PEDIATRIC HEALTH CARE PROVIDERS’ ADVICE ABOUT HOME USE OF IPECAC

Erica L. Liebelt MD* , Keqin Qi PhD**, Alan D. Woolf MD MPH+
*Department of Pediatrics and Emergency Medicine; University of Alabama; Birmingham, AL
**Wyeth Research; Philadelphia, PA
+Department of Pediatrics; Harvard Medica

Int J Med Toxicol; 6(2):6


Corresponding Author:

Erica L. Liebelt MD
Director, Medical Toxicology Services
University of Alabama Hospitals
1600 7th Avenue South, Midtown Center Suite 205
Birmingham, AL 35233
Phone: 205-939-9587
Fax: 205-975-4623
Email : Eliebelt@peds.uab.edu

ABSTRACT

Background: Home-administered ipecac syrup for poisoned children has been largely abandoned by medical toxicologists and poison control centers; however the opinions and recommendations of pediatric health care providers (PHCPs) have not been investigated. Organizational endorsement to avoid the use of ipecac is being discussed. If PHCP’s attitudes and practices are different from organizational recommendations for change, there could be resistance to this change.

Objective: To describe the knowledge, attitudes, and practices of PHCPs about advising the home storage and use of syrup of ipecac and whether their practices have changed over time.

Methods: Cross-sectional survey of a sample of PHCPs attending postgraduate courses.

Results: Questionnaires were distributed; 445 were completed and analyzed. Of the respondents, 61% were physicians, 37% were nurses or nurse practitioners (NPs), and 2% other (i.e. paramedics). The majority of PHCPs (68%) reported that they usually or always advise home storage/availability of ipecac. Only 20% indicated that they have either discontinued or seldom give this advice. Nurses and nurse practictioners advise home storage of ipecac more than physicians (77% vs. 63%; p< 0.05). The majority also reported that their advice on home availability (56%) and use (58%) of ipecac had not changed in the previous 5 years. PHCPs would still advise parents to give ipecac at home in a childhood poisoning scenario involving iron (63%), acetaminophen (66%), and a smaller percentage, 43%, would do so in a mushroom poisoning.

Conclusions: Contrary to data suggesting a decline in poison control center support of a role for ipecac, many pediatric physicians, nurses, and nurse practitioners still routinely advise parents to store and use ipecac syrup for home-based decontamination of poisoned young children. Current efforts to address such discrepancies by professional organizations nationally should be coordinated so as to avoid confusion concerning home poisoning prevention advice.

INTRODUCTION

Poison ingestion among children less than 6 years of age continues to be a common cause of injury. In 2001, the American Association of Poison Control Centers (AAPCC) reported just over 1 million exposures in children less than six years of age.1 Ipecac syrup has been advocated as a home gastrointestinal decontamination measure to reduce toxicity and prevent Emergency Department visits. However, AAPCC data over the last 10 years have demonstrated that over 95% of exposures in young children result in either no injury or only minimal effects.1 Whereas in 1985, ipecac was recommended by poison control centers for 15% of telephone consultations, in 2001 it was used in only 0.7% of consultations (Figure 1).1 Since many poison control centers now recommend home-administered ipecac only rarely, if ever, questions arise whether storage and use of ipecac in the home was ever or is currently necessary.

Organizational endorsement to avoid the use of ipecac is currently under discussion, although it is likely that the revised guidelines for poisoning first aid will discourage its use. The opinions and practices of pediatric health care providers (PHCPs) may represent barriers to any organizational recommendations for change. Furthermore, if PHCP’s attitudes and practices are different from new recommendations, there could be resistance to change. Thus, the objective of this study was to investigate current PHCPs’ knowledge, attitudes, and practices about advising the home storage and use of ipecac in poisoned children and whether this advice has changed over time.

METHODS

During a 3-year period, pediatric practitioners were recruited at three postgraduate meetings in the greater Boston, Massachusetts area (November 1998, May 1999, and November 2000) and Baltimore, Maryland (November 1999 and April 2000). These meetings were regional postgraduate continuing medical education targeted toward general pediatricians and did not have any lectures on poisoning or gastrointestinal decontamination. Only health care providers in practice (no trainees) were asked to complete a 35-item anonymous questionnaire about their advice to child caregivers concerning storage and use of ipecac as well as other poison prevention practices. (Figure 2 ) Nurses, nurse practitioners (NPs), and paramedics were included since advice about administering ipecac syrup is part of general pediatric nurse advice protocols as well as many pre-hospital protocols. In many practices, nurse/NPs man the phone lines answering families’ questions and providing advice. Questionnaires were distributed at the beginning of meetings and only those returned by the end of the meeting were analyzed. Participation was voluntary.

