Pediatric Organophosphates Toxicity Clinical Presentation

  • Author: William Freudenthal, MD; Chief Editor: Timothy E Corden, MD  more...
Updated: Sep 07, 2015


See the list below:

  • Most symptoms appear within 12-24 hours of exposure.
  • Exposure can occur by means of ingestion, dermal exposure, or inhalation.
  • Children often ingest home pesticides they find in unmarked or poorly stored containers.
  • Children can also be exposed when playing in areas recently treated with organophosphate compounds.
  • A history of possible exposure combined with physical signs and symptoms consistent with exposure often lead to diagnosis.
  • Many organophosphates can irritate the skin and mucous membranes. Some have a characteristic odor, such as a garliclike smell.


Physical findings vary according to the route of exposure, the age of patient, and the specific chemical.

  • Muscarinic findings may include the following:[7]
    • Diaphoresis and diarrhea, urination, miosis, bradycardia, bronchorrhea, bronchospasm, emesis, lacrimation and salivation (DUMBELS)
    • Wheezing and/or bronchoconstriction
    • Pulmonary edema
    • Increased pulmonary and oropharyngeal secretions
    • Sweating
    • Bradycardia
    • Abdominal cramping and intestinal hypermotility
    • Miosis
  • Nicotinic findings may include the following:
    • Muscle fasciculations (twitching)
    • Fatigue
    • Paralysis
    • Respiratory muscle weakness
    • Diminished respiratory effort
    • Tachycardia
    • Hypertension
  • CNS findings may include the following:
    • Anxiety
    • Restlessness
    • Confusion
    • Headache
    • Slurred speech
    • Ataxia
    • Seizures
    • Coma
    • Central respiratory paralysis
    • Altered level of consciousness and/or hypotonia
  • Predominant symptoms and signs vary according to the age of the affected person. Children, particularly young children, present with altered levels of consciousness rather than the classic DUMBELS signs that are most commonly observed in adults.
    • Zwiener and Ginsburg (1988) retrospectively examined 37 patients aged 1 month to 11 years who had been exposed to insecticides.[8] The most common signs were miosis, excessive salivation, muscle weakness, and lethargy. Approximately 49% of these children presented with tachycardia.
    • Lifshitz et al (1999) retrospectively examined 36 children aged 2-8 years who were exposed to organophosphates or carbamates in Israel.[9] The authors observed a decreased level of consciousness, including coma, stupor, and hypotonicity in all children.
    • Lima and Reis (1995) reported carbamate poisoning in Rio de Janeiro.[10] Symptoms included salivation, lacrimation, urination, defecation, GI distress, and emesis (SLUDGE) and were more commonly observed in adults than in children.
    • Sofer et al (1989) retrospectively examined 25 patients aged 3 months to 7 years with carbamate or organophosphate poisoning in Israel.[11] The most common presenting symptoms were CNS depression, stupor, coma, and flaccidity. The classic SLUDGE symptoms were more likely to be absent in these children.


Exposure to organophosphates through the skin, mucous membranes, conjunctiva, GI tract, or respiratory systems is the cause of organophosphate toxicity.

Other diagnostic considerations include the following:

  • Toxicity due to various poisons, such as carbamates, phosgene, paraquat,[12] and nerve agents, can cause symptoms similar to those of organophosphates.
  • In young children, suspect organophosphate poisoning if they have any illness that depresses the level of consciousness.
Contributor Information and Disclosures

William Freudenthal, MD Staff Physician, Department of Emergency Medicine, St. Vincent Hospital Indianapolis, IN

William Freudenthal, MD is a member of the following medical societies: American College of Emergency Physicians, Association of Military Surgeons of the US

Disclosure: Nothing to disclose.


Mark E Ralston, MD, MPH Staff Pediatrician, Naval Hospital Oak Harbor; Assistant Professor of Pediatrics, F Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences

Mark E Ralston, MD, MPH is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Jeffrey R Tucker, MD Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut School of Medicine, Connecticut Children's Medical Center

Disclosure: Received salary from Merck for employment.

Chief Editor

Timothy E Corden, MD Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, Wisconsin Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

Michael E Mullins, MD Assistant Professor, Division of Emergency Medicine, Washington University in St Louis School of Medicine; Attending Physician, Emergency Department, Barnes-Jewish Hospital

Michael E Mullins, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians

Disclosure: Received stock ownership from Johnson & Johnson for none; Received stock ownership from Savient Pharmaceuticals for none.

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