When Alice drinks from the wrong “drink me” bottle: a case series of not fatal drug intoxication in young children

Child abuse (CA) includes not only sexual abuse and physical maltreatment, but also neglect (CN). CN can be described as “persistent failure to provide health care and to protect the child from exposure to any type of danger”. Accidental drug intoxication is an indicator of neglect as a failure of appropriate supervision by parents which can cause severe and long-term damage to the child or even death.The authors report 13 suspected cases of life-threatening CN due to acute drug intoxication which were evaluated from January 2016 to February 2019 by the multidisciplinary unit (“Bambi”) of the Pediatric Hospital “Regina Margherita” in Turin (Italy), which is dedicated to the assessment of CA. Among them, 7 children were male and 6 female, with a mean age of 5.9 years (4 months -14.5 years). One case (the oldest child) was a voluntary alcohol intoxication. The remaining cases were all accidental poisonings. In 8 children the intoxication was due to the ingestion of drugs: marijuana candylike edible (n=5), cocaine (n=1), and psychiatric drugs (n=2). Two children unintentionally inhaled opioids, and the last 2 cases overdosed on acetaminophen, administered rectally. Most of the events occurred at home; the poisoning took place at the park in 4 cases. Parents were responsible for the accidental intoxication of 7 children, while in 5 cases extra-familial people was suspected. Eight cases were reported to the Judicial Authority as highly suggestive of CN. Social workers intervened in all cases, and the child was entrusted to a foster family in 2 cases because the parents were unable to properly care for them.All the children were brought to the Paediatric Emergency Department showing severe symptoms such as hyporeactivity, hypotonia, difficulty of speech, and ataxia. Toxicological analyses of urine and blood confirmed the drug exposure.The most serious case involved a 2-year-old girl who was admitted to the Intensive Care Unit in a comatose state, showing respiratory insufficiency, pin-point pupils, and lethargy. As an acute opioid intoxication was suspected, the drug screening tests were performed, revealing near fatal levels of heroin and methadone. The unexpected survival of the child was explained by opioids tolerance following repeated exposure. Hair analysis confirmed a chronic consumption of opioids. In suspected cases of poisoning in children, it is crucial an appropriate evaluation based on clinical findings and toxicology, in order to discriminate between accident and neglect.