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Effect of milk on ipecac-induced emesis
Volume 110 Number 6
Clinical and laboratory observations
973
Effect of milk on ipecac-induced emesis Patricia A. G r b c i c h , B.S.Pharm., J.D., Peter G. L a c o u t u r e , Ph.D., William J. L e w a n d e r , M.D., a n d Frederick H. Lovejoy, Jr., M.D. From the Massachusetts Poison Control System, Division of Clinical Pharmacology and Toxicology, The Children's Hospital, and the Department of Pediatrics, Harvard Medical School, Boston, and The Rhode Island Poison Center, and the Department of Pediatrics, The Rhode Island Hospital, Providence
Ipecac syrup is the most commonly used emetic in the treatment of poisonings in pediatric patients. It is safe, effective, and easily administered to young children by parents or others involved in the initial management of these poisonings. In an attempt to optimize its efficacy, several studies have investigated the influence of various factors on ipecac-induced emesis. The effect of motion. ~ the time of administration of fluid. / the temperature of the fluid given,3 and the administration of various fluids4-6 were evaluated. Two of these studies5,6 investigated the effect of the administration of milk on ipecac-induced emesis, and reported a 10-minute delay in the time to emesis when milk (as contrasted with clear fluid) was given after !pecac syrup9 These findings resulted in a recommendation to avoid the use of milk with ipecac. This recommendation. however, has complicated instructions given to parents. They must already remember what treatment to give their child and what signs and symptoms to monitor. If milk could be used. it would simplify instructions enabling parents to administer ipecac with any fluid the child will accept. In a study that assessed the efficacy of expired ipecac syrup, no significant difference was observed in the mean time to emesis between patients given milk before ipecac syrup and those given clear fluids. 7 Therefore, we undertook a prospective study among pediatric patients requiring ipecac syrup to determine whether milk decreased the efficacy as judged by time to emesis and the number of episodes of vomiting. METHODS Our prospective study was conducted at the Massachusetts and Rhode Island poison centers over 6 consecutive
Presented in part at the annual meeting of the American Association of Poison Conn'ol Centers and the American Academy of Clinical Toxicology,Santa Fe, New Mexico, 1986. Submitted for publication Nov. 11, 1986; accepted Jan. 8, 1987. Reprint requests: Patricia A. Grbcich, B.S., J.D., Massachusetts .Poison Control System, 300 Longwood Ave., Boston, MA 02115.
months during 1985-1986. Approval to conduct the study was obtained from the Human Investigation Committees of each institution (The Children's Hospital , Boston, and The Rhode Island Hospital, Providence). All telephone calls to the two poison centers involving children 5 years of age or younger in which ipecac syrup was required were entered in the study: Children were randomly assigned to receive either milk or clear fluids (non-milk-containing fluids). Exclusions included children who had consumed liquids in the 30 minutes before !pecac administration or those who were allergic to milk. Standard instructions for ipecac use included the administration of 10 mL ipecac syrup to children younger tha n 1 year of age and 15 mL to those 1 year and older9 The dose was administered while the poison information specialist was on the telephone so that the time of administration could be accurately recorded. Callers were asked to give at least 6 oz fluid, and the type and amount of fluid administered were recorded. If
See related article, p. 970.
emesis did not occur in 25 minutes, the dose of ipecac was repeated in those patients 1 year of age or older. The time of emesis and the number of episodes of vomiting were also recorded. In addition; the following data were obtained for all children: age and sex, presence of signs and symptoms before ipecac administration, product and amount ingested, time since ingestion, number of doses of ipecac syrup required to produce emesis, and any signs and symptoms reported at a 24- to 48-hour follow-up telephone call. Results were evaluated using the two-tailed Student t test, on the basis of comparisons made between the milk and clear fluid groups. RESULTS Two hundred fifteen children were enrolled in the study; 108 received milk, 'and 107 clear fluids. Of these 215 children, the Rhode Islarid center contributed 25 to the milk group and 27 to the clear fluid group9 The character-
974
Clinical and laboratory observations
The .Journal of Pediatrics June 1987
T a b l e I. Characteristics of patients in milk a n d clear fluid groups
Age (yr) Sex (M/F) (%) ingestion within 20 min of call (%) Presence of signs and symptoms before ipecac administration (%) Volume of fluid given (oz)
Milk g r o u p (n = 108)
C l e a r fluid g r o u p (n = 107)
2.5 + 0.1 57/43 75 2.7
2.5 + 0.1 54/46 78 4.7
5.7 + 0.3
5.9 + 0.4
Values represent mean + SEM. *There was no statistical difference between milk and clear fluid groups in any of these characteristics.
