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Toxicology Pearls · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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The Poison Center, which is a public health institution, so it's housed here.
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I'm Holly Wehmint, and this is Pediatrics Now, cases, updates,
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and discussions for the busy pediatric practitioner.
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Click on the link in this podcast for free credit that may include CME,
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MOC, or ethics credit, depending on our topic or podcast.
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Today, we're talking about toxicology pearls.
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Joining me here in the podcast studio is Robert Miller.
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Robert, you have a PharmD. So I'm a pharmacist by education.
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I've been in the toxicology world for the past eight years.
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You work for the Long School of Medicine here at UT Health San Antonio.
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Of course, the larger name here is the University of Texas at San Antonio.
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You have an important message for clinicians. There's a phone number that's
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important to call if they have a patient who's in trouble, and there can be
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a lot of benefits to the doctor calling.
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So, yeah, I work for the South Texas Poison Center. The phone number is 1-800-222-1222.
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That is the phone number for the, or really the Poison Center helpline,
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and this number is very useful to have.
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And in terms of for clinicians, there's a good reason to call where they can
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document this for a case and they can let their patient know,
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I just talked with the poison experts, or can you tell me more about that?
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We still get a substantial amount of phone calls from parents.
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However, it's pretty close to 50-50 these days in terms of calls from parents,
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but then also calls from triage nurses,
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physicians in the emergency department who have a patient in front of them with
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a toxic congestion that they're looking for guidance on.
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And we work at every other level too.
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Most of our calls will be the emergency department from the clinical perspective,
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but I also get calls all the time from school nurses, from pediatrician offices.
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Toxicology, we have a bit of a, when we're teaching and just from a didactic
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approach, sick or not sick. And that's kind of your first assessment.
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So if the patient is sick, we can walk you through what this is gonna look like.
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Length of stay, and obviously the not just supportive care, but the specific
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types of supportive care.
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Antidotal therapy, when it's indicated, when it's not indicated.
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And I can give you, for patients who come in and they're just completely asymptomatic
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and you're trying to figure out, you know, how long do I need to watch this patient for?
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We can try and give you some pretty good ballpark disposition information.
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You can reassure parents and say, look, we talked to the poison control center.
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Your child's going to be fine. Or I just got off the phone, poison control.
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This is the plan. Correct. Yeah. And from an emergency medicine perspective,
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this happens all the time.
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A lot of parents will just take their kids straight to the emergency room instead of calling us.
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And then so now it's the hospital staff that are calling us and we're giving guidance.
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And often, you know, because of EMTELA, I will never say, oh,
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they don't need to be in the ER. Just just kick them out.
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That's not how it works. Obviously, if they're in the emergency room,
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they get to be seen by a provider and evaluated.
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So we will never say, oh, you can just turn them away. You don't need to see
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them. They're totally fine. They still get assessed.
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But we can walk you through the process of trying to get them a very rational kind of disposition.
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And once again, let's say that the child, maybe they don't need to be in the emergency department.
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Maybe this is something that the phrase we often use is home observation is
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appropriate, but the parent is concerned and they need reassurance.
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You can provide them the case number that we gave you, and they are welcome
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to when they get back home, if they continue to have any questions or concerns,
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they can use that same case number.
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We'll be able to see the chart in the emergency room communication and can kind
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of provide that sort of continuity of care.
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And so it's confidential, but not necessarily anonymous. Exactly.
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Yeah. Confidential, but not anonymous.
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This really is similar to any other medical charting software.
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We have the same precautions and the same training in how we're handling protected
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health information, and we do take it seriously.
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Robert, you work closely with our emergency clinicians, and I can only imagine
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what it's like when you're working a
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A 10-hour shift and you're getting call after call of people who are panicked,
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probably. How do you do that?
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What is your strategy? I'm not rushing things along. There's no metrics.
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I am going to handle the call start to finish. I will say that I think we are
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very similar to pediatrics in that sense, and that a large part of our job is
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reassurance, and it is taking care of, you know, the child is our patient,
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but just as much to some degree, so is the parent.
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And we are once again trying to offer them up reassurance.
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There's a lot of strategies and things I've learned over the years as to how I approach that.
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I think some things parents appreciate hearing is that this is,
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you know, to them, this is a very unique situation.
