A practical guide for resident doctors in the emergency department, focusing on the assessment and management of paediatric poisoning and toxic exposures — where early recognition and decision-making are crucial.

Paediatric poisoning is a common yet often anxiety-provoking presentation in the emergency department (ED) – for both parents and clinicians! Each year, approximately 40,000 children across England and Wales are assessed following suspected toxic exposures, with about half requiring admission for observation with or without treatment.

The majority of ingestions are accidental, and involve exposure to small doses of non-toxic or minimally toxic substances  – most often in children aged 1 to 5 years. Histories are frequently unclear, events may be unwitnessed, and the ingested substance and dose are often uncertain.

The challenge therefore is not simply recognising poisoning, but rapidly distinguishing benign exposures from those that may cause a child to deteriorate quickly and require urgent intervention.

This guide focuses on a number of common presentations, alongside high-risk exposures that require urgent recognition. Clinicians should always consult up to date guidance – both local guidance where appropriate, and national – notably TOXBASE, for case specific advice.

It is not possible to cover every potential toxin or exposure in a single article. This guide focuses on common and high-risk toxicological presentations. The management of foreign body ingestion and aspiration is beyond the scope of this article and should be considered separately.

Focused History

Obtaining a clear history from the caregiver responsible for the child is imperative.

• Establishing the exact time of ingestion is crucial – many guidelines are based on observation for a certain number of hours post the time of ingestion.
• Establish whether the child is symptomatic – particularly coughing, choking, vomiting, diarrhoea, reduced level of consciousness.
• Often parents will bring along packets of suspected ingestions  – check these carefully
• There are often multiple children involved during a suspected ingestion, making it difficult to know exactly who took what – in this case assume a worst-case ingestion
• Could this have been a deliberate ingestion?
• Weight of the child (for dose based risk assessment). If no recent weights at home, measure this in department

Examination

Guidelines such as TOXBASE will clearly delineate the specific symptoms to examine for different types of ingestions – make sure to follow these carefully.

In the asymptomatic child presenting to ED, examination is likely to be unremarkable – however it is important to assess the child from top to toe, as subtle abnormalities may be the first indicator of significant toxicity.

A full set of observations should be recorded. Children are effective physiological compensators, and abnormalities such as tachycardia or altered conscious level may represent early deterioration.

General Examination

• Level of consciousness: AVPU (used more often in children than GCS)
• Behaviour: agitation, irritability, drowsiness
• Skin: flushing, pallor, diaphoresis, hypothermia
• Hydration status

Focused Examination

• Pupils – size, reactivity
• Cardiovascular – Heart rate, rhythm, perfusion (Capillary refill time? Any mottling? Warm and well perfused peripherally?)
• Respiratory – work of breathing, signs of aspiration, lung sounds
• Abdomen – tenderness, distension
• Neurological – tone, reflexes, focal neurology
• Mucous membranes – oral burns, ulceration, drooling, conjunctival irritation
• Temperature – fever or hypothermia

💡 Top Tip!

Many household substances can cause local irritation, so careful examination of the mucous membranes (mouth and eyes) is particularly important.

Recognising Toxidromes

Identifying a toxidrome – a constellation of clinical signs – can help to guide early management, particularly when the ingested substance is unclear. Although not every toxidrome can be covered in this article, the following are some of the more clinically important patterns to be aware of in paediatric practice. These presentations should always prompt careful assessment and early senior involvement.

• Anticholinergics (e.g. anti-histamines, some antidepressants)
  • Tachycardia, dry skin and mucous membranes, dilated pupils, agitation or delirium
• Cholinergics (e.g. some Alzheimer’s medications)
  • SLUDGE: Salivation, lacrimation, urination, diarrhoea, gastric irritation, emesis
• Opioids (e.g. codeine, morphine, methadone)
  • Reduced level of consciousness, respiratory depression, pinpoint pupils
• Sympathomimetics
  • Tachycardia, hypertension, agitation, diaphoresis, dilated pupils
• Sedatives (benzodiazepines)
  • Drowsiness, reduced tone, slurred speech

One Pill Can Kill

While toxidromes can help to guide diagnosis, it is important to recognise specific high-risk substances that can cause severe toxicity even in very small amounts, particularly in small children. Rapid deterioration in health can occur even without a clear toxidrome. Even a single tablet can cause significant toxicity and even death in young children.

All cases should be escalated to a senior clinician without delay.

• Tricyclic antidepressants (e.g. amitriptyline)
  • Risk of arrhythmias and seizures
• Calcium channel blockers (e.g. verapamil, diltiazem)
  • Profound hypotension and shock
• Beta-blockers (e.g. propranolol)
  • Bradycardia, seizures
• Opioids (e.g. codeine, morphine, methadone)
  • Respiratory depression – can be delayed
• Sulfonylureas (e.g. gliclazide)
  • Severe hypoglycaemia
• Iron tablets
  • Metabolic acidosis and organ failure

Non-Drug Exposures

Not all dangerous ingestions are medication. Many children will present following exposure to household or environmental substances, and it is important to recognise those that can be rapidly life-threatening in children.

