, so keeping abreast of the latest poison control data is essential. Much of the progress thus far can be attributed to advances like the Poison Prevention Packaging Act or possibly to the Mr. Yuk campaign. However, personal change may lead to the greatest and most significant impact with a problem that is as widespread and situational as this. Psychological research, using multiple behavioral theories, suggests that if adults are convinced of danger, motivated to change, and feel they are effective in doing so, they are more likely to comply with healthcare advice. Likewise, the more awareness that is imparted to the media and healthcare realm, the more likely current practice will change. This highly preventable health risk can be diminished. As nurses, we need to not only educate parents about prevention but also empower them to do so.

Acknowledgments I would like to thank Dr. Rita Marie John for her guidance and mentorship during the construction of this article.

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Pick your poison: what's new in poison control for the preschooler.

Accidental childhood poisonings are a major public health concern despite many efforts to alleviate this problem. While the rate of pediatric fataliti...
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