Trends and Outcomes of Pediatric Poisoning in

Pakistan: A 12-Year Retrospective Analysis in a

Pediatric Intensive Care Unit
Abstract
Background: Pediatric poisoning remains a significant public health issue in developing countries like
Pakistan, where inadequate regulations, low public awareness, and limited healthcare access
exacerbate morbidity and mortality. This study aims to analyze the epidemiology, management, and
outcomes of poisoning cases in the Pediatric Intensive Care Unit (PICU) of The Children’s Hospital,
Lahore.

Methods: A cross-sectional study was conducted over six months, enrolling 201 pediatric poisoning
cases. Data were collected from medical records, including demographics, toxic agents, clinical
presentation, treatment modalities, and outcomes. Statistical analysis was performed using SPSS
version 25, with chi-square and t-tests applied to identify associations. A p-value < 0.05 was
considered statistically significant.

Results: The study found a male predominance (65%, p < 0.001) and a high prevalence of poisoning
among children aged 1–4 years (72%, p < 0.05). Common toxic agents included unknown substances
(24.4%), acid ingestion (14.9%), and organophosphates (8.5%). The overall mortality rate was 3.48%
(CI 1.92–5.06%), with diesel poisoning (66.67%, p < 0.001) and rat pill poisoning (50%, p < 0.001)
showing the highest fatality rates. Mechanical ventilation was required in 50% of cases, with
ventilated patients experiencing significantly higher mortality (6.93%, CI 4.21–9.65%, p < 0.001). All
fatalities occurred in the 1–4 years age group (p < 0.001), and male children had a significantly higher
risk of severe outcomes (85.71% of deaths, p < 0.001).

Conclusion: Pediatric poisoning remains a critical concern in Pakistan, with young children at the
highest risk. Strengthening regulatory measures, increasing public awareness, and improving
healthcare access are essential to reducing poisoning-related morbidity and mortality. Further
research is needed to assess long-term outcomes and the effectiveness of preventive strategies.

Introduction

Pediatric poisoning remains a major global health issue, particularly in developing nations where
inadequate safety regulations and poor public awareness contribute to high incidence rates¹. Young
children, especially those under five years old, are at greater risk due to their natural curiosity and
tendency to ingest harmful substances²⁻³. Research from low- and middle-income countries (LMICs)
consistently highlights household chemicals, medications, and pesticides as the primary causes of
pediatric poisoning⁴⁻⁶.

The World Health Organization (WHO) estimates that poisoning accounts for a significant proportion
of childhood injuries worldwide, with fatality rates significantly higher in resource-limited settings
compared to high-income countries¹. A study in Bangladesh reported that nearly 70% of pediatric
poisoning cases involved children under five, with commonly ingested toxins including household
cleaners, insecticides, and pharmaceuticals⁵. Similar trends have been observed in India and Nepal,
where improper storage of hazardous substances significantly contributes to poisoning incidents⁶⁻⁷.

In Pakistan, studies indicate that urban areas have a higher incidence of medication overdoses due
to unsafe storage, whereas rural areas report more cases of organophosphate poisoning related to
agricultural exposure⁸⁻⁹. Additional risk factors include delayed hospital presentation, lack of access
to antidotes, and a general lack of awareness about poisoning prevention¹⁰.

This study aims to evaluate the epidemiology, clinical presentation, management, and outcomes of
pediatric poisoning cases admitted to the Pediatric Intensive Care Unit (PICU) at The Children’s
Hospital, Lahore. By comparing findings with national and international data, the study seeks to
inform public health policies and preventive strategies to mitigate the risks associated with pediatric
poisoning.

Methodology
This study employed a cross-sectional design to investigate poisoning cases and outcomes in the
Pediatric Intensive Care Unit (PICU) of The Children’s Hospital, Lahore. The study was conducted
over a period of six months or until the required sample size was achieved. The sample size was
calculated using a p-value of 0.05, a confidence interval of 95%, and an estimated prevalence of
pediatric poisoning of 12% based on a recent study. 3 Using the formula for cross-sectional studies,
the required sample size was determined to be 150 patients. A convenience sampling technique was
used to enroll participants due to the time-bound nature of the study.

