Home Syrup of Ipecac Use Does Not Reduce Emergency Department Use or Improve Outcome
From the Drug and Poison Information Center, Department of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Background. The usefulness of syrup of ipecac as a home treatment for poisoning and the need to keep it in the home has been increasingly challenged. Many poison centers do not recommend any use of syrup of ipecac.
Objective. To determine if use of syrup of ipecac in children at home is associated with reduced utilization of emergency department (ED) resources or improved outcome after unintended exposure to a pharmaceutical.
Design. Cohort comparison.
Setting. American Association of Poison Control Centers’ Toxic Exposure Surveillance System Database.
Patients. Blinded data for each of the 64 US poison centers included ED referral recommendation rate, actual rate of ED use, actual home use of syrup of ipecac, and outcome. These data were derived from cases in 2000 and 2001 involving children <6 years of age who unintentionally ingested a pharmaceutical agent and in which the call to a poison center came from home (752 602 children).
Outcome Measures. Correlation between rate of home use of syrup of ipecac and rate of recommendation for ED referral was the primary outcome sought. Rate of adverse outcome was also compared. In addition, the actual ED use and home syrup of ipecac utilization rates at 7 specific centers were identified and compared with the published rates from these same centers from 1990 data to look for the trend in practice for this subgroup.
Results. Mean rate of referral to ED was 9% (range: 3%–18%). Mean home use of syrup of ipecac was 1.8% (range: 0.2%–14%). Increased home use of syrup of ipecac was not associated with referral to ED (r = 0.18; 95% confidence interval of r = –0.06–0.41). Adverse outcome was rare: 0.6% (range: 0.2%–2.1%). There was no difference in referral rate or adverse outcome rate between 2 groups of 32 centers divided by relative syrup of ipecac use. In the 7 centers, ED use decreased from a mean of 13.5% in 1990 to a mean of 8.1% in 2000–2001. Ipecac use decreased from a mean of 9.6% to 2.1%.
Conclusions. This study suggests there is no reduction in resource utilization or improvement in patient outcome from the use of syrup of ipecac at home. Although these data cannot exclude a benefit in a very limited set of poisonings, any benefit remains to be proven.
Key Words: ipecac • decontamination • poisoning • ingestion • poison center
Abbreviations: ED, emergency department • AAPCC, American Association of Poison Control Centers • TESS, Toxic Exposure Surveillance System • CI, confidence interval • SD, standard deviation
The year 2003 marks the 50th anniversary of the founding of the first poison center in the United States. For much of that time, it has been argued that home use of syrup of ipecac allows poison center staff and pediatricians to safely manage children at home who otherwise would need to receive care in an emergency department (ED).1,2 Home decontamination with syrup of ipecac is said to save lives and reduce health care expenses.1
Since at least 1984, as part of The Injury Prevention Program, the American Academy of Pediatrics has recommended that parents keep syrup of ipecac at home.3,4 In many pediatricians’ offices, poison prevention instructions, including stocking syrup of ipecac in the home, are a part of anticipatory guidance.
However, in the last 2 decades physicians in the United States and Europe have increasingly questioned the benefit of syrup of ipecac.5–7 At the same time the use of syrup of ipecac in the United States has decreased dramatically. In 1986 syrup of ipecac was administered after 13.3% of all exposures reported to poison centers.8 By 2001 that percentage had fallen to 0.7%.9 Several factors have contributed to this trend. Poison centers have gained an understanding of the low risk associated with various exposure scenarios and manage more patients at home without any intervention.2 Child-resistant packaging has reduced the number of poisoning events and reduced the dose per event, decreasing the need for intervention.10–12 Research has justified more selective use of decontamination generally.13 EDs have switched from syrup of ipecac to activated charcoal as the preferred form of decontamination when decontamination is indicated.13
Since 1990 an increasing number of poison centers have stopped recommending syrup of ipecac under any circumstances. Other centers use referral dose guidelines that are independent of whether or not syrup of ipecac is in the home. Still others continue to refer children to an ED at different exposure doses depending on whether syrup of ipecac is available in the home or not. The current study proposes to exploit these differences in practice and the extensive data collected on every poison center call to determine if the use of syrup of ipecac by children at home is associated with reduced utilization of ED resources or improved outcome after unintended exposure to a pharmaceutical agent.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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The American Association of Poison Control Centers’ (AAPCC) Toxic Exposure Surveillance System (TESS) assimilates data from every human exposure call to every poison center in the United States. The 64-member poison centers serve 98.8% of the US population. In 2001, 2 267 979 human exposures were reported to the system.9
A request for data from each of the 64 poison centers was submitted to the TESS. The request was limited to the years 2000 and 2001. The request was further limited to cases involving children <6 years of age who unintentionally ingested a pharmaceutical agent and in which the call to a poison center came from home. Data for each center included the number of calls, number of children referred to the ED, number of children who went to the ED, syrup of ipecac use (including location of use), and outcome distribution.
