Paediatrics — Poisoning, Injury and Child Protection, NMC MBBS licence examination syllabus (Nepal Medical Council).
Two questions run through this chapter: what did the child take, and does the injury match the story you were given?
Small children swallow things. Most of those exposures are harmless, a few are not, and the ones that are not often look harmless at first. Running alongside every childhood injury is a second question that is easy to leave unasked — and the exam asks it deliberately.
The assessment does not change because a poison is suspected. Airway, breathing, circulation — and check the blood glucose in any drowsy child, because hypoglycaemia is common, imitates almost anything, and is correctable in seconds.
Specific antidotes exist for only a minority of substances. The great majority of ingestions are managed with supportive care and observation, and good supportive care saves more children than antidotes do.
Do not work from remembered doses or toxic thresholds. Strengths and preparations differ, a threshold applied to the wrong formulation is worse than no threshold at all, and a poisons service or current chart is available. Knowing to look it up is the correct answer.What, how much, when — and who else.
Ask for the container to be brought in. A parent's description of "a syrup" or "a white tablet" is not an identification, and the strength changes the assessment entirely.
Assume the worst case for both amount and timing: count what is missing from the container rather than relying on what a frightened child admits to, and if the timing is uncertain assume the earliest possible.
Some poisons have a silent interval. The child remains well for hours while damage accumulates, and deteriorates later. This is why "he seems fine" is never sufficient grounds for discharge until the substance itself has been checked — the reassuring examination and the dangerous ingestion are entirely compatible.
Corrosives: do not make the child vomit. The substance burns the oesophagus a second time on the way back up, converting one injury into two.
Kerosene and other fuels: the danger is aspiration into the lungs rather than absorption from the gut. Vomiting is what makes that happen, so it must not be induced. Watch for cough, breathlessness and hypoxia.
Certain features should raise a concern about how an injury was sustained.
The history does not explain the injury, or it changes between tellings or between family members. An injury the child is not yet capable of causing — bruising in a baby who cannot roll, crawl or walk is the classic example, because a child who cannot move cannot injure themselves. Delayed presentation, injuries of visibly different ages, injuries in protected sites, patterns suggesting an implement, and repeated attendances.
Neglect is easier to miss than injury and is just as serious: missed appointments, untreated conditions, faltering growth, a child who is consistently inadequately supervised. It presents as a pattern over time rather than as a single alarming event, which is exactly why it gets overlooked.Record what you saw and what you were told, in the words that were used, with the time. Observations, not conclusions — "a 3 cm bruise on the left cheek; mother stated he fell from the bed" rather than "suspected abuse". Contemporaneous notes are what protect the child months later, and they are frequently the weakest part of a candidate's answer.
Escalate the same day, to a senior clinician and through the agreed local pathway. Investigating it yourself or confronting the family is not the pathway, and can make the child less safe rather than more.
Treat the injury, and keep the child safe in the meantime. A child must not be discharged into a situation you believe to be unsafe while the concern is being considered.
A two-year-old who drank kerosene from a bottle, now coughing. The risk is aspiration into the lungs. Do not induce vomiting. Assess breathing and oxygenation, and observe for chemical pneumonitis.
A child who swallowed tablets an hour ago and appears completely well. Appearing well is not reassurance until the substance is identified — some agents have a silent interval before organ damage becomes evident. Identify it, seek poisons advice, and observe appropriately.
A four-month-old with bruising to the cheek, said to have rolled off a bed. A four-month-old who cannot yet roll cannot have caused this. Document precisely, escalate the same day, and keep the infant safe pending assessment.
A child brought repeatedly with minor injuries, growth faltering, immunisations incomplete. This is a pattern suggesting neglect. It needs the same escalation as a single dramatic injury, and it is the one more often missed.
Looking well and being safe. A silent interval means both can be true simultaneously.
Inducing vomiting and decontamination. Vomiting is not a first-aid measure, and in corrosives and fuels it causes further harm.
Swallowing and aspirating a fuel. The lung, not the gut, is what threatens the child.
Suspicion and proof. The threshold for escalating a protection concern is a reasonable concern — never certainty.
Abuse and neglect. Neglect is quieter, presents as a pattern, and carries the same duty.
Airway, breathing, circulation — and check the glucose in every drowsy child.
Most ingestions need supportive care. Look the substance up; do not recall doses.
What, how much, when, who else — and ask for the container.
Do not induce vomiting, and least of all with corrosives or fuels.
Some poisons have a silent interval, so a well child is not yet a discharged child.
Bruising in a baby who cannot yet move is a red flag until explained.
Document observations, escalate the same day, keep the child safe. Raise it — do not prove it.
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