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Most parents will comment that they, you know, oh, this is my first time calling,
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or I've only had to call once before for my other kid.
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But for us, you know, we typically end a shift with anywhere between 30 and
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40 calls. And so this is just business as usual.
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So often I will try and reassure parents by explaining, oh, no,
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this happens all the time.
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You know, kid gets into a Zyrtec. Kids get into Zyrtec all the time. Kid got into melatonin.
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Well, ever since they made it a gummy, kids love to get into it.
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Oh, my kid got into my medicine cabinet and he ate the whole bottle of Tums.
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Well, no, that's not your fault ever since they made it into a smooth berry
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flavor instead of tasting like chalk.
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Yeah, if kids get into one, they never get into one. They get into 30.
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And our listeners know very well, we're going through an epidemic right now
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of depression, anxiety, and adolescent self-harm. So.
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Let's start off with that, with these toxicology pearls.
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What is your advice there when it comes to things that kids could easily find
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around the house, such as Tylenol, Advil?
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Exactly. So I think that really sets the stage for, we're kind of very unique in that regard.
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You know, most people will see, or excuse me, most physicians will get into
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a specialty and they will see just a very wide range of demographics.
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Obviously, in pediatricians, the demographic is the specialty.
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And we're kind of like that, too. So there's kind of a there's an interesting
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sort of U-shaped curve where a very substantial amount of our call volume are
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what we call pediatric exploratory ingestion.
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So these are your children that are age zero through six that are crawling around,
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getting into stuff. And the median age is overwhelmingly two.
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The moment they start moving around, they are going to find things.
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And, you know, kids explore the world with their mouth.
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So if they find something, they will get into it. So it might sound a little
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bit trite, but probably the number one advice for this age range is just basic
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practices of keeping stuff up high, keeping stuff locked up.
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Be cautious about storing chemicals and things of that nature under the cabinet.
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Be cognizant of the fact that when your relatives visit, they might bring pill minders.
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So even if you're very careful, you know, they may not be. Especially grandparents.
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Grandparents in particular. And partly the issue is that for thinking about
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like a geriatric population, what medications are they on?
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They're frequently on anti-diabetic medications, blood pressure medicines, painkillers.
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And these are unfortunately a
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lot of the medications that do often send children to the emergency room.
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In contrast, if a child gets into a cholesterol drug, that usually we can keep
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something like that at home.
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When I have three kids, when they were younger, we had this rule that I would stress with them.
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If they find something that looks like a candy, piece of candy on the floor
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to come show it to me or wherever they find it, the couch or whatever.
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And if it is a candy that they could eat, they could eat it.
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But if no matter what, if it's a medication, then I will give them a piece of candy.
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And even just at a very young age, that did happen where there was a grandparent
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visiting and red pill had fallen out of the grandpa's pocket.
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And when one of the kids came up and showed it to me and I was so glad.
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So I don't know, does that sound like an OK strategy or?
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Well, you definitely hit on this is a fundamental just double edged sword with pediatrics.
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How do you convince kids to take medicine?
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And, you know, we take steps both both at the personal level as parents,
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but also on sort of a commercial level, you know, kind of going back to what
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I previously mentioned, you know, we make these things taste good.
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We make them look like candy to sort of coax kids into being more amenable to taking them.
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But that comes with the consequence that at that age, they cannot tell the difference
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between candy and pills.
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And so that can sort of complicate the issue.
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So what we typically recommend is, yeah, there's some specific context in which you have to use it.
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So it doesn't fit every single permutation of a toxic ingestion.
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But for most people with an acute acetaminophen ingestion within the past 24
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hours that present to the emergency room, we can do a pretty good job of assessing
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if they need or do not need the antidote.
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So the antidote is in acetylcysteine.
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If the child is having anxiety, depression, there's a risk of self-harm.
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Keep all medications locked up.
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Another thing that you encounter is something that happens because so many medications,
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as we know today, have so many different ingredients in them.
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Yeah, I will say that kind of gets to another core problem, kind of talking
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about acetaminophen in general. This is a very common situation I'll get.
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The parents bring their child into the emergency room and say,
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oh, they overdosed on ibuprofen.
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So we might be having a conversation with the physician on, oh,
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here's what to expect with that.
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Generally, I don't want to say well-tolerated, but let's just say it takes a
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substantially greater amount of ibuprofen to cause true toxicity relative to acetaminophen.
