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 DOI: 10.1177/096032719601500310

1996 15: 245Hum Exp ToxicolAnne Lamminpää and Marja KinosPlant poisonings in children

  

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245

Plant poisonings in children Anne Lamminpää and Marja Kinos

Poison Information Centre, Department of Clinical Pharmacology, University of Helsinki, Finland

1 Plant poisonings comprise 5% of all hospitalizationsdue to poisonings in children and plant inquiries to PoisonInformation Centre consist about 28% of calls concerningchildren.2 A search of 71 cases of hospitalization due to plants ina 5 year period obtained from two children’s hospitals inHelsinki were reviewed and 105 plant inquiries concern-ing poisonings among children to the Poison InformationCentre in a 6 month period were studied.3 The most frequent plant poisonings involved lily-of-the-valley, dumb cane and cotoneaster plant. Only 11% ofthe cases treated in hospital were evaluated to be

unequivocal poisonings.4 Mezereon, snowberry, cotoneaster plant, honeysuckle,

and woody nightshade caused the most serious symptoms.Symptoms in mezereon poisoning were increased salivaexcretion, haematuria and diarrhoea in a 1.2-year-old girl.Snowberries caused a semicomatose state and difficulty inurination, cotoneaster caused severe stomach ache,honeysuckle abudant gastrointestinal symptoms andmuscle cramps, and nightshade led to prolonged highfever and sweating.5 It appears that almost all plant poisonings could betreated with medical charcoal. Gastric evacuation isseldom required.

Keywords: children; plants; poisoning

Correspondence: A Lamminpää, Juhannusmäki 11 D, FIN-02200Espoo, FinlandReceived 22 February 1995; accepted 23 August 1995

Introduction

There is often considerable difficulty in estimatingthe toxicity of poison plants. The reason for this isthat the patient is often under six-years old andexact information on toxicity of the plant is not

always available.Serious plant poisoning is rare. The last known

fatal case in Finland was in 1959, and it was caused

by rhubarb leaves.’ In 1993 there were 34 plantpoisonings in children under 10 years of age takingup 41 treatment days in hospitals, according to theFinnish Hospital Discharge Register where all

poisonings treated for over 15 h are registered.Plants consisted 5% of all hospitalized poisoningsin children. In 1993 plant inquiries comprised asmuch as 23% of all 27 705 calls to the PoisonInformation Centre (PIC). In some other Nordic

countries, plants comprised fewer calls according totheir own 1992 statistics; Sweden 17%, Denmark15% and Norway 20%.The aim of the present study was to investigate

the range and the severity of plant poisonings.

Methods

Plant poisonings in children treated in hospitalCases of hospitalization due to plants were obtainedfrom two main children’s hospitals in Helsinki (the

Aurora Hospital, and the Children’s Clinic, Uni-versity of Helsinki). All cases treated in the

emergency department were included. There were71 plant poisonings in 1988 -1992. The number ofplant poisonings was on average 14 poisonings peryear (range 6 to 22).The cases were reviewed by two independent

investigators on the basis of all hospital documents.The conclusions concerning the incident status bynature and cause were ultimately reached bymutual agreement.The sex ratio of patients was even; 35 were boys

and 36 were girls. The mean age of the patients was2.3 years (range 0.11- 5.8 years).

Plant inquiries to the Poison Information CentreThe study was performed between May and October1993. All children calling during the study periodbecause of plant poisonings were included. Exclu-sion criteria were ingestion of a non-poisonousplant, ingestion of an amount known to be non-toxicor an uncertain case history. At the end of the callpermission was asked for us to make a later

telephone interview to follow-up the plant poison-ing.

During the study period, 16 288 calls were madeto the Centre. Altogether 1859 calls (11%) con-cerned plant poisonings among children less than10 years of age. In total, 105 (6%) of these calls wereincluded in the study. The mean age of the childrenwas 2.8 years (range from 4 months - 9 years). Thesmall majority (53%) were boys.

