Arsenic Poisoning in Pediatric Age
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Introduction to Pediatric Arsenic Poisoning
Definition: Arsenic poisoning in children represents exposure to toxic inorganic or organic arsenic compounds, leading to multi-system toxicity with both acute and chronic manifestations.
Epidemiology
- Primary sources of exposure:
- Contaminated groundwater
- Industrial pollution
- Agricultural pesticides
- Traditional medicines
- Wood preservatives
- Higher risk in developing countries with contaminated water sources
- Children are particularly vulnerable due to:
- Higher absorption rates
- Immature metabolic pathways
- Hand-to-mouth behavior
- Greater water consumption per body weight
Pathophysiology
- Mechanism of toxicity:
- Inhibition of cellular respiration
- Disruption of ATP production
- Generation of reactive oxygen species
- Interference with DNA repair mechanisms
- Alteration of multiple enzyme systems
- Distribution:
- Rapid absorption through GI tract
- Accumulation in liver, kidneys, heart, and skin
- Crosses blood-brain barrier
- Deposits in hair, nails, and bones
Clinical Presentation
Acute Poisoning
- Gastrointestinal symptoms (onset within hours):
- Severe abdominal pain
- Profuse rice-water diarrhea
- Projectile vomiting
- Hemorrhagic gastroenteritis
- Cardiovascular manifestations:
- Hypotension
- Tachycardia
- QT prolongation
- Ventricular arrhythmias
- Neurological symptoms:
- Encephalopathy
- Seizures
- Delirium
- Coma
Chronic Poisoning
- Dermatological changes:
- Hyperkeratosis
- Hyperpigmentation
- Mees' lines in nails
- Raindrop pigmentation
- Developmental effects:
- Growth retardation
- Cognitive impairment
- Behavioral changes
- Organ system involvement:
- Peripheral neuropathy
- Hepatomegaly
- Chronic lung disease
- Anemia
Diagnosis & Assessment
Initial Evaluation
- History taking:
- Source of exposure
- Duration of exposure
- Environmental assessment
- Family history
- Physical examination:
- Vital signs
- Hydration status
- Neurological assessment
- Skin changes
Laboratory Studies
- Immediate tests:
- Spot urine arsenic level
- 24-hour urine collection
- Complete blood count
- Comprehensive metabolic panel
- Blood gas analysis
- Specialized testing:
- Hair analysis (chronic exposure)
- Nail analysis
- Speciation of arsenic compounds
- Additional studies:
- ECG monitoring
- Chest X-ray
- Abdominal imaging
- Nerve conduction studies (if indicated)
Management
Emergency Management
- Immediate interventions:
- Airway protection
- Fluid resuscitation
- Hemodynamic support
- Seizure control if needed
- Decontamination:
- Removal from exposure source
- Gastric lavage (if indicated)
- Activated charcoal (controversial)
Chelation Therapy
- Indications:
- Acute symptomatic poisoning
- Elevated arsenic levels
- Significant chronic exposure
- Chelating agents:
- Dimercaprol (BAL):
- Dose: 3-5 mg/kg IM q4h
- Duration: 2-10 days
- Succimer (DMSA):
- Dose: 10 mg/kg q8h for 5 days
- Then 10 mg/kg q12h for 14 days
- Dimercaprol (BAL):
Supportive Care
- Fluid and electrolyte management
- Nutritional support
- Pain management
- Treatment of specific complications
Prevention & Monitoring
Prevention Strategies
- Environmental interventions:
- Water testing
- Use of arsenic removal systems
- Safe water alternatives
- Education:
- Family awareness
- Community programs
- Healthcare provider training
Long-term Monitoring
- Regular follow-up:
- Growth monitoring
- Developmental assessment
- Neurological evaluation
- Periodic arsenic level testing
- Complications surveillance:
- Skin cancer screening
- Cardiovascular assessment
- Cognitive function testing
- Quality of life evaluation