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And so I'll walk them through the process of getting the labs and watching them
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for a couple hours. And then the labs come back and they have a positive Tylenol level.
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And so, well, what's that happening? And then we go back and talk to the parent
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and we say, wait, so did they overdose on ibuprofen or did they overdose on Tylenol?
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And we'll get that, well, aren't they the same thing? And it's one of those
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things you kind of take for granted is when you're a healthcare worker,
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you recognize that aspirin and ibuprofen, naproxen and acetaminophen,
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these are all three distinct drugs.
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But for parents often it's just, well, that's the over-the-counter painkiller
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we have at home. They're all the same.
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So that happens a lot. One thing I'll also mention is there's this phenomena
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called the acetaminophen occult ingestion.
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And here's how this generally plays out is where the child is trying to hurt
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themselves, so they overdose on the Tylenol at home. It doesn't do anything.
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So they conclude that, oh, it didn't work. So now they overdose on,
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let's say, their prescription medicine. So just to grab an example,
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let's say it's their eschatolopram, so Lexapro.
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So the parents recognize that that's a problem.
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So they take them to the emergency room and, you know, we're working them up
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for the Lexapro overdose and we get that Tylenol level or we see their,
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or more realistically, if it's been greater than 24 hours, you might have a
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situation where the Tylenol level is undetectable.
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But now their liver enzymes are rising and we're trying to figure out what's going on.
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And then they finally disclose that they actually had overdosed on acetaminophen earlier.
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So we actually have pretty good data on this about somewhere in the ballpark
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of 3% to 5% of patients who present to the emergency room with a chief complaint
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of a toxic ingestion that is not acetaminophen will ultimately end up having
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a positive acetaminophen level.
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So if you're curious, this is why we are so adamant that if a psychiatric patient
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shows up to the emergency department with a toxic ingestion,
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we're going to recommend a Tylenol level just because it's easy to check and
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it can spare a ton of misery over the next 72 hours as opposed to if we miss it.
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And there are a lot of marijuana products out there that look like candy and
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probably taste really good.
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Let's talk about THC. Let's talk about THC. So THC is a very interesting substance.
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Obviously, it's been around pretty much forever.
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But over the past 10 to 15 years, it really has just exploded in popularity.
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And a particular inflection point happened in 2018. This was when the federal farm bill passed.
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So this is kind of a piece of omnibus legislation. It's just one of those things
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that every Congress has to pass to, you know, mostly what it's doing is keeping
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like farm subsidies going.
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However, in this particular 2018 version of the bill,
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it had an exception in which products that had less than 0.3% of THC and were
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hemp-derived were kind of legally allowed federally.
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And so it's an interesting kind of gray zone where technically marijuana is
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still schedule one, but this particular product,
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let me rephrase that, these products that were derived from that hemp at that
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certain percentage were legally allowed.
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This was really the catalyst that caused this explosion of why there's a vape
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shop on every corner, basically.
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I'm sure anyone who's driving around Texas has observed this phenomena.
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The problem is that these products, they're generally intended for what we would
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call like the experienced marijuana user.
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You know, these are people who know what dose gets them their desired effect.
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And most people would traditionally be smoking marijuana, which kind of is self-titrating, right?
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They smoke to a desired effect and then they stop smoking.
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However, for most users that do not want to smoke, they have turned to edibles.
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And edibles present a pretty unique risk profile for children for multiple reasons.
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You know, one is kind of what we already talked about. These products are intended,
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and this is not an accident, like they look like candy.
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And more concerning is that they're explicitly marketed as candy in some context.
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They may obviously have warning signs and symbols all over them.
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What does that mean if you're a two-year-old, of course, right?
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So parents may be able to read that and understand some precautions.
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But if kids find them and they look like candy, they will eat them.
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The main problem with edibles, of course, is that there's two issues.
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One is kind of a pharmacokinetic issue, right?
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Once again, you smoke, you get a desired effect, you stop. With edibles,
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you may not see the inebriation for two or three hours.
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And so this applies to both adults that are trying it for the first time,
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but also for our kids that are just accidentally getting into it.
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They may eat one, they may eat two, they may eat ten. Thank you.
