Dr Katie Knight, Dr Lara Ziebers

Countless trips to the ED happen as a result of toddler misadventure, but few are life threatening. That’s why this post is about what CAN potentially kill a toddler – the contents of Grandma’s handbag. There are several common medications – used mostly in older patients – that contain a high enough dose in one or two tablets to do serious harm (or worse) to a small child.

This post is not here to run through the details of all the toxicology and treatments. This aim of this post is to highlight some drugs that should start alarm bells ringing at triage, and get you running over to the child who is about to become the sickest kid in the department.

When thinking about the toxic doses of the drugs mentioned below, remember that an average toddler weighs 10-15kg.

Cardiac drugs

Calcium channel blockers (nifedipine, verapamil, amlodipine, diltiazem) – these are used therapeutically as antihypertensives and antiarrhythmics. In toxicity, they cause hypotension, bradycardia and cardiac arrest. A dose as low as 0.2mg/kg (depending on drug) could be lethal.

Clonidine – sometimes used as an antihypertensive (also can be used to treat menopausal symptoms and migraine)

	Tablet doses available	Toxic dose per kg
Amlodipine	5mg, 10mg	0.2mg/kg
Nifedipine	5mg, 10mg; sustained release up to 60mg	1.2mg/kg
Verapamil	5mg, 10mg	5mg/kg
Diltiazem	60mg; sustained release tablets up to 360mg	5mg/kg
Clonidine	0.025mg, 0.1mg	0.01mg/kg

LET’S REPEAT THAT WEIGHT… the average toddler weighs 10-15kg.

Antidiabetics

Sulphonylureas (gliclazide) – stimulate insulin release from beta cells, cause hypoglycaemia in non-diabetics.

	Tablet doses available	Toxic dose per kg
Gliclazide	40mg, 80mg; sustained release up to 60mg	1.3mg/kg

AGAIN, the average toddler weighs 10-15 KILOGRAMS.

Antidepressants

Tricyclic antidepressants, or TCAs (amitryptyline, imipramine). Blockade of sodium channels, muscarinic (M1), histaminergic (H1), and peripheral alpha1-adrenergic receptors. Effects include tachycardia, dry mouth, urinary retention, confusion, agitation… leading on to hypotension, arrythmias, and seizures.

Benzodiazepines (diazepam, temazepam, etc) – cause respiratory depression.

	Tablet doses available	Toxic dose per kg
Amitryptiline	10 mg, 25 mg, 50 mg	15mg/kg
Diazepam	2mg, 5mg, 10mg	0.7mg/kg
Temazepam	10mg, 20mg	1.5mg/kg

Parkinsons drugs

Selegiline – a monoamine oxidase inhibitor (MAOI) which in overdose causes hypertension, tachycardia, tremors, seizures, and hyperthermia.

	Tablet doses available	Toxic dose per kg
Selegiline	5mg, 10mg	0.7mg/kg

One last time: an average toddler weighs 10-15kg. Any of the drugs listed above have a SERIOUS RISK of causing significant harm or worse to a tiny human. Commit these drugs to memory, and get ready to move if you hear the word.

Disclaimer: This is NOT a comprehensive list of all potentially fatal one-dose drugs. Always check your local toxicology protocols.

Drug doses and toxic doses from toxbase.org

With thanks to Dr Lara Ziebers, whose excellent talk this post is based on.