Pediatric Ethanol Toxicity Treatment & Management

The mainstay of treatment of patients with ethanol toxicity is supportive care. Many modalities for treating ethanol intoxication and enhancing ethanol clearance have been attempted. In general, a conservative approach is recommended.

Hypoglycemia and respiratory depression are the 2 most immediate life-threatening complications that result from ethanol intoxication in children.

Initial care includes the following:

• Assess the airway. If necessary, secure the airway with an endotracheal (ET) tube if the patient is not maintaining good ventilation or if a significant risk of aspiration is observed. Provide respiratory support and mechanical ventilation if needed.

• Obtain intravenous (IV) access and replace any fluid deficit or use a maintenance fluid infusion. Use plasma expanders and vasopressors to treat hypotension, if present.

• Ensure that the patient maintains a normal body temperature.

• Quickly correct hypoglycemia. In children, 2-4 mL/kg of 25% dextrose solution is usually administered. A maintenance infusion of dextrose-containing IV fluids is often required. Note that this treatment does not clear ethanol from the blood

• Correct any electrolyte abnormalities found with laboratory studies. Routine empiric electrolyte replacement is not helpful; only documented electrolytic abnormalities should be corrected.

• If the ingestion occurred within 1 hour of presentation, placing a nasogastric tube and evacuating the stomach contents can be helpful.

• In patients with chronic ethanol abuse, administer thiamine 100 mg IV/intramuscularly (IM) to prevent neurologic injury.

• Additional care: If other substances have been co-ingested, initiate specific treatment for those substances, if available. For instance, naloxone can be used to reverse respiratory depression if opiate co-ingestion is suspected.

Treatments that are not recommended include the following:

• The administration of medications to cause emesis is not recommended because of the rapid onset of central nervous system (CNS) depression and risk of aspiration.

• The administration of activated charcoal is not recommended for isolated alcohol ingestions because it does not bind hydrocarbons or alcohols. If the clinician suspects a concomitant ingestion of other toxic products, activated charcoal may be effective in absorbing these toxins.

• Forced diuresis is not helpful because 90% of ethanol metabolism occurs in the liver, and only 10% of the ethanol load is secreted in the urine.

• Gamma aminobutyric acid (GABA) receptor antagonists such as naloxone and flumazenil have little effect on the CNS or respiratory depression caused by ethanol; their use is not recommended in isolated ethanol intoxication.

• Fructose infusion can increase the ethanol clearance by 25%. However, the use of fructose is not recommended because significant adverse effects may occur, such as lactic acidosis, severe osmotic diuresis, and GI symptoms

• The effects of insulin, glucose, caffeine, and several other medications have been studied, but none consistently increases ethanol metabolism or alleviate CNS depression.

Hemodialysis efficiently clears ethanol from the blood but is an invasive procedure; thus, its use is not routinely recommended. Hemodialysis can be used in patients whose clinical condition is deteriorating or in patients whose CNS depression, respiratory depression, or hypotension is refractory to standard therapy. Patients who have impaired hepatic function may require dialysis to clear an ethanol load.

Indications for hospital admission include the following:

• Presence of hypoglycemia
• Suspected neglect or inadequate social support at home
• Unstable home environment or unreliable caregiver at home
• Presence of focal neurologic signs
• Need for supportive care

Inpatient care includes observation of the patient with ethanol toxicity until his or her mental status has returned to normal. Monitor the patient's blood glucose level until it is stable and is within the normal range. Correct any electrolytic disturbances. Watch for signs of ethanol withdrawal in patients who have abused alcohol for several years: Sympathetic discharge, tremor, and tongue fasciculations are typical; hallucinations may occur; seizures are possible. Thiamine administered daily on an inpatient basis is recommended in patients who have chronically abused ethanol. The length of therapy is well documented.

Pediatric intensive care unit (PICU) monitoring is recommended in all patients who have continuing CNS or respiratory depression. Children requiring PICU monitoring, respiratory or cardiovascular support should be transferred to a facility with the appropriate resources. Patients who chronically abuse alcohol should be referred to an outpatient treatment group. Family counseling is also helpful.9 Patients who had an unintentional ingestion may follow up with their primary pediatrician. A safe home environment must be emphasized.

Contact the regional or local poison control center for treatment guidance and reporting purposes. Consider consulting social services personnel in all cases of ethanol intoxication in children. Patients who chronically abuse alcohol may have serious nutritional deficiencies and may require a consultation with a nutritionist on an inpatient basis.

If no specific electrolyte abnormalities are present, the patient should maintain a healthy well-balanced diet. All electrolytic disturbances should be corrected prior to discharge from the hospital.

The U.S. Preventive Services Task Force (USPSTF) concluded in 2018 that current evidence is insufficient to assess the balance of benefits and harms of screening and brief behavioral counseling interventions for alcohol use in primary care settings in adolescents aged 12 to 17 years. ^[15]  However, the American Academy of Pediatrics recommends screening all adolescent patients for alcohol use with a formal, validated screening tool (such as the CRAFFT) at every health supervision visit and appropriate acute care visits, and responding to screening results with the appropriate brief intervention and referral if indicated. Pediatricians should become familiar with adolescent SBIRT approaches and their potential for incorporation into universal screening and comprehensive care of adolescents in the medical home. ^[16]

WIth adolescents, preventive measures include the following:

• Areas where alcoholic beverages are stored should be kept locked.
• Have the parents or pediatrician talk to the patient about his or her experiences with alcohol and about the dangers of alcohol consumption.

With toddlers or young children, preventive measures include the following:

• Keep all ethanol-containing fluids (eg, perfumes, aftershaves, colognes) out of the reach of young children.
• Do not leave unfinished alcoholic beverages unattended, especially during and after parties.
• Keep alcoholic beverages stored in locked cabinets and out of the reach of the children.