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And eventually, they're going to get that entire dose. It may be in a delayed
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fashion, but it may be a substantially greater dose than what they can tolerate.
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Obviously, in a two-year-old, any dose is going to be intolerable.
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But even, quote-unquote, experienced users may be taken for a surprise.
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And so this is why you're seeing this kind of substantial explosion of this
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sort of alphabet soup of THC products.
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Most people are familiar with THC, but unless you work in toxicology and you
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see these ingestions or you're a user, then you may not recognize Delta-8,
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Delta-9, Delta-10, THCA, THCP, et cetera, et cetera.
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And while there are some potency differences, and I don't want to say there's
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absolutely no qualitative difference between them, that that's not entirely correct,
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at the end of the day, from a pediatric perspective, all of them can be potentially
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inebriating for a child.
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And marijuana products, marijuana itself is much stronger today.
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Yeah, that's correct. You know, generally the people who were making marijuana,
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but, you know, growing the plants, cultivating it, selling it,
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the stuff that would kind of come in from overseas, it was relatively weak in a modern sense.
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You know, your kind of person who's at Woodstock and smoking a blunt,
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that may have been like 5% THC back in the day. These days, this really is like
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an enthusiast industry.
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These people are obsessed with getting these concentrations as high as possible.
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They're looking for a certain experience. And so these products,
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not only is this concerning for just the pediatric exposure,
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but I even run into this with adults too.
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A 50-year-old who has never tried marijuana before, or maybe they tried it as
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a teenager, might go to the gas station and see one of these products. Yeah.
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So they may find one of these products and try it for the first time.
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And, you know, spoiler alert, a 30 milligram dose is not a really smart idea
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for someone who is completely naive to these products.
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So even adults can be really surprised at the magnitude of inebriation they
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can end up experiencing.
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And it can't be good for the brain. Yeah, that's another concern,
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too, is there's obviously a very large debate about this,
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and I won't pretend that it is necessarily settled science, but epidemiologically,
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it's becoming pretty clear that these adolescents who,
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the earlier they start smoking, and obviously there's a cumulative dose effect,
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that it does seem to be linked to psychosis, psychosis,
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especially if there's any kind of either direct history or family history of
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psychiatric illness, it does seem to just substantially increase their risk
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that as they move on to young adulthood and as an adult,
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there'll be higher risk for things like schizophrenia,
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anxiety, depression, etc.
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And so many medications and come in gummies, gummy form now.
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I remember even like prenatal vitamins in gummy form. Like if my toddler at
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the time got into that, that could be disastrous.
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But when it comes to a THC gummy, I just can't even imagine.
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What do you do if a child ingests a gummy or gummies?
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Exactly. And this is what kind of gets to the heart of the matter.
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Someone might kind of naively, because in adults, it really isn't a big deal. most of the time.
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And I'm trying, I don't intend to be tried or anything like that.
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But as long as there's no fall risk or risk of secondary accident,
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most adults are not going to seize or have airway issues or a cardiac dysrhythmia.
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It's just not going to happen at any reasonable dose in an adult as far as we can tell.
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But this kind of gets into a classic problem of just, you know,
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children are not small adults.
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Their CB1 receptors are fundamentally different and they do seem more sensitive to it.
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So, you know, don't get me wrong, your kid who gets into a single edible most
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likely will be okay with just clinical observation. They probably won't need
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substantial interventions or anything of that nature.
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However, these kids who, you know, get the 400 milligram thing that looks like
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a nerd rope and down the whole thing, we actually do see children who have airway
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issues, dysrhythmias, seizures.
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So they are just categorically different. And once again, And because these
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are edible products, they can have substantially longer half-lives than the
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pyrolyzed marijuana products.
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And so these children may have a length of stay of sometimes as long as three days.
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And then is there anything you want to say about the process of helping the child to survive?
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But we very rarely will go to stomach pumping just because by the time the child's
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presenting to the ER, most likely that that risk is passed.
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And, you know, with a child who's coming in and already kind of attended and at risk for a seizure,
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we would be really concerned about being really aggressive with gastric lavage
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just because unless the airway is protected, you really are introducing an aspiration risk.
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So the care is symptomatic and supportive at the end of the day.
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I will say from a disposition perspective, what we've kind of observed is generally,
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assuming the child is ambulatory to begin with, ambulatory status is kind of
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the first thing to go and the last thing to come back.