The AAPCC is the owner and overseer of the TESS human database. Data for this study was obtained under guidelines approved by the Board of Directors of the AAPCC. Data were provided to the investigator in a coded fashion so that the investigator was blinded to the identity of the individual poison centers.
The correlation between rates of home use of syrup of ipecac (proportion of study-eligible children calling from home and intended by the poison center for management at home who received ipecac and remained at home) and recommendation for ED referral (proportion of study-eligible children calling from home that the poison center thought should go to the hospital) was the primary outcome sought. Correlation was analyzed using the Pearson correlation coefficient.
Adverse outcome was the secondary outcome measure. Adverse outcome was defined as moderate effect, major effect, or death using the TESS standardized criteria. The adverse outcome rate for each center was the proportion of all study-eligible children with adverse outcome. Referral rate and outcome partially reflect precall risk (the percentage of children at each center who take large amounts of more dangerous medications). There is likely to be some variation in the percentage of high-risk calls between centers.14 Therefore, centers were grouped for outcome comparison. Centers were divided into 2 equal groups by rate of home use of syrup of ipecac. These groups were first compared by referral rate distribution then, if similar, by outcome distribution. The outcome and referral rate between these groups were compared using the Student t test. The 95% confidence interval (CI) of the difference between the means was also calculated.
To identify the trend over time, the ED utilization and home syrup of ipecac utilization rates from 7 centers for which similar 1990 data were available14 were identified. After obtaining permission from these directors, a key to identify the 2000–2001 data from these 7 centers was provided to the investigator. In this analysis, to parallel the type of data collected in 1990, the actual ED utilization rate—as distinct from referral recommendation rate—was used.14
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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In 2000 and 2001, 754 602 calls meeting the screening criteria came to 1 of the 64 poison centers (mean number of these calls per center: 11 791; range: 1419–26 224). Six centers submitted data that did not include the full 24-month period. In total: 669 869 children were managed at home intentionally; 7294 refused referral and were managed at home; 60 681 were referred to an ED by poison center staff; 14 404 self-referred; and 2354 were not classified as to referral status. Mean rate of poison center referral to ED was 9% (range: 3%–18%). Mean home use of syrup of ipecac was 1.8% (range: 0.2%–14%). Adverse outcome was rare: 0.6% (range: 0.2%–2.1%).
Regarding the primary outcome, increased home use of syrup of ipecac was not associated with referral to an ED (r = 0.18; 95% CI of r = –0.06–0.41). See Fig 1. Without the sole outlier, the result is essentially unchanged (r = –0.06).
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When higher and lower home syrup of ipecac use groups were compared by referral rate and outcome, there was no difference. The higher ipecac group had a mean referral rate of 9.59% (standard deviation [SD]: ±3.76%; range: 2.8%–18.4%) and a mean adverse outcome rate of 0.58% (SD: ±0.27%; range: 0.2%–1.1%). The lower ipecac group had a mean referral rate of 9.02% (SD: ±3.6%; range: 3.3%–16.2%) and a mean adverse outcome rate of 0.58% (SD: ±0.40%; range: 0.2%–2.1%). The groups were not significantly different with respect to referral rate (P = .53; difference between the means: 0.57%; 95% CI: –1.26–2.42). The groups were not significantly different with respect to adverse outcome rate (P = .95; difference between the means: 0.005%; 95% CI: –0.16–0.17).
In the 7 centers, ED use in this subgroup decreased from a mean of 13.5% in 1990 to a mean of 8.1% in 2000–2001. Home syrup of ipecac use decreased from a mean of 9.6% to 2.1%. See Table 1.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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This study provides evidence that syrup of ipecac selectively administered at home will not improve outcome or reduce utilization of emergency services in a large portion of the population of children served by poison centers. These data call into question the importance of syrup of ipecac in population-based home injury prevention strategies. Time and money spent emphasizing syrup of ipecac is taken from some other injury prevention strategy. Thus, the cost of emphasizing syrup of ipecac in poison prevention education or discussing it during time devoted to anticipatory guidance at routine pediatric visits may exceed its value to children’s health—even if it has benefit in rare circumstances.
Home use of syrup of ipecac is based on the logic that in appropriately selected cases it can reduce the exposure dose sufficiently to allow home management of a portion of those cases that would otherwise require hospital evaluation.2,14,15 The application depends on identifying a group of patients who are at some risk of symptoms worse than vomiting but not at risk for life-threatening symptoms (requiring ED evaluation) or of symptoms that contraindicate vomiting.
One explanation for the lack of benefit demonstrated in this study is that as poison center experience has grown, the number of circumstances even potentially meeting these criteria has decreased. Patients are now so carefully selected for home management that syrup of ipecac cannot uniformly reduce individual risk sufficiently to allow use of a different referral threshold dose when it is available in the home. Syrup of ipecac can shift a population’s mean dose absorbed.15 Yet each child’s response is different. Some children experience a great dose reduction while others experience no dose reduction—even if they vomit.15 To use syrup of ipecac based on its population dose reduction effect is unnecessary at the low (nontoxic) doses of pharmaceuticals that many poison centers safely manage at home. Because the dose reduction in an individual is inconsistent and may be zero, it is unsafe to rely on the mean population-based reduction in an individual case at or above the toxic dose.