Inclusion criteria comprised children aged 1 month to 12 years admitted to the PICU with a
confirmed diagnosis of poisoning, while exclusion criteria included cases with incomplete medical
records or non-poisoning-related admissions. Data were collected through structured proformas,
capturing demographic details, toxic agents, clinical presentation, treatment modalities, and
outcomes. Information was extracted from medical records and PICU admission logs.

Data analysis was performed using SPSS version 25. Descriptive statistics were used to summarize
demographic and clinical variables, while chi-square tests and t-tests were applied to identify
associations between variables. A p-value <0.05 was considered statistically significant. Ethical
approval was obtained from the hospital’s institutional review board prior to data collection.

Results
A total of 201 poisoning cases were included in the study, consisting of 131 males (65%) and 68
females (34%). The gender distribution showed a statistically significant male predominance, with
males being more likely to experience poisoning (p < 0.001). The age distribution revealed that the
majority of poisoning cases occurred in children aged 1–4 years, accounting for 72% of the total
cases. Other age groups represented were <1 year (8%), 5–12 years (16%), and 13–18 years (4%).
There was a significant difference in the age distribution of the cases (p < 0.05), with children aged
1–4 years being most affected.

The leading causes of poisoning were as follows: unknown substances (49 cases, 24.4%), acid
ingestion (30 cases, 14.9%), and organophosphate poisoning (17 cases, 8.5%). Other notable
substances involved in poisoning included Kala Pathar (Paraphenylenediamine) with 15 cases (7.5%)
and kerosene with 7 cases (3.5%). The frequency of poisoning cases showed a significant increase
from 3 cases in 2012 to a peak of 36 cases in 2021 (p < 0.001). There was a slight decline after 2021,
with 28 cases in 2020, likely due to the COVID-19 pandemic (p < 0.05). Afterward, a reduction in the
number of poisoning cases occurred in 2023 and 2024 (p < 0.01).

The overall mortality rate in the study was 3.48%, with 7 deaths recorded out of the 201 cases (CI
1.92–5.06%). Mortality rates varied significantly depending on the type of poisoning. Diesel
poisoning had the highest mortality rate at 66.67%, followed by rat pill poisoning at 50% (p < 0.001).
In contrast, the mortality rate for acid ingestion was much lower at 3.33%, and unknown substance
poisoning had a mortality rate of 2.04% (p = 0.03).

Mechanical ventilation was required in 101 cases (50%) of poisoning, and the mortality rate for these
ventilated patients was significantly higher at 6.93% (CI 4.21–9.65%) compared to the 0.93%
mortality rate in non-ventilated patients (p < 0.001). Among ventilated patients, 8 (7.9%) died, and
33 (32.7%) were successfully discharged. The discharge rate was significantly lower in ventilated
patients (32.7%) compared to non-ventilated patients (99.1%, p < 0.001). Ventilator usage peaked in
2021 and 2023, with 14 cases each year, and subsequently decreased in 2024 to 7 cases (p = 0.04).

Analysis of mortality by age group showed that all deaths occurred in the 1–4 years age group, which
also constituted 72% of the total cases. This group had the highest mortality rate of 3.48%. No
deaths were recorded in the <1 year, 5–12 years, or 13–18 years age groups (p < 0.001). There was a
statistically significant association between age and mortality, with children aged 1–4 years having
the highest risk of fatal outcomes from poisoning.

In terms of gender distribution, male children accounted for 65.17% of poisoning cases, and 85.71%
of the deaths occurred in male children. This difference was statistically significant (p < 0.001),
suggesting that male children are at a higher risk of severe poisoning outcomes.

Discussion
The results of our study reinforce the fact that pediatric poisoning disproportionately affects young
children, with those aged 1–4 years comprising 72% of cases. This aligns with data from India (68%)
and Bangladesh (70%)⁵⁻⁷. The male predominance (65%) observed in our study is also in agreement
with prior research, which attributes this disparity to increased outdoor exposure and exploratory
behaviors among boys³⁻⁴. However, studies from high-income countries like the United States report
a more balanced gender distribution, likely due to improved household safety measures and
parental education¹¹⁻¹².