Table
II. Effect of milk versus clear fluids on !pecac-induced emesis
Successful emesis (%) One dose of ipecac (%) Time to emesis (min)* Massachusetts Rhode Island Time to emesis with volume (min)~ --<2 oz >2-4 oz >4-6 oz >6-8 oz >8 oz Episodes of vomiting Signs and symptoms on follow-up (%)
Milk g r o u p (n = 108)
C l e a r fluid g r o u p (n = t07)
100 92 23.6 _+ 1.2 23.6 + 1.3 23.7 _+ 2.5
100 95 23.1 -2-_1.2 23.5 _+ 1.5 21.7 _+ 2.1
19.1 19.7 23.2 31.5 30.8 3
17.7 20.8 22.6 25.4 31.7 2.8
_+ 1.7 _+ 1.4 +_ 2.0 ___4.0 + 4.0 + 0.2 24
_+ 2.4 + 2.3 + 2.0 + 2.4 + 4.5 _+ 0.1 29
Values represent mean _+ SEM. *There w~tsno significant difference in mean time to emesis between Massachusetts and Rhode Island in milk and clear fluid groups. tAnalysis of variance demonstrated significant difference in both milk and clear fluid groups with increasing volume of fluid given.
istics of t h e children in the two groups were c o m p a r a b l e (Table I). In b o t h groups, 63% of the children were younger t h a n 3 years of age, and boys accounted for slightly more t h a n 50% of each group. Ipecac syrup was ' administered within 20 minutes of ingestion in approximately 75% of children in both groups. Signs and symptoms present at the time of the call were uncommon. N o statistical differences were observed between the milk a n d the clear fluid groups in relation to successful emesis, success with a single dose of ipecac, m e a n time to emesis, n u m b e r of episodes of vomiting, or presence of signs a n d symptoms on follow-up (Table II). Signs and symptoms on follow-up included drowsiness, diarrhea, a n d continued vomiting. N o serious adverse effects were reported in either group. However, there was a significant difference in mean time to emesis with increasing volume of fluid administered ( T a b l e II). DISCUSSION In the only studies that investigated the effect of milk on ipecac-induced emesis, 11 adult volunteers were given 15
m L ipecac and 8 oz fluid. T h e find!ngs of these studies indicated t h a t milk significantly delayed time to emesis. The present study was conducted because we believed t h a t (1) adults m a y not be the best subjects to evaluate because ipecac is most commonlY used in children younger t h a n 5 years of age, (2) the evaluation of actual poisoning cases m a y be more clinically relevant t h a n the use of volunteers, (3) the n u m b e r of subjects evaluated was small, a n d (4) 15 m L ipecac in an adu~lt is less t h a n the currently recommended dose. T h e results of our study indicate t h a t the administration of milk does not alter the effectiveness of ipecac syrup. All children given ipecac followed by milk vomited, and the m e a n time to emesis was not prolonged compared with t h a t in the clear fluid group. In addition, the m e a n time to emesis in the milk group was c o m p a r a b l e to the m e a n time to emesis reported in other s t u d i e s ) Milk did not increase the incidence of advers e effects experienced after the use of ipecac, and the n u m b e r of patients experiencing d i a r r h e a and mild lethargy was consistent with those reported?.~~ T h e r e was a significant difference in the m e a n time to
Volume 110 Number 6
Clinical and laboratory observations
emesis with increasing volume of fluid administered, that is, the greater the volume administered the longer it took for emesis to occur. However, this observation needs further investigation, because several factors may be responsible, including age and weight of the child and the time over which the fluid is administered. Our investigation is strengthened by the large number of children in each group and the comparability in patient characteristics in the two groups studied. Furthermore, the results obtained from Rhode Island are comparable to those from Massachusetts. The analysis of cases from two independent poison centers strengthens our study by decreasing the possibility of bias inherent with a single study site. We conclude that the administration of milk does not delay onset of ipecac-induced emesis. Therefore, we believe that milk can be administered with ipecac syrup in children who have ingested a toxin.
