Pediatric Ethanol Toxicity Clinical Presentation

Ethanol intoxication is often difficult to diagnose in young children and toddlers. Important questions to ask parents include the following:

• Was a source of ethanol easily available to the child? For instance, was an open alcoholic drink left out after a party?
• Is the alcohol in the house locked up? Are alcoholic beverages in a place that the child can easily reach?
• Is the child taking any over-the-counter medications that might contain alcohol, such as cough and cold medications?
• Could older siblings in the house have given the child alcohol?
• Did the parents give the child an alcohol bath?
• Did the child drink an ethanol-containing substance (eg, perfume, cleaning fluids) not meant to be ingested?

If ingestion is known or suspected, determining exactly what and how much the patient ingested is important. The name, composition, and concentration of the alcohol are helpful. Be aware that patients often grossly underestimate the amount of ethanol that they ingested.

In cases where parents bring in a young child who has ingested an unknown amount, have the parents estimate how much was in the container and subtract that amount from the total volume of the container to estimate the amount ingested or possibly ingested.

The amount of ethanol in a product is often expressed as a percentage, which is the ratio of the volume of pure ethanol to the total volume of fluid. The formula for determining the percentage of ethanol is as follows:

                                           X% = X g/100 mL

The concentration of ethanol in distilled spirits may be expressed as a proof, which is equal to twice the percentage of ethanol.

Ethanol concentrations in some common substances are as follows:

• Liquid cold remedies, 2-25%
• Mouthwashes, 7-27%
• Rubbing alcohol, usually 70% (although most commonly, rubbing alcohol contains isopropanol)
• Aftershave lotions, 15-80%
• Perfumes and colognes, 25-95%

Other toxic alcohols are also often found in these products, such as methanol in perfume or cologne. Be aware of the other substances in the ingested fluid that may be toxins.

Ethanol concentrations in some common alcoholic beverages are as follows:

• Whiskey, 40-60%
• Liqueurs, 22-50%
• Wine, 8-16%
• Beer, 3-7%

Obtain a history from the emergency medical services (EMS) personnel, parents, relatives, or anyone else who accompanied the patient to the hospital.  Because of potential legal implications in the United States, pediatric patients are often evasive in stating their history of possible ingestion. Outside the United States, ethanol consumption by children is often more culturally acceptable and less stigmatized.

Adolescents often present to the emergency department (ED) with acute illness or decreased mental status. Often, these patients do not admit to their use of alcohol. Assess for a history of possible ethanol use in all patients who present to the ED with an altered mental status. Because ethanol predisposes patients to other causes of altered mental status (eg, trauma), consider the other causes as well.

A positive family history of alcohol abuse is significant because children of parents with alcoholism have a 2-fold to 4-fold increased risk of alcoholism.

 

Infants and toddlers have a clinical course significantly different from that of adolescents and adults. Ethanol ingestion and intoxication can lead to a marked hypoglycemic state in infants and young children. Ethanol has a CNS depressant action that can also lead to respiratory depression and hypoxia. Ethanol has a sedative effect, producing general CNS depression, respiratory depression, and often hypoglycemia. Young children often present to the ED after drinking discarded alcoholic beverages left within their reach during and after parties or after ingesting a fluid that contains ethanol. In older children and adolescents, ethanol intoxication causes CNS depression, leading to respiratory depression. Hypoglycemia is less common in this group.

As with all patients, a careful physical examination is warranted. In patients in whom ethanol ingestion is suspected, carefully evaluate his or her mental status and perform a thorough neurologic examination. Evaluate for signs of trauma, neglect, and illicit drug use. Ethanol ingestion makes the patient more prone to trauma due to accidents or crime. The clinician's most crucial clues to ethanol ingestion are a change in the patient's mental status and the smell of alcohol on the patient's breath. The presence or absence of ethanol on breath cannot be used to diagnose or exclude ethanol intoxication.

Compared with nonintoxicated teenagers, intoxicated teenagers are much more likely to be affected by violence, even after drinking only one alcoholic beverage. Recent reports describe the use of sedatives with alcohol to create date-rape drug combinations. Therefore, possible sexual assault should be considered in teenaged patients.

Young children commonly ingest ethanol when they drink a liquid not meant for consumption, such as perfume or cleaning agents. Frequently, other chemicals in the ingested substance are more toxic than the ethanol. Therefore, a detailed physical examination is important to evaluate for any signs and symptoms caused by these other toxins. Also, give special attention to the examination of the oral cavity and airway because substances in cleaning agents can cause chemical burns to these areas.

In children, the classic triad of signs of ethanol intoxication includes coma, hypoglycemia, and hypothermia. These signs usually occur when the Ethanol level in the blood exceeds 50-100 mg/dL. However, hypoglycemia can be seen with serum Ethanol levels as low as 50 mg/dL. Relatively small amounts of ethanol can produce hypoglycemia, especially in patients with low glycogen stores, such as infants and small children who have not eaten for several hours.

Acute ethanol intoxication can cause the following:

• CNS depression
• Mild vasodilatation leading to a modest decrease in blood pressure
• Flushed skin
• Urticaria  ^[14]
• Inhibition of spermatogenesis
• Hypothermia
• Tachycardia
• Myocardial depression
• Variable pupillary response
• Respiratory depression
• Decreased pulmonary secretion clearance
• Decreased sensitivity to airway foreign body
• Diuresis
• Loss of behavior inhibitions
• Hypoglycemia
• Loss of fine motor control
• High doses of ethanol can cause the following:
• Loss of gross muscle control (ataxia, slurred speech)
• Acute pancreatitis
• Severe myocardial depression
• Hypotension
• Atrial fibrillation
• Lactic acidosis
• Congestive heart failure
• Pulmonary edema
• Arrhythmias
• Cardiovascular collapse
• Sudden death

Chronic ethanol use can lead to the following:

• Fetal alcohol syndrome
• Chronic pancreatitis
• Hepatic dysfunction
• Hematologic disorders
• Numerous electrolyte abnormalities
• Hypertension
• Cardiomyopathy
• Malnutrition
• Obesity