A copy of the questionnaire is shown in Figure 2. Questions included frequency of advising home availability/storage of ipecac, explaining to caregivers how and when to use ipecac, discussing safe storage of home cleaners and medicines, and discussing use of child resistant containers. Multiple-choice answers were never (0%), seldom (1-33%), sometimes (34-66%), usually (67-99%), and always (100% of time). In addition, participants were asked whether their poison prevention advice to parents had changed over the past five years (more, same, less, don’t use). Specific demographic questions were asked in addition to questions about how the practitioners formulate their opinions in counseling families on poisoning prevention.

Participants were asked to respond to three clinical scenarios involving an unintentional ingestion by a toddler of a potentially toxic dose of iron, toxic dose of acetaminophen, and one unknown mushroom. The respondent was asked to choose the answer that best reflects how he/she would handle the situation, assuming availability of home ipecac and emergency medical care within a 20-minute drive from the child’s house. Specifically, would they advise the child’s caregiver to give ipecac at home (either alone with their follow-up or followed by other actions, call the poison control center, refer the child to the hospital) or call the poison control center first and follow recommendations, or refer the child to the hospital first without any home interventions?

Data were analyzed using descriptive and inferential statistics. Questionnaires that did not contain greater than 25% of the questions answered were considered incomplete and not analyzed. Chi-square analysis was done for comparison of groups. An alpha < 0.05 was considered statistically significant. The Human Investigations Committees at Children’s Hospital, Boston and Johns Hopkins School of Medicine in Baltimore approved this study.

RESULTS

Six hundred eight surveys (608) were distributed. One hundred sixty three (163) were excluded due to incomplete information (N= 17) or because the PHCP no longer saw patients (N=146). No subanalysis was done because there was either no information and/ or incomplete information. Four hundred forty five (445) surveys were analyzed (rate 73%). Of the respondents, 61% were physicians (n=272), 37% were nurses or NPs (n=164), and 2% other (i.e. paramedics; n=9). Sixty-seven percent of the PHCPs had been in practice for more than 10 years. Distribution of PHCPs according to pediatric practice type were: 60% group practice or HMO/PPO, 13% solo, 13% hospital-based, 7% public health clinic, and 7% other (i.e., independent practice association, independent nurse advice/telephone triage practice).

Advice to Store and Use Ipecac

PHCPs were asked how frequently they advise home availability of ipecac. Distribution of responses as the total group and by professional degree and years in practice are shown in Table 1. PHCPs always or usually advise home storage of ipecac 68% of the time. Nurses/NPs advise home storage of ipecac (always or usually) more than physicians (77% versus 63%, p= 0.003). As Table 2 illustrates, 56% of all PHCPs always (30%) or usually (26%) explain how and when to use syrup of ipecac. Again nurses/NPs more frequently explained when and how to use ipecac than did physicians (69% versus 48%; p= 0.001).

Case Scenarios - Telephone Advice Whether to Give Ipecac

Results of the case scenarios are presented in Table 3. In the iron ingestion scenario, 63% of PHCPs would advise giving ipecac at home first while 37% would advise other interventions first. PHCPs in practice > 10 years were more likely to advise giving ipecac for this iron ingestion compared to those in practice £ 10 years (69% vs. 52%, p=0.001).

For the acetaminophen ingestion by a toddler, 66% of PHCPs would advise giving ipecac in the home initially. There was no statistically significant difference between physicians and nurses/NPs (70% versus 60%; p= 0.06).More PHCPs in practice > 10 years would advise giving ipecac at home than those in practice £ 10 years (70% vs. 57%; p=0.007).

In the scenario involving a child ingesting one unknown mushroom, only 43% of PHCPs would advise giving ipecac at home. Fifty seven percent would call the poison control center first or refer the child directly to the hospital.

In the three scenarios, 67% of the respondents stated they would call the poison control center as part of their response for the iron scenario, 55% for the acetaminophen scenario and 75% for the mushroom scenario. Thirty-seven percent (37%) would recommend giving ipecac and calling the poison control center for the iron scenario, 31% for the acetaminophen scenario, and 26% for the mushroom scenario.

