Indian J Pediatr 1987; 54:427-430

Organophosphorus poisoning V.P. Choudhry, A.J. Jallali, G. Haider, G.N. Aram and A.R. Ghani

Department o f Pediatrics, lndira Gandhi hzstitute o f Child Health,

Kabul Afghanistan

Organophosphorus poisoning was seen in 42 children between the ages of 26 days to 13 years. Twenty-seven children developed this poisoning following accidental oral ingestion and mothers o f two btfants administered the melathane mistakenly as cough syrup. Thirteen children developed the symptoms following pesticides appli- cation to either hair for treatment of lice or wearing the clothes which were pre- served with these chemicals. Alteration in sensoriam, excessive secretions, vomi- tings, h'ritability and constricted pupils were the frequent manifestations. Headache was observed in six of eight children who had applied these compotmds to their hair, while cough and aspiration pneumonia was seen only following oral ingestion. Nine of the 42 (21" 4%) children died in the present study. Mortality following hair and skin application was 38"5% as compared to 13"8~ following oral accidental ingestion. Accidental poisoning by these compounds can be easily prevented and possible measures for the same have been suggested.

Organophosphorous compounds are being increasingly used as insecticides for the past few years. These compounds are very toxic and poisonous and are not re- commended for either oral consumption or local application. However, because of poor health education, poverty, lack of information on the toxic effects of these compounds and poor socio-economic status, these compounds are being stored in houses and are generally kept within the reach of children. Unfortunately, these compounds are being used in Afgha- nistan by certain community for preser- vation of clothes and for local applica- tion on hair for lice etc.

Reprint requests : Dr. V.P. Choudhry, Associate Professor, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi 110029.

The present communication describes the clinical presentation of these patients along with their outcome and measures which should be taken to prevent the occurrence of lethal accidental poisoning.

Material and Methods

All children admitted with organo- phosphorous poisoning to Indira Gandhi Institute of Child Health, Kabul, during the two Afghan calendar years 1362-1363" were the subjects of the present study.

Diagnosis in these cases was estab- lished on the basis of history of either oral accidental consumption of these com- pounds or their application on hair or clothes along with the clinical features of organophosphorous poisoning. All these children were kept in the intensive

*This period according to Afghan calendar commences from 21st March, 1983 to 20th March, 1985.

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care room for close observation and mana- gement. Investigations done on these children included complete hemogram, blood urea, blood sugar, serum electro- lytes, urine for presence of organophos- phorous compotmds and radiograph of chest, cerebrospinal fluid examination etc. were done wherever indicated.

These children were treated with Am- picillin (100 mg/kg.) prophylactically and atropine 0.05-0.1 mg/kg I/2-I hourly ini- tially and later the dose was decreased depending upon the pupil size. pharyn- geal secretions, vital signs and general condition of each child.

Results

During the period of study 22 boys and 20 girls belonging to 37 families (three sibs from one family and two sibs from three families) between the ages of 26 days to 13 years were admitted to IGICH. Of these, 15 children were below four years, 15 between four and eight years while the remaining 12 were over eight years of age. Twenty-seven children developed organophosphorus poisoning accidentally following oral ingestion and to a 26-day-old and two-nlonth-old infants the mother had administered one and two teaspoonful respectively of melathane mistakenly as medicine for cough. The exact quantity of organophosphorus c6m- pounds ingested could not be judged in majority of cases, however, it seems the amount ingested was four to six tea- spoonful. Eight children developed orga- nophosphorus poisoning as they had applied these chemicals to their hair for treatment of lice while five developed poisoning after wearing unwashed clothes which were sprinkled with organophosphorus compounds. How- ever, these compounds were applied

to hair or clothes not on doctor's advice. Majority of these children had this poiso- ning during sunmler or start of the winter season. Twenty-four children reached the hospital within eight hours, four between eight to 24 hours, seven between one to three days, three between three to seven days and one on the 1 Ith day of exposure. In three children the interval between the exposure and hospital admission could not be deter- mined. Generally the children to whose hair or clothes these compounds were applied attended the hospital late (bet- ween two-eleven days after exposure).

Majority of these children presented with variable change in sensorium (drowsiness to unconscious level), excessive secretions in throat, vomiting and constricted pupils (Table I). Headache was observed in six of eight children who had applied these compounds to their hair for treatment of lice. Irritating cough and evidence of aspiration pneumonia in seven and I1

Table I. Clinical features in organophosphorus poisoning

Symptoms Oral Skin & hair ingestion application n=29 n=13

Sensorial changes 26 11 Excessive pharyngeal 24 12

secretions Constricted pupils 27 11 Vomiting 22 7 Irritability 14 3 Convulsions 3 2 S/S Shock 5 3 Fever 5 2 Headache _ 6 Cough 7 Aspiration pneumonia 11 Cynosis __ 2

CHOUDHRY ET AL : ORGANOPHOSPHORUS POISONING 429

childre~l respectively were observed after oral ingestion of these compounds. Child- ren following oral ingestion recovered within 24 to 40 hours, while children who had applied these compounds to their hair or skin recovered in 40 to 120 hours.

Mortality. There were nine deaths in the present series giving a mortality rate of 21.4%. Five of the 13 (38-570)children who had applied these compounds to their hair or had used clothes sprinkled with organophosphorus compounds died as compared to four of 29 (13"87o) children who had ingested these compounds orally. Mortality in these children was compared with the time taken by the parents to bring their children after exposure to these agents. No definite relation was observed.