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Results

Plant poisonings in children treated in hospital71 children were admitted to hospital due to 29different plants. The dominating plants were lily-of-the-valley (Convallaria majalis; 13), dumb cane(Dieffenbachia; 9), cotoneaster plant (Cotoneaster;6) and european red elderberry (Sambucus; 6). Eightplants consisted 72% of all plant poisonings (Table1). Two cases or more were associated with each ofthe following plants: Lupin (Lupinus), tulip (Tulipa),Aronia, honeysuckle (Lonicera tatarica), yew(Taxus baccata) and mezereon (Daphne mezereum).One case was associated with eleven different

plants. The ingested part was in the majority berries(50, 70%). The amount ingested was not known andnot recorded in case histories in 29 cases.As many as 22 (31 % ) children had received some

treatment at home. The delay for admission to

hospital was on the average 2 h 26 min (range25 min-16 h). Minority of the children had symp-toms prior to admission to hospital (24, 34%) (Table1) and 23% were symptomatic when arriving at

hospital. The symptoms had begun in 2 h in 13

patients and in over 5 h in 11 patients. Great

majority of symptomatic children had gastrointest-inal symptoms such as vomiting, stomach ache ordiarrhoea. Only 11 patients had some symptomsfrom the poisoning and the symptoms were likelymerely due to ipecacsyrup in 5 patients.

In hospital the treatment was charcoal (56),ipecac syrup (57) and intravenous fluid (5). Twocases were transferred to an intensive care unit

(Table 2).Most children were discharged from the emer-

gency department after a few hours follow up (52,75%). No child stayed at hospital more than oneday. In the series of 71 cases 11 % were evaluated asunequivocal poisonings because they fulfilled thecriteria of characteristic, or at least strongly

suggestive symptoms and signs pertaining to

poisonings, as well as to significant exposure, 27%were exposed but had no symptoms, 10% wereexposed but the symptoms could have been fromthe treatment. 44% of the patients had no symptomsand the exposure was questionable. Other illnesswas likely in 8% of cases. Out of the 34 clinicalpoisonings the poisoning was insignificant in 24,moderate in 8 and severe in 2 patients. Retro-

spective assessment showed that 61% could havebeen treated at home.

Plant poisoning enquiries to the Poison InformationCentre

Inquiries involving 105 children were caused by 42different plants; most often lily-of-the-valley (14)and european red elderberry (9) (Table 1). Eightplants consisted half of the ingested plants (Table1). 98 children had swallowed the plant and 7

children had had cutaneous contact with burdock,dieffenbachia, euphorbia, giant hogweed, or mea-dow buttercup (Ranunculus). Cutaneous contactcaused itching, flushing, rashes or blister vesicleson skin.

Poisonings occurred outdoors in 73% (57% in thegarden, 13% in fields and forest and 3% in

kindergarten). The incident of ingestion was un-certain in 26%, the ingestion was observed in 44%, 9the child told about the ingestion in 2 7% and in 3 %the case history was not known.

Out of 36 symptomatic children who had

ingested a piece of a plant symptoms lasted oneday or more in 31% (12) of the patients (Table 3).Nearly all symptomatic patients had gastrointest-inal signs. One 1.4-year-old girl had irregular pulsefor a while, but a normal ECG finding, after

ingestion of flowers from lily-of-the-valley. Theother 3.5-year-old girl who had ingested 4 berriesof lily-of-the-valley had stomach ache. Dumb canecaused ache and swelling in the mouth of two

Table 1 Plants involved in plant-related incidents in two hospitals and inquiries to the PIC

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Table 2 Clinical moderate and severe plant poisonings in chidren admitted to hospital

children. Honeysuckle caused mainly vomiting intwo children. Mezereon poisoning appeared in a1.2-year-old girl who had an increased saliva

Table 3 Plant poisonings that caused symptoms for 24 hours ormore in 12 children out of 105 inquiries made to the PIC

excretion, hematuria and diarrhoea. The girl wasstudied in hospital due to hematuria, and the reasonremained unknown until after a week the parentsnoticed the berries near their summer cottage. Othersymptomatic patients who had ingested mezereonberries vomited for about 1 h.The recommendation from the PIC was diluting

with water or milk (55%), medical charcoal (63%)and ipecac syrup (6%). Other recommendationswere ingestion of calcium (eg milk) or rinsing theskin. The recommended place for treatment was thehome (80%) and the public health center (15%).Treatment in hospital was recommended in 5 cases(5%) after ingestion of honeysuckle, tulip’s bulbs,mezereon, european red elderberry and lily-of-the-valley.