Change in Advice to Store and Use Syrup of Ipecac in the Last Five Years

When asked whether their advice to caregivers regarding home availability and use of ipecac has changed in the last five years, 56% of PHCPs responded that their advice has remained the same (Table 4 ). Twenty percent (20%) of PHCPs reported they advise home storage of ipecac less often than they did 5 years ago; whereas 18% reported they advise it more often than they used to. More physicians than nurses/NPs have decreased their mention of ipecac to parents over the last five years (28% versus 7%; p=0.001).

Resources Used to Formulate Opinions and Practices

The majority of PHCPs (77%) always or usually use recommendations from the American Academy of Pediatrics in counseling families on poison prevention, and cited the pediatric textbooks (53%) and regional poison control center (49%), as the next most frequent source (Table 5 ).

Advice about General Poison Prevention & Trends

Regarding poison prevention advice, 84% of PHCPs usually or always discuss the safe storage of home cleaners and medicines; 58% give parents the poison control center telephone number; and 56% discuss use of child resistant containers. Sixty percent of PHCPs’ advice to caregivers regarding safe storage of home cleaners and medicines has remained the same, while 36% reported discussing this issue more now than they did 5 years ago.

When the responses were compared between the five different groups of care providers surveyed at five different points in time, no substantive differences between groups or clear trends over time during the 3 years sampled could be appreciated. The aggregate responses were largely the same as those at each sampling point.

DISCUSSION

Ipecac has been recommended as a home gastrointestinal decontamination measure for potentially toxic ingestions in young children for the past five decades, and it has been demonstrated to decrease the number of pediatric referrals to emergency departments. 2 Syrup of Ipecac has been promoted as a household item that should “protect” young children when unintentional ingestions occur. The use of ipecac has been a routine and integral component of anticipatory guidance in the well-child visit when discussing poison prevention. The American Academy of Pediatrics (AAP) still recommends that a one ounce bottle of ipecac syrup be kept at home as part of its injury prevention program (TIPP) and guidelines for office-based counseling for injury prevention.3 The American College of Emergency Physicians advocates that ipecac syrup be stored in home first aid kits.4 Studies have shown high rates of compliance of parents with home storage of ipecac when it is recommended by health care providers.5,6

The results of this study demonstrate some variability among pediatric health care providers regarding their advice on home storage and use of ipecac. However, many still usually or always advise its home availability. When PHCPs were asked whether this advice had changed in the last 5 years, over half reported that it had remained the same, but 18% reported that they more frequently advise ipecac storage than they did 5 years ago. Responses to the three scenarios involving iron, acetaminophen, and mushroom poisoning confirmed the continuing belief by the majority of pediatric health care providers that home-administered ipecac be recommended as the first aid for childhood poisoning.

We found that nurses/NPs still advise home availability of ipecac, and they are more likely to explain when and how to use ipecac compared to physicians. Certainly, many PHCPs might advise its availability at home, but then rely on other resources like poison control centers to recommend how and when to use it. Many poison control centers rarely advise ipecac in the management of childhood poisonings. Home administration of ipecac may play a significant role in the reduction of health care facility visits due to unintentional ingestions in young children.7 However, recent position statements, original research, reviews and editorials have questioned the role of home ipecac.8-12 In 1997 the American Academy of Clinical Toxicology’s position statement concluded that no data demonstrate that ipecac-induced emesis improves clinical outcome.9 Marchbanks et al documented inconsistencies among toxicology and poison control center professionals themselves in their recommendations concerning a role for ipecac in a life-threatening poisoning scenario.10 Internationally, ipecac syrup was removed from distribution in New Zealand, a policy supported by the New Zealand National Poisons and Hazardous Chemical Information Centre.13

The American Academy of Pediatrics (AAP) has recently signaled its intention to revise its policy statement on ‘Poison Treatment in the Home.14 The American Association of Poison Control Centers (AAPCC) likewise has convened a panel to develop new guidelines for poison control centers regarding the advisability of home-administered ipecac.15 Both groups may conclude that ipecac be either severely restricted or dropped from the recommendations given to both health professionals and parents for poisoning prevention. In our study, PHCPs used recommendations from the AAP more often than those of poison control centers, textbooks, original research, CME courses, or advice from their colleagues. Thus if the recommendations of the AAP and the AAPCC regarding the advisability of home ipecac are changed, both organizations are well advised to collaborate to effect change ultimately. The current study demonstrates a continuing strong belief of PHCPs in the efficacy and role of ipecac in childhood poisoning. The information provided in this study may suggest an information gap between pediatric health care providers and other experts regarding ipecac syrup. It suggests that a focused and intense national campaign will be necessary to inform health professionals of any modifications of this long-standing practice. Additional national educational campaigns such as NP and prehospital/paramedic conventions and emphasis on poison prevention week will also be necessary for other important health care providers that advise and/or utilize ipecac syrup.