Centers that use more home syrup of ipecac may also be centers that tolerate fewer toxic effects at home. These centers may attempt to use the population dose reduction effect of syrup of ipecac to avoid mild symptoms they believe mandate ED evaluation but which other centers do not. The equality of outcome in the 2 groups of centers suggests this strategy is unjustified.
The lack of correlation between home syrup of ipecac use and referral reduction does not prove lack of benefit at some minimal level of home use. However, 8 of the 10 centers with the lowest referral rate had home ipecac use rates below the mean (1.8%) with 5 of the 10 below 1%. The fact that no center had a rate of home syrup of ipecac use below 0.2% to 0.3% may indicate that some low rate is beneficial but more likely suggests that the minimum level of use observed is related to parental action independent of poison center advice.
This study does not prove there are no combinations of substance and reported dose in which syrup of ipecac could be used at home to reduce symptoms or frequency of ED use. It does suggest such circumstances are rare and remain to be proven. There may be some pharmaceutical or possibly nonpharmaceutical (eg, mushrooms) exposure circumstances that meet the application criteria outlined. Nonpharmaceuticals were not evaluated in this study. However, poison centers recommended syrup of ipecac for nonpharmaceuticals in the same population even less frequently (0.68% of nonpharmaceutical cases in 2000–2001—statistic provided by T. L. Litovitz, MD, AAPCC Executive Director and TESS database manager, December 23, 2002). The most common nonpharmaceutical substances involved in exposures in this age group include: cosmetics and personal care products, cleaning substances, foreign bodies, plants, pesticides, arts/crafts/office supplies, and hydrocarbons.9 In the past many poison centers recommend emesis after plant exposure at home, but that has also changed in recent years.2 Importantly, even if a benefit were demonstrable in a limited set of pharmaceutical or nonpharmaceutical circumstances, such a limited application may not justify the place syrup of ipecac has held in injury prevention strategies.
A further reduction in ED visits after pediatric poison exposure is less likely to come from focused use of syrup of ipecac than from a greater understanding of the differences between poison centers revealed in this study and greater sharing of information about successful management strategies. Statistically, some variation in the frequency of high-risk exposures between poison centers is expected.14 But, the referral rate is unlikely to vary by the 15% observed given the large populations served and the relative homogeneity of the group selected for comparison (preschoolers, pharmaceutical agents, at home). There is no reason to expect geographic variation in the substance distribution and quantity of pharmaceuticals ingested. Most importantly, there is no reason to believe the preintervention outcome risk should vary systematically with tendency of a regional poison center to use syrup of ipecac. The range of exposure to high referral risk medications in the 1990 study varied by only 3% between the 7 centers (13.2%–16.4%).14 That difference is much smaller than the variation in referral rate observed in that group (range: 8.8%–20.1%) or in this study of 64 centers, 3% to 18%, suggesting variation in understanding risk, assessing risk, and accepting risk between poison center directors, ie, referral style, plays an important role. Lack of information about the success of alternative approaches leads to this style variation. Wider dissemination of practice and outcome by those centers with the lowest referral rates could safely reduce referrals at other centers.
Much has been achieved in safely reducing ED visits. It may be difficult to reduce visits further except by broader adoption of the proven restrictive referral strategies used by those centers with the lowest referral rates. Some exposures will always require ED assessment and there will always be some variation in the rate of precall risk. Parents may also oppose a further reduction in the referral rate. There is evidence in these data that some parents are uncomfortable with poison center recommendations for home management with or without home syrup of ipecac. Almost 2% of all callers self-referred their child to ED care. Of those originally calling from home and ultimately seen in an ED, 19.2% decided to go to an ED without a specific recommendation from the poison center to do so. It may be the poison center staff did not object to the decision, but this group was not listed as referred. It is likely that many parents call the poison center for initial recommendations already intending to go to an ED and will not be guided by a poison center.
These data suggest that it is time for the American Academy of Pediatrics to reevaluate its recommendation regarding syrup of ipecac in the home. If syrup of ipecac does not play a significant role in helping poison centers reduce ED visits, it is unlikely to play a significant role in injury prevention. In any case, syrup of ipecac only has a role in reducing injury and cost after a poison exposure occurs. Pediatrician anticipatory guidance time and effort may be better spent emphasizing primary injury and poison prevention strategies.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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This study suggests that there is no reduction in resource utilization or improvement in patient outcome from the use of syrup of ipecac at home. Although these data cannot exclude a benefit in a very limited set of poisonings, any benefit remains to be proven.
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ACKNOWLEDGMENTS |
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I wish to thank Robert Tamer, MPH, MPA, for his invaluable statistical assistance.
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FOOTNOTES |
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Received for publication Jan 31, 2003; Accepted Jun 9, 2003.
Address correspondence to G. Randall Bond, MD, Emergency Medicine ML 2008, 3333 Burnet Ave, Cincinnati, OH 45229. E-mail: randy.bond{at}cchmc.org
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics
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