975
2. Barkis D, Kurwahara L, Robertson W. Results of forcing fluids pre-vs-post ipecac. Vet Human Toxicol 1978;20:90-1. 3. Spigiel R, Abdouch 1, Munn D. The effect of temperature on concurrently administered fluid on the onset of ipecac induced emesis. Clin Toxicol 1979;14:281-4. 4. Uden D, Davidson A, Kohen D. The effect of carbonated beverages on ipecac-induced emesis. Ann Emerg Med 1981;10:79-81. 5. Varipapa R, Oderda G. Effect of milk on ipecac induced emesis. N Engl J Med 1977;296:11%3. 6. Varipapa R, Oderda G. Effect of milk on ipecac induced emesis. J Am Pharm Assoc 1977;17:510. 7. Grbcich P, Lacouture P, Kresel J, et al. Expired ipecac syrup efficacy. Pediatrics 1986;78:1085-9. 8. Manoguerra A, Krenzelok E. Rapid emesis from high dose ipecac syrup in adults and children intoxicated with antiemetics or other drugs. Am J Hosp Pharm 1978;35:1360-2. 9. Czajka P, Russell S. Nonemetic effects of ipecac. Pediatrics 1985;75:1101-4. 10. Chafee-Bahamon C, Lacouture P, Lovejoy FH Jr. Risk assessment of ipecac in the home. Pediatrics 1985;75:1105-9.
REFERENCES 1. Eisenga BH, Meester W. Evaluation of the effect of motility on syrup of ipecac induced emesis [Abstract]. Vet Human Toxicol 1978;20:462.
BOUND VOLUMES AVAILABLE TO SUBSCRIBERS Bound volumes of the 1987 issues of THE JOURNALOF PEDIATRICSare available to subscribers (only) from the Publisher, at a cost of $44.00 ($60.00 international) for Vol. 110 (January-June) and Vol. 111 (July-December), shipping charges included. Each bound volume contains subject and author indexes, and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram, with the Journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact The C. V. Mosby Company, Circulation Department, 11830 Westline Industrial Dr., St. Louis, MO 63146, USA/800-325-4177, ext. 351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular Journal subscription.
Clinical and laboratory observations
973
Effect of milk on ipecac-induced emesis Patricia A. G r b c i c h , B.S.Pharm., J.D., Peter G. L a c o u t u r e , Ph.D., William J. L e w a n d e r , M.D., a n d Frederick H. Lovejoy, Jr., M.D. From the Massachusetts Poison Control System, Division of Clinical Pharmacology and Toxicology, The Children's Hospital, and the Department of Pediatrics, Harvard Medical School, Boston, and The Rhode Island Poison Center, and the Department of Pediatrics, The Rhode Island Hospital, Providence
Ipecac syrup is the most commonly used emetic in the treatment of poisonings in pediatric patients. It is safe, effective, and easily administered to young children by parents or others involved in the initial management of these poisonings. In an attempt to optimize its efficacy, several studies have investigated the influence of various factors on ipecac-induced emesis. The effect of motion. ~ the time of administration of fluid. / the temperature of the fluid given,3 and the administration of various fluids4-6 were evaluated. Two of these studies5,6 investigated the effect of the administration of milk on ipecac-induced emesis, and reported a 10-minute delay in the time to emesis when milk (as contrasted with clear fluid) was given after !pecac syrup9 These findings resulted in a recommendation to avoid the use of milk with ipecac. This recommendation. however, has complicated instructions given to parents. They must already remember what treatment to give their child and what signs and symptoms to monitor. If milk could be used. it would simplify instructions enabling parents to administer ipecac with any fluid the child will accept. In a study that assessed the efficacy of expired ipecac syrup, no significant difference was observed in the mean time to emesis between patients given milk before ipecac syrup and those given clear fluids. 7 Therefore, we undertook a prospective study among pediatric patients requiring ipecac syrup to determine whether milk decreased the efficacy as judged by time to emesis and the number of episodes of vomiting. METHODS Our prospective study was conducted at the Massachusetts and Rhode Island poison centers over 6 consecutive
Presented in part at the annual meeting of the American Association of Poison Conn'ol Centers and the American Academy of Clinical Toxicology,Santa Fe, New Mexico, 1986. Submitted for publication Nov. 11, 1986; accepted Jan. 8, 1987. Reprint requests: Patricia A. Grbcich, B.S., J.D., Massachusetts .Poison Control System, 300 Longwood Ave., Boston, MA 02115.