There are several limitations to this study. This survey represents one point in time for the respondents. It may represent a biased convenience sample, as PHCPs who attend postgraduate courses may not be a representative sample of practicing PHCPs. The sample size is small to generalize this group of PHCPs’ beliefs to all health care providers in the country caring for children. Indeed, there may be geographic differences based on poison center recommendations, availability of toxicology specialists, and primary care practice patterns. The theoretical nature of the case scenarios versus actual practices must be acknowledged, as a slight change in the amount ingested, time to call for advice, and other substances may have produced different results. In addition, PHCPs might be reluctant to change their current practices until more definitive recommendations are made for medico-legal purposes. Finally, the responses are those to a survey and may not truly reflect clinical PHCP practice.

CONCLUSIONS

Contrary to data suggesting a decline in poison control center support of a role for ipecac syrup, many pediatric physicians, nurses, and nurse practitioners still routinely advise parents to store and use ipecac for home-based decontamination of poisoned children less than 6 years of age. The AAP, pediatric textbooks, and poison control centers are frequently used resources of information to PHCPs about poison prevention strategies. Current efforts by professional organizations nationally should be coordinated so as to create consistency concerning home poisoning prevention advice.

REFERENCES
  1. Litovitz TL; Klein-Schwartz W; Rodgers GC; Cobaugh DJ; Youniss J; Omslaer JC; May ME; Woolf AD; Benson BE. 2001 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 2002, 20 (5), 391-452.
  2. Bond GR. Home Use of Syrup of Ipecac is Associated with a Reduction in Pediatric Emergency Department Visits. Ann Emerg Med 1995, 25(3), 338-343.
  3. American Academy of Pediatrics – TIPP: The Injury Prevention Program. Protect Your Child…Prevent Poisoning. http://www.aap.org/family/poistipp.htm. Citation 10/16/02
  4. American College of Emergency Physicians. How to Protect your Child from Poison. http://www.acep.org/1,194,0.html. Citation 10/16/02
  5. Woolf A; Lewander W; Filippone G; Lovejoy F. Prevention of Childhood Poisoning: Efficacy of an Educational Program Carried Out in an Emergency Clinic. Pediatrics 1987, 80 (3), 359-363.
  6. Woolf AD; Saperstein A; Forjuoh S. Poisoning Prevention Knowledge and Practices of Parents After a Childhood Poisoning Incident. Pediatrics 1992, 90(6), 867-870.
  7. Banner W, Veltri JC. The Case for Ipecac Syrup. AJDC 1988, 142, 596-597.
  8. Henry JA; Hoffman JR. Continuing Controversy on Gut Decontamination. Lancet 1998, 352 (9126), 420-421.
  9. Krenzelok EP; McGuigan M; Lheur P. Position Statement: Ipecac Syrup. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol 1997, 35(7), 699-709.
  10. Marchbanks H; Lockman P; Shum S; Beard D. Trends in Ipecac Use: A Survey of Poison Center Staff. Vet Human Toxicol 1999, 41(1) 47-48.
  11. Miller MD; Eng J; Schneiderman E. Ipecac Use: Are We Practicing What We Preach? [abstract] J Tox Clin Tox 1999, 37, 600.
  12. Quang LS; Woolf AD. Past, Present, and Future Role of Ipecac Syrup. Curr Opin Pediatr 2000, 12, 153-162.
  13. Fountain JS; Beasley DMG. Activated Charcoal Supercedes Ipecac as Gastric Decontaminant. NZ Med J 1998, 111 (1076), 402-404.
  14. Section on Injury & Poison Prevention Newsletter, American Academy of Pediatrics, Elk Grove Village, Illinois. Fall 2002.
  15. PoisonLine Newsletter. American Association of Poison Control Centers, Washington D.C., October, 2002.

Figure 1. Trends in ipecac administration as documented by United States poison control centers.

Figure 1. Trends in ipecac administration as documented by United States poison control centers.

Table 1. Advise Home Availability / Storage of Ipecac Syrup

Never

Seldom

Sometimes

Usually

Always

PHCPs (N=436)

8% (36)

11% (50)

12% (54)

28% (121)

40% (175)

MDs (N=269)

10% (26)

14% (38)

13% (36)

28%(74)

35% (95)

Nurses/NPs (N=158)

6% (9)

8% (12)

9% (15)

28% (45)

49% (77)

Practice £ 10 years (N=143)

9% (12)

14% (20)

15% (22)

29% (42)

33% (47)

Practice > 10 years (N=284)

8% (23)

11% (30)

11% (32)

26% (75)

44% (124)

MDs – Medical Doctors
PHCPs – Pediatric Health Care Providers
NPs – Nurse practitioners
Data are presented as percentages with actual numbers in parentheses.