Discussion

Ingestion of plants is frequent among small chil-dren. Although the number of poisonous plants isenormous, about 12 different plants comprised themajority of cases in the present study. Only 6% ofthe telephone inquiries to the PIC about plants wereeligible for this study and the rest of the inquiriesconsidered plants that were either not poisonous orthe amount eaten was insignificant. Treatment isseldom needed in hospital in plant poisonings .2,1 Ithas been estimated that about 40% of the admis-sions to hospital could have been avoided bycalling to the PIC.4 In the present study about60% could have been treated at home out of those

patients visiting hospital.Less than one third of the children admitted to

hospital were symptomatic in this study. In a seriesof 160 plant poisonings treated in hospital, about30% showed mild or moderate symptoms, mostoften intestinal disturbances, but no child had

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serious symptoms.5 Our study showed that snow-berry (Symphoricarpos albus), cotoneaster (6),mezereon, honeysuckle, nightshade, and woodsorrel poisonings can cause serious symptoms.Snowberry’s toxicity was reported by Amyot asearly as in 1885/ It can cause a semicomatoticstate.8 In this study it caused not only semicomato-tic state but also difficulties to urinate. Hematuria,caused by mezereon, was extensively tested for in agirl, but the symptom disappeared without treat-ment in two weeks. Furthermore, albuminuria andstrangury have been seen with mezereon ingestion.9

Phototoxic reactions occur following contact

with plants that contain photosensitizing chemicaland the appropriate wavelength of radiation.10,11 Inour study giant hogweed (Heracleum species) andburning bush (Dictamnus albus) caused these

symptoms.Dieffenbachia and euphorbia juices caused

symptoms in the eye. Dieffenbachia’s active irritantis probably a protein.&dquo; Euphorbia’s sap or latex areirritants causing inflammation and blistering of theskin and severe inflammation of the eye, both

externally and intraocularly.5~13In the present study nearly one third had some

symptoms due to Dieffenbachia, mainly irritation ofthe mouth and throat. Chewing Dieffenbachia andPhilodendron has been reported to cause minorsymptoms in only 4% of 118 cases and the onsetwas within 5 min with short duration. 14 There is arare case report of lethal poisoning caused byPhilodendron in a ii-month-year old child withesophageal lesions.1-9 In our study one patientvomited after ingesting Philodendron.

In the present study one woody nightshadepoisoning with typical high longterm fever, sweat-ing and vomiting is reported. Deadly nightshade(Atropa belladonna) has led to atropine poisoningafter ingestion of 20-25 berries by a 9-year-old boy,who was successfully treated with physostigmine. 16Glycosides are compounds of plant origin.17,18 Onepatient had irregular pulse for a short time; a known

effect of lily-of-the-valley.19 The toxicity of yew haslong been known, but only a few cases have beenreported. Yew can lead to conduction disturbancesdue to the pseudoalkaloids Taxine A and Taxine B 20and to unexpected death .21 The only effect of yew inthis study was vomiting.

It is not always the plant that is responsible forthe symptoms; it can be parasitic fungus (Sclerotinamegalospora) as in bog whortleberry. This funguscauses vomiting, nausea, vertigo and mydriasis. 22Pesticides may be also a reason for symptoms.

It appears that almost all plant poisonings can betreated with medical charcoal. Gastric evacuation isindicated only if a large amount or potentially verytoxic plant material has been ingested. Medicalcharcoal is often much more effective than in ipecacsyrup in preventing absorption23,24 when givensufficiently early. 25 Patients treated with charcoalhave been reported to have fewer complications andthey stay for a shorter time in the EmergencyDepartment than those treated with ipecac syrup.26Some PIC have stopped recommending ipecacsyrup as a treatment. 27The danger of plant poisonings is often exagger-

ated in popular handbooks, e.g. a book published inFinland reported that water in a vase of narcissiwould be fatal if ingested. Plant ingestion seldomcauses severe symptoms and if it does otherillnesses are often suspected. The most frequenteffect is gastrointestinal disturbances, that are

probably milder than those caused by ipecac syrup.However, if toxic effects do occur, analysis of theircausality and overall risk for the patient can be adifficult task, which often requires involvement of abotanical specialist.

AcknowledgementsWe are grateful for the assistance of the personnel ofthe PIC and Dr J Vilska, for valuable comments onthe study.

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