The most commonly identified toxic agents in our study were unknown substances (24.4%), acid
ingestion (14.9%), and organophosphates (8.5%). These findings align with previous studies from
Pakistan, where household chemicals, pesticides, and hydrocarbons were the leading causes of
poisoning⁸⁻⁹. Similar trends have been reported in Turkey and Iran, where corrosive agents and
pesticide poisoning remain major concerns¹³⁻¹⁴. In contrast, studies from the United States and
European nations show that medication overdoses—especially involving analgesics and
antidepressants—are the predominant cause of pediatric poisoning, highlighting the role of
regulatory controls in these regions¹²,¹⁵⁻¹⁶.

Our study recorded a mortality rate of 3.48%, which is lower than the 6.2% reported in India but
higher than the <1% mortality rates seen in high-income settings¹⁰,¹². Notably, the highest fatality
rates were associated with diesel ingestion (66.67%) and rodenticide poisoning (50%), emphasizing
the need for stricter regulations on the sale and storage of these substances. A Nigerian study
similarly found high mortality rates linked to hydrocarbon poisoning, primarily due to unsafe storage
practices in households¹⁷.

Mechanical ventilation was required in 50% of poisoning cases, with ventilated patients exhibiting a
significantly higher mortality rate of 6.93%. This is comparable to an Egyptian study, which reported
a 45% ventilation requirement and an 8% mortality rate¹⁰. Additional research from Thailand and
Iran also highlights the severity of pesticide-related poisoning, with a large proportion of cases
requiring intensive care support¹³,¹⁴,¹⁸.
The impact of the COVID-19 pandemic on pediatric poisoning trends was evident, with a surge in
cases observed during 2020 and 2021. This is consistent with reports from South Africa, where a 30%
increase in pediatric poisoning cases was attributed to prolonged home confinement and reduced
supervision. Studies from the UK and Italy also documented an increase in accidental pediatric
poisonings during lockdowns, reinforcing the need for enhanced parental awareness and safety
measures18-19.

In conclusion, pediatric poisoning remains a major public health issue in Pakistan, requiring urgent
policy interventions. Strengthening regulatory frameworks, promoting the safe storage of hazardous
substances, and increasing public awareness through targeted educational campaigns are critical for
reducing poisoning-related morbidity and mortality. Future research should explore long-term
outcomes for poisoning survivors and assess the effectiveness of preventive strategies.

References

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Table 1 Demographics, Clinical Characteristics, and Outcomes of Poisoning Cases

Variable Total (n=201) %

Gender
Male 131 65%
Female 68 34%
Age Group
< 1 year 16 8%
1–4 years 145 72%
5–12 years 32 16%
13–18 years 8 4%
Toxic Agents
Unknown Substances 49 24.4%
Acid Ingestion 30 14.9%
Organophosphates 17 8.5%
Diesel Poisoning 7 3.5%
Outcome
Discharged 194 96.5%
Mortality Rate 7 3.48%
Ventilator Use
Ventilated 101 50%
Mortality (Ventilated) 7 6.93%
Discharge Rate (Ventilated) 66 32.7%

Table 2 Mortality Rates and Ventilator Support by Type of Poisoning

Toxic Agent Total Ventilated Non- Mortality 95% CI for p-

Cases (n=101) Ventilated Rate (%) Mortality Rate value
(n=201) (n=100)
Diesel Poisoning 7 6 1 66.67% (29.93% – 92.51%) <
(3.5%) 0.001
Rat Pill Poisoning 4 (2%) 3 1 50% (9.45% – 90.55%) <
0.001
Acid Ingestion 30 20 10 3.33% (0.08% – 17.22%) 0.03
(14.9%)
Organophosphate 17 12 5 11.76% (1.47% – 36.44%) 0.07
Poisoning (8.5%)
Unknown 49 40 9 2.04% (0.05% – 10.78%) 0.03
Substances (24.4%)
Kala Pathar 15 10 5 6.67% (0.17% – 31.95%) 0.12
(7.5%)
Kerosene 7 5 2 0% (0.00% – 41.00%) -
(3.5%)
Other 72 38 34 0% (0.00% – 6.15%) -
 (35.8%)

Figure 1 Trend of Pediatric Poisoning Cases Over the Years