Table 2. Advise When and How to Use Ipecac Syrup

Never

Seldom

Sometimes

Usually

Always

PHCPs (N=423)

13% (55)

16% (66)

15% (65)

26% (108)

30% (129)

MDs (N=262)

16% (42)

19% (50)

17% (44)

24%(62)

24% (64)

Nurses/NPs (N=152) 9% (13)

9% (14) 13% (19) 28% (43) 41% (63)
Practice £ 10 years (N=139) 17% (23) 17% (24) 16% (22) 25% (35) 25% (35)
Practice > 10 years (N=275) 12% (32) 15% (41) 15% (41) 25% (70) 33% (91)

Table 3. Case Scenarios

  Give Ipecac At Home + Other Advice Other Advice (No Ipecac)
Iron Ingestion    
PHCPs (N=443) 63% (280) 37% (163)
MDs (N=272) 66% (180) 34% (92)
Nurses / NPs (N=162) 58% (94) 42% (68)
Practice £ 10 years (N=145) 52% (75) 48% (70)
Practice > 10 years (N=290) 69% (200) 31% (90)
     
Acetaminophen Ingestion    
PHCPs (N=441) 66% (291) 34% (150)
MDs (N=269) 70% (187) 30% (82)
Nurses/NPs (N=163) 60% (98) 40% (65)
Practice £ 10 years (N=143) 57% (81) 43% (62)
Practice > 10 years (N=289) 70 % (203)> 30% (86)
     
Mushroom Ingestion    
PHCPs (N=436) 43% (188) 57% (248)
MDs (N=267) 44% (117) 56% (150)
Nurses/NPs (N=161) 42% (68) 58% (93)
Practice £ 10 years (N=143)> 35% (50) 65% (93)
Practice > 10 years (N=286) 47% (133) 53% (153)

Case Scenarios
For the following scenarios, choose the answer that best reflects how you would handle the situation. Assume emergency care is within a 20-minute drive from the child’s house.
a. An otherwise healthy 2-year old swallowed 10 prenatal iron tablets (calculation shows this is a toxic dose) 5 minutes ago. Mother is calling you at 9:00am from home and has ipecac at hand.
b. An otherwise healthy 2-year old swallowed 10 extra-strength acetaminophen tablets (calculation shows this is a toxic dose) 5 minutes ago. Mother is calling you at 9:00am from home and has ipecac on hand.
c. An otherwise healthy 2-year old swallowed one mushroom (unknown type) while outside in the yard 5 minutes ago. Mother is calling you at 9:00am and has ipecac on hand.

Table 4. Change of Advice in the last 5 years Regarding Storage and Use of Ipecac

  More Same Less Do Not Use
Advise home availability of ipecac        
PHCPs (N=415) 18% (74) 56% (233) 20% (84) 6% (24)
MDs (N=258) 14% (37) 52% (135) 28% (73) 5% (13)
Nurses/NPs (N=149)      23%  (35)    63% (94)     7% (10)     7%   (10)
Advise Use of Ipecac        
PHCPs (N=408) 13% (53) 58% (237) 23% (95) 6% (23)
MDs (N=256) 11% (27) 54% (137) 31% (80) 5% (12)
Nurses/NPs (N=144)    16%   (23)    67%  (97)   9%   (13)   8%   (11)

Table 5. Resources Used To Formulate Opinions and Practices (all PHCPs)

Always
Usually
Sometimes
Seldom
Never
American Academy of Pediatrics (N=425)

25% (108) 52% (221) 16% (67) 4% (16) 3% (13)
Pediatric Textbook (N=424) 9% (40) 43% (184) 30% (128) 13% (54) 4% (18)
Poison Center (N=422) 19% (79) 30% (126) 26% (108) 17% (72) 9% (37)
CME Course (N=417) 9% (39) 34% (143) 34% (142) 15% (63) 7% (30)
Advice of other health care providers (N=421) 9% (37) 32% (136) 40% (170) 14% (60) 4% (18)
Read original research (N=417) 5% (22) 22% (93) 38% (157) 23% (96) 12% (49)

Poison Pervention Practice Survey (PDF Format)



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