Discussion

Afghanistan is mainly an agricultural country and is famous for fresh fruits and other agricultural products. While the literacy rate is very low (23. 570) 1 the insecticides are being commonly used to protect fruits and other crops. Often these compounds are used in much higher con- centration because of poor education and secondly the literature provided is not in a local language. As farmers are not aware that those agents are not recommended for human use and of its toxicity effects so these compounds have been often stored in houses.

Incidence of pesticide poisoning in Afghanistan was 9.770, 2 which was higher than that of Buhariwalla et al 3 (6"270) and Gaind et al 4 (4.5%). However, the incidence of organophosphorus poisoning was similar to that el" Chatterjee and Banerjee 5 (9.570). Higher incidence was

observed due to their frequent domes- tic and agricultural use and lack of health education. In some countries there had been epidemics of poisoning by pesti- cides following contamination of food by pesticides formulation during transport or storage.6,7, s Another source of epide- mics primarily in children has been the use of parathion to treat human lice. 9 It was not possible to determine the exact amount of organophosphorus compounds ingested by the children or applied over the skin or hair in majority of the cases. However, it is possible that they had ingested in smaller amounts. Similarly, the exact nature of organophosphorus compounds could not be determined in all except two because (i) these compounds were not stored in proper bottles with labels and (ii) parents could not bring these compounds to the hospital.

These children presented with disturb- ances in sensorial changes, excessive phar- yngeal secretions, constricted pupils, vomit- ing and irritability (Table I). Cough and aspiration pneumonia was present only following oral ingestion, whereas head- ache, convulsions and cynosis were more frequently seen following its application on head for possible treatment of lice or its use on clothes. Children following oral ingestion were admitted much earlier because of early onset of manifestation and so they were managed early and majority of them recovered within 48 hours. On the contrary children following local application of organophosphorus on hair or skin manifested late because of its slow absorption and its cumulation in the body. These patients took two to five days to recover because of their prolonged exposure and possible slow absorption from the skin. Similar obser- vations were made by Koeffler. 9

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The season distribution as observed by us and others in the present study was due to greater use of pesticidal formula- tion in summerl0,11 and start of winter when the clothes preserved by pesticidal formulations are used. Rapid absorption of pesticides by the skin at higher ambient temperature may be another additional factor. Absorption from the skin is gene- rally slower than from gastrointestinal tract but it is more prolonged. 11 Children in the present study were managed on these principles, (a) removal of the toxic material, (b) symptomatic care, and (c) physiological and specific antidotes. After oral ingestion, if the patient was conscious, the vomiting was preferable to lavage. When the insecticide was applied to the skin or hair most of it could be removed by washing with detergent and water. The greater the delay in washing, the lesser is tile chance of success in treating these patients. 12 Atropine is a physiolo- gical antidote. It has no effect on inhibited cholinestarase but it blocks the action of acetylcholine on parasympathetic re- ceptors.12 Atropinization should be ade- quately done and should be maintained for 24-72 hours depending upon the seve- rity of the case.

Mortality in the present series was high as the children were brought late to the hospital, the history of exposure to various insecticides was not available in many cases and adequate atropinization in some children could not be done be- cause of poor availability of atropine sulfate.

Poisoning by various organophos- phorus compounds can be easily preven- ted by health education. These compounds should be kept in farms in properly label- led bottles and should never be kept at home. If these compounds are kept at

home they should not be within the reach of children. By publicity media people should be educated that these compounds are not meant for preservation of clothes or for treatment of lice. These compounds should be sold/distributed along with the literature in the local language indicating the proper strength of their uses, side effects and toxic reactions.

R e f e r e n c e s

1. Results of population census 1979. Publica- tion of Central Statistics Office Publication, Government of Democratic Republic of Afghanistan.

2. Choudhry VP, Jallali AJ, Haider G, Quresbi SA. Spectrum of accidental poisoning among children in Afghanistan. Tropical J Pediatr (Accepted for publication)

3. Buhariwalla RJ, Sanjanwalla. Poisoning in children : A Study of 303 cases. Indian Pediatr 1969; 6 : 141-145.

4. Gaind BN, Mohan M, Ghosh S. Changing pattern of poisoning in children. Indian Pedlatr 1977; 14 : 295-301

5. Chatterjee B, Banerjee DP. Accidental poison- ing in children. Indian Pediatr 1981; 18 : 157-162

6. Karunakaran CO. The Kerala feed poisoning. J Indian Meal Assoc 1958; 31 : 204-207

7. Kanugoratnam K, Boon WH, Hob TK. Para- thion poisoning from contaminated barley. Lancet 1960; 1 : 538-542

8. Weeks DE. Endrin food poisoning. A report on four outbreaks caused by two separate shipments of endrin contaminated flour. Bull WHO 1967 ; 37 : 455-512

9. Koeffler H. Acute E-605 poisoning by percu- taneous absorption of the poison. Med Kiln Berlin 1958 ; 53 : 749-541

I0. Hayes WJ Jr., Pirkle CI. Mortality from pesticides in 1961. Arch Enviorn Health 1966; 12 : 43-55

11. Hayes WJ Jr. Epidemiology and general management of poisonings by pesticides. Pediatr Clin North Am. 1970 ; 17 : 629-644

12. Fredricksson T. Percutaneous absorption of parathion and paraoxon IV. Decontamination of human skin from parathion. Arch Environ Health 1961;3 : 185-188