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So that can be kind of valuable to a clinician who's assessing,
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you know, is this child sick and when is this child ready to go home?
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Anything else, Robert, you want to say about THC and the products out there
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for the pediatrician or the parent?
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So it was kind of interesting. There was a toxicology conference where we actually
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did have one of the, and I apologize, I don't remember his name,
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but one of the big wigs of kind of the,
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let's call it the Colorado cannabis industry came and kind of talked to us.
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It was interesting to see because people were really just kind of grilling this
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guy with questions, but he made a comment that, look,
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you know, if you are using these products at home, you absolutely should have
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a lockbox, and they should be in that lockbox, no exceptions.
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And, you know, you can definitely kind of push back and say that,
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no, you know, you as an industry have some responsibility for this,
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and you really should be changing the packaging.
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I think you kind of have to accept the reality that unless there's legislation
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forcing them to do this, they're probably not going to voluntarily do anything
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to kind of stop this situation.
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So while I kind of understand why people were very critical of him.
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Ultimately, he's not wrong. I actually do agree with that. If you are using
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these products, you absolutely need to have a lockbox.
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Okay. And that's great advice. And then I know we're going to talk in a minute
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about Zen pouches, which I didn't even know what that was until over spring
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break when my son told me a relative we were with was taking them on the ski slopes.
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Zen pouches, so that's, it has a delayed response.
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Can you tell us about this? Yeah, so Zen pouches are becoming very popular,
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and they also have kind of introduced a unique concern for pediatrics.
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So most of your typical nicotine products, well, one, you have to kind of differentiate,
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you know, is this a tobacco product or is this a straight nicotine product.
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And in both of these situations, traditionally, they've kind of been self-limiting.
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Like, it doesn't take that much nicotine for a child to develop nicotine toxicity.
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What are Zen pouches? Is it nicotine?
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So there's no tobacco in a Zen pouch. It's nicotine only? Yeah, exactly.
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Correct, yeah. So your typical nicotine products are kind of divided into the
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kind of what we would call straight nicotine products.
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So these are things like a lot of smoking cessation aids, right?
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So you go and buy the nicotine gum, the nicotine lozenge, and then you have
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all your tobacco products, of course.
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Snuff, dip, cigarettes, of course.
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The other major nicotine player these days, of course, are the vaping products.
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Both the kind of refillable ones with nicotine solution, but also what's kind
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of becoming the predominant one there are the disposable vapes you can buy at
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the gas stations and things of that nature.
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What makes Zinn unique is that this is a pouch that you kind of insert into
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your mouth and kind of just keep there either under the tongue or kind of bucally
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in general, and it will absorb the nicotine.
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And these are unique because this is not a tobacco product. This is straight nicotine.
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And so this has kind of introduced a risk for children for a very specific reason,
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and that has to do with the kind of delayed absorption aspect of it.
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So kids frequently get into nicotine, and while it's very dangerous,
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you know, it only takes about 20 milligrams, and children really can have like
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full-blown nicotine toxicity,
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with fasciculations and airway problems because their accessory muscles are getting weak.
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Yeah. So essentially what I'm concerned about is, you know, children having tremors.
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Nicotine is kind of what we would call biphasic in the sense that it starts
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kind of stimulatory, but then their muscles essentially just fire to a point
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where they get very rapidly fatigued after that sort of stimulant period.
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And that's when they start turning in. So what I would generally tell a parent
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is what I'm mostly concerned about sort of a floppy baby kind of situation, this hypotonia.
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So how much, again, can you stress like in a Zen pouch if a child ingests can be dangerous?
25:57
Yeah. So what makes Zen, yeah, basically any amount.
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And the reason for that is you might look at the Zen pouch and not think much
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of it because it's quote unquote only three to six milligrams of nicotine.
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Whereas in contrast, a cigarette can have quite a bit more than that.
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But you start getting into finer details of pharmacokinetics.
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So if a child ingests a cigarette, it's kind of gross.
26:22
But at the same time, like when you think about how much nicotine in that tobacco
26:26
is bioavailable, kids ultimately only end up getting a couple of milligrams.
26:30
And usually it'll be what we consider sort of self-limited.
26:35
So the child will pretty much guarantee to get some an emetic effect from it.