Although most children will not ingest large quantities due to unpleasant taste, clinicians should assume a worst-case ingestion where there is uncertainty – particularly if a caregiver reports access to a potentially harmful substance.

Alcohol

• Hypoglycaemia, CNS depression (especially in younger children)

Caustic substances (alkalis/acids such as bleach)

• Oral burns, drooling, dysphagia

Carbon monoxide

• Vague symptoms such as headache, dizziness, nausea and vomiting
• Check the history – exposure will likely have affected household members
• Check carboxyhaemoglobin early

Silica gel packets

• Can scare parents as packets say DO NOT EAT. In reality, silica is non-toxic. However, due to being a choking/aspiration hazard, medical assessment is warranted

Laundry pods

• Usually cause no symptoms or mild gastrointestinal irritation only
• Most cases are managed supportively

Hand sanitisers

• Usually low risk in small quantities
• Check ingredients (methanol, ethanol, isopropanol), and refer to the relevant management guideline

Investigations

Not all children require extensive investigation. Investigations should be guided by the suspected ingestion and clinical presentation – consult the local guidelines to confirm the appropriate steps. If unsure of what has been ingested/you have an unwell child with suspicion for ingestions, consult a senior and consider:

• Blood gas (for metabolic acidosis)
• U+Es
• LFTs
• Blood glucose
• Paracetamol level (if unclear ingestion)
• ECG (if unknown ingestion, or suspected cardiotoxic drugs)

Management Principles

Management of paediatric poisoning is guided by clinical condition, the suspected toxin and the timing of the ingestion. In many cases, treatment is primarily supportive, however early recognition of those requiring specific interventions is key.

Supportive Care

• Airway and breathing: Consider airway support and oxygen therapy in children with reduced consciousness or respiratory compromise
• Circulation: Manage shock with fluid resuscitation as appropriate
• Disability: Treat seizures promptly. Check and correct hypoglycaemia early.

Antidotes

• Different ingestions require different antidotes, but the following are a few notable examples that are useful to be aware of
• Paracetamol: N-acetylcysteine (NAC)
  • Use trust-specific nomograms to guide management
• Opioids: Naloxone
  • Indicated in respiratory depression
• Always refer to TOXBASE for toxin-specific antidote guidance

💡 Key Point

Antidotes are not required in most cases, but should be given promptly when indicated

Safeguarding Consideration

Safeguarding should be considered in all paediatric poisoning presentations.

Safeguarding is everyone’s responsibility – if something doesn’t feel quite right, escalate concerns early to a senior clinician.

• Is the history consistent with the developmental stage and height of the child?
  • For example a non-ambulating child reaching a medication on a table should ring alarm bells
• Is the level of supervision appropriate? Were they inappropriately left unattended?
• Any recurrent presentations? This may be a sign that a family network requires some extra support.
• Consider the possibility of deliberate ingestions – particularly in adolescents. These cases should be referred to the appropriate teams for your trust – for example paediatric mental health teams. 

Key Takeaways:

• Most paediatric ingestions are benign – but a small number deteriorate quickly. Your job is to identify that minority early.
• If the history is unclear, assume a worst-case ingestion and manage accordingly
• Not all serious toxicity presents with obvious symptoms early – a well child does not always mean a safe ingestion
• Know the “one pill can kill” drugs – even a single tablet can be life-threatening
• Think beyond medications: household and environmental exposures can be equally dangerous
• When unsure, discuss with a senior – don’t try to manage complex cases alone
• Every poisoning presentation is a safeguarding opportunity – pause and ask if the history makes sense

Written by Dr Evy Phillips (Foundation Year 2 Doctor), reviewed by Dr Kiran Raju (Paediatric ST3)

References

Lauren Fraser. (2023). Paediatric Toxicology Considerations. [Online]. RCEM (Royal College of Emergency Medicine) Learning. Last Updated: 7th September 2023. Available at: https://www.rcemlearning.co.uk/reference/paediatric-toxicology-considerations/#1570720107893-ea26573 [Accessed 9 April 2026].

Tessa Davis. (2023). Toxicology – a crash course in accidental overdoses. [Online]. Don’t Forget the Bubbles. Last Updated: 11th March 2025. Available at: https://dontforgetthebubbles.com/paediatric-toxicology/ [Accessed 9 April 2026].

Joe Rotella. (2018). Non-Toxic Exposures. [Online]. Don’t Forget The Bubbles. Last Updated: 10th January 2026. Available at: https://dontforgetthebubbles.com/non-toxic-exposures/ [Accessed 9 April 2026].