Pediatric exploratory ingestions involving novel pill pack packaging

Pill packs are novel packaging systems designed to contain multiple medications and increase medication access but are not child-resistant and increase the risk of pediatric ingestions. We present two pediatric ingestion cases suspected to involve pill packs. Case 1 describes a 19-month-old male pre...

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Bibliographic Details
Published in:The American journal of emergency medicine 2022-03, Vol.53, p.282.e1-282.e3
Main Authors: Gable, Christopher J., Spencer, Sandra P., Middelberg, Leah K., Scherzer, Daniel J., Suer, Matthew, Casavant, Marcel J.
Format: Article
Language:English
Subjects:
Ataxia
Buspirone
Caregivers
Clonazepam
Clonidine
Data collection
Drug overdose
Drug Packaging
Emergency medical care
Emergency medical services
Emergency Service, Hospital
Female
Gait
Gait Disorders, Neurologic
Health risks
Humans
Infant
Ingestion
Male
Medication safety
Metabolism
Metabolites
Overdose
Packaging
Patients
Pediatric ingestions
Pediatrics
Pharmaceutical Preparations
Pill packs
Poisoning
Prescription overdose
Public health
Regulatory agencies
Vital signs
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Summary:Pill packs are novel packaging systems designed to contain multiple medications and increase medication access but are not child-resistant and increase the risk of pediatric ingestions. We present two pediatric ingestion cases suspected to involve pill packs. Case 1 describes a 19-month-old male presenting to the Emergency Department with altered mental status and unsteady gait after a suspected clonidine and buspirone ingestion. The patient's father reportedly received his medications in mail delivery “baggies”. Case 2 involves a 21-month-old female presenting to the Emergency Department with unsteady gait. During an extensive workup we eventually found a clonazepam metabolite in her urine. A family friend supervising the patient at the time reportedly received medications through mail delivery in “plastic packs”. Emergency physicians should be alert to this packaging system as these products contain multiple medications, potentially increasing injury risk and obfuscating diagnosis. Manufacturers, regulatory agencies and public health authorities should assess and reduce the dangers these products pose to children.
ISSN:0735-6757
1532-8171
DOI:10.1016/j.ajem.2021.09.012