26:40
And they'll generally kind of puke it up before it's a problem.
26:42
So one of those exposures that in theory is very serious, but it's actually
26:47
pretty infrequent that we have to send them into the emergency room.
26:50
The Zen pouch becomes really problematic because it's sort of bypassing that issue, right?
26:57
So because it's nicotine in this pouch and the child swallows it,
27:02
what they've done is they've essentially swallowed an extended release nicotine product.
27:07
So it's going to get past the stomach, it's going to go into their bowels,
27:11
and there it's going to absorb.
27:14
So yes, it's quote-unquote only three to six milligrams, but the child is often
27:18
getting the full burden of that nicotine dose, whereas more pragmatically in
27:23
other contexts, they might have a much more limited exposure.
27:26
And the emetic effect might not be as pronounced, so their ability to quote-unquote
27:31
self-decontaminate is limited as well.
27:34
And the parents may not even, what I've had very frequently happening is the
27:38
kids like digging into the trash or finding these used Zen pouches, excuse me.
27:44
And what's concerning is you might think, well, they're used up,
27:48
but you're not absorbing every bit of the nicotine.
27:52
So even the used pouches still have some nicotine content.
27:56
What's the appeal with the Zen pouches? I think, so I'm not personally a user,
28:01
so I won't try and give like a subjective answer.
28:04
Yes, I would have been very worried if you said you were Zen pouches.
28:07
My understanding is just that, well, one, they're frequently flavored.
28:12
So people tend to like that.
28:14
And I think also just like, once again, they are straight nicotine.
28:19
So if you think of all the, a lot of the cancer risk and things like that stem
28:24
primarily from the tobacco product.
28:26
So let's say like if you're using snuff, you know, there is a risk of oral cancer
28:30
that's pretty uncontroversial.
28:33
Not to say that we don't have a ton of evidence that these Zen pouches are safe
28:36
necessarily, but they're not tobacco. So a lot of your more traditional risk
28:41
factors in theory may be lower. So I think that's part of the popularity.
28:46
I also think it's a little bit of like a Kardashian effect. like they're popular
28:49
because they are popular.
28:51
But nicotine can't be good for us, right?
28:55
Yeah. I mean, often people will say, well, nicotine itself is harmless,
28:59
but go ask any vascular surgeon and they will disagree with you.
29:04
That said, you know, it's kind of a risk like we talked a lot about marijuana
29:08
and, you know, that obviously always triggers a very large debate of marijuana versus alcohol.
29:14
And it's kind of like at the end of the day, yeah, some of this societal burden
29:20
of these substances are pretty gargantuan.
29:23
But when you get into the specifics of like which one is worse and which one
29:26
is better, you know, it's all going to be very context dependent.
29:30
And again, it's something that's flavored, so it could be really attractive
29:34
to a child who finds it. Exactly.
29:36
And dangerous. Kratom. Kratom. What is kratom and what's the concern there?
29:42
So kratom is kind of an interesting substance. This is a plant that's had a
29:47
very interesting history in the past 20 years.
29:50
So this is a plant from Southeast Asia.
29:53
And originally, so it's a very interesting pharmacologically,
29:58
this is an atypical opioid, which you just don't run into that much.
30:03
There's a few synthetic ones like tramadol, but as far as naturally occurring
30:07
ones, there really aren't too many.
30:09
So this is kind of a unique drug in that context. And Kratom has had very much
30:13
a transition period where originally Kratom was being used primarily by adults
30:19
who were suffering from opioid addiction.
30:22
And this was essentially their way of trying to do medication-assisted therapy
30:27
or what we would call MOUD these days.
30:31
You know, trying to stave off that Kratom withdrawal while they try and get
30:35
off their fentanyl or their prescription opioids.
30:39
That has kind of transitioned into several interesting phenomena.
30:43
One is that, yes, I don't want to say it's effective because we don't have any
30:50
RCTs, obviously, randomized controlled trials.
30:54
So no one is really doing any kind of evidence-based assessment of this as an
30:59
opioid alternative. Mm-hmm.
31:02
That being said, you know, just talking to patients and looking at kind of forums
31:07
where people discuss using Kratom, it's very clear that Kratom itself has some addictive properties.
31:13
And so, you know, kind of the traditional accusation against MAT or medication-assisted
31:19
therapy, excuse me, is, well, isn't the patient just replacing one addiction with the other?
31:23
And that kind of happens with Kratom too.
31:26
You know, this is not really physician-supervised in most contexts,
31:29
and so that's kind of been a problem. But what's really happened is Kratom has
31:34
kind of also emerged in this sort of gray, you know, legal but not legal kind of drug scene.
31:40
And so it's kind of transitioned to if you were an opioid user and you learned
31:45
about Kratom, it was a very kind of under the table thing. You learned about it.
31:49
You knew to ask for it. It was kind of a behind the counter thing.
31:52
And that's really changed in the very recent history where now like everyone's
31:57
familiar with this and it's kind of becoming more just like a general recreational
32:01
drug and that's concerning for multiple reasons.
32:05
One is it is an opioid but it's an atypical opioid and as far as we can tell
32:10
it's a bit controversial if this drug causes seizures or if it's kind of simply
32:15
lowering the seizure threshold and so other risk factors are necessary for that to manifest.
32:20
But regardless, you do have patients showing up to the emergency room with seizures.
32:24
Obviously, the reason I'm bringing this up is, you know, from a pediatric toxicology
32:29
perspective, we now have the phenomenon of parents have this product in their
32:33
home and their kids are getting into it because they can't tell the difference.
32:38
Of course, once again, they typically don't look explicitly like candy,
32:42
but they are in sort of an edible.
32:45
They often don't look like pills either. So that can be a problem as far as pediatric exposure.
32:51
And when they come in, they actually, they can have seizures and we also,
32:55
you know, it can also function like a more classic opioid in kind of children.
32:59
And so we do see some respiratory depression as well.
33:02
There's also been a very increasing incidence of adolescents that are using it.
33:07
You know, this is sort of a, this is very popular right now on social media
33:11
and Instagram. So, same basic principle.
33:14
If you have a teenager, they may be very tempted to kind of start this stuff.
33:19
And once again, you know, there's really no doubt here that there are addictive qualities to it.
33:24
And so, you know, if you have a child who's using it, it is something to seek medical advice about.
33:30
And can you tell us about the harm it could be causing you?
33:34
So as far as longitudinal risk, I think that is still to be determined at this time.
33:39
Acutely, it does go back to just that very basic pharmacology,
33:43
just atypical opioid with a risk of seizures and with a risk of airway depression
33:49
if they use too much of it.
33:50
Well, Robert, this is all so insightful. I really appreciate you being here
33:55
in the podcast studio and talking about what you see on a day in, day out basis.
34:02
Right now, the 1-800 number for the Poison Center, it might be moved to a three
34:10
number like 911, but that hasn't happened yet.
34:13
Exactly. So as of right now, the phone number is 1-800-222-1222.
34:19
We would love to transition to a sort of three-digit number,
34:22
so to speak, but there's some logistical issues, and you do have to have some
34:27
legislative involvement for that to happen. And so it's something we're working on.
34:30
But unfortunately, I don't have a time frame at the moment.
34:35
And Robert, I know you said that you're working on studying for your board exams.
34:40
So there's not a lot of things you're doing outside of the world of medicine.
34:43
But you have a favorite quote.
34:45
So my favorite quote is by H.L. Mencken.
34:48
And this is me paraphrasing it. Originally, it has a slightly different connotation.
34:54
But essentially, it's this idea that, you know, for every complex problem in
34:58
the world, there's always a solution that's simple, elegant, and wrong.
35:04
And I think that a lot about, that quote comes to mind a lot when we talk about medicine.
35:10
Robert Miller with the Department of Emergency Medicine and the South Texas
35:15
Poison Center in UT Health San Antonio.
35:17
Thank you so much for being here today on Pediatrics Now. Been really insightful.
35:23
Yeah, thank you so much. Pediatrics Now is brought to you by the Department
35:26
of Pediatrics at UT Health San Antonio and University Health's new Women's and Children's Hospital.
35:34
Don't forget to click on the link in this podcast for free credit.
35:39
I'm Holly Wayment. I'll see you next week. And so one thing I really want to
35:44
stress is, you know, when you call a poison sinner, you talk to a human being.
35:48
You know, there's no robots. There's no artificial intelligence.
35:51
There's no complicated phone tree standing between you and answer.
35:56
You really just talk to another person.