months during 1985-1986. Approval to conduct the study was obtained from the Human Investigation Committees of each institution (The Children's Hospital , Boston, and The Rhode Island Hospital, Providence). All telephone calls to the two poison centers involving children 5 years of age or younger in which ipecac syrup was required were entered in the study: Children were randomly assigned to receive either milk or clear fluids (non-milk-containing fluids). Exclusions included children who had consumed liquids in the 30 minutes before !pecac administration or those who were allergic to milk. Standard instructions for ipecac use included the administration of 10 mL ipecac syrup to children younger tha n 1 year of age and 15 mL to those 1 year and older9 The dose was administered while the poison information specialist was on the telephone so that the time of administration could be accurately recorded. Callers were asked to give at least 6 oz fluid, and the type and amount of fluid administered were recorded. If
See related article, p. 970.
emesis did not occur in 25 minutes, the dose of ipecac was repeated in those patients 1 year of age or older. The time of emesis and the number of episodes of vomiting were also recorded. In addition; the following data were obtained for all children: age and sex, presence of signs and symptoms before ipecac administration, product and amount ingested, time since ingestion, number of doses of ipecac syrup required to produce emesis, and any signs and symptoms reported at a 24- to 48-hour follow-up telephone call. Results were evaluated using the two-tailed Student t test, on the basis of comparisons made between the milk and clear fluid groups. RESULTS Two hundred fifteen children were enrolled in the study; 108 received milk, 'and 107 clear fluids. Of these 215 children, the Rhode Islarid center contributed 25 to the milk group and 27 to the clear fluid group9 The character-
974
Clinical and laboratory observations
The .Journal of Pediatrics June 1987
T a b l e I. Characteristics of patients in milk a n d clear fluid groups
Age (yr) Sex (M/F) (%) ingestion within 20 min of call (%) Presence of signs and symptoms before ipecac administration (%) Volume of fluid given (oz)
Milk g r o u p (n = 108)
C l e a r fluid g r o u p (n = 107)
2.5 + 0.1 57/43 75 2.7
2.5 + 0.1 54/46 78 4.7
5.7 + 0.3
5.9 + 0.4
Values represent mean + SEM. *There was no statistical difference between milk and clear fluid groups in any of these characteristics.
Table
II. Effect of milk versus clear fluids on !pecac-induced emesis
Successful emesis (%) One dose of ipecac (%) Time to emesis (min)* Massachusetts Rhode Island Time to emesis with volume (min)~ --<2 oz >2-4 oz >4-6 oz >6-8 oz >8 oz Episodes of vomiting Signs and symptoms on follow-up (%)
Milk g r o u p (n = 108)
C l e a r fluid g r o u p (n = t07)
100 92 23.6 _+ 1.2 23.6 + 1.3 23.7 _+ 2.5
100 95 23.1 -2-_1.2 23.5 _+ 1.5 21.7 _+ 2.1
19.1 19.7 23.2 31.5 30.8 3
17.7 20.8 22.6 25.4 31.7 2.8
_+ 1.7 _+ 1.4 +_ 2.0 ___4.0 + 4.0 + 0.2 24
_+ 2.4 + 2.3 + 2.0 + 2.4 + 4.5 _+ 0.1 29
Values represent mean _+ SEM. *There w~tsno significant difference in mean time to emesis between Massachusetts and Rhode Island in milk and clear fluid groups. tAnalysis of variance demonstrated significant difference in both milk and clear fluid groups with increasing volume of fluid given.
istics of t h e children in the two groups were c o m p a r a b l e (Table I). In b o t h groups, 63% of the children were younger t h a n 3 years of age, and boys accounted for slightly more t h a n 50% of each group. Ipecac syrup was ' administered within 20 minutes of ingestion in approximately 75% of children in both groups. Signs and symptoms present at the time of the call were uncommon. N o statistical differences were observed between the milk a n d the clear fluid groups in relation to successful emesis, success with a single dose of ipecac, m e a n time to emesis, n u m b e r of episodes of vomiting, or presence of signs a n d symptoms on follow-up (Table II). Signs and symptoms on follow-up included drowsiness, diarrhea, a n d continued vomiting. N o serious adverse effects were reported in either group. However, there was a significant difference in mean time to emesis with increasing volume of fluid administered ( T a b l e II). DISCUSSION In the only studies that investigated the effect of milk on ipecac-induced emesis, 11 adult volunteers were given 15
m L ipecac and 8 oz fluid. T h e find!ngs of these studies indicated t h a t milk significantly delayed time to emesis. The present study was conducted because we believed t h a t (1) adults m a y not be the best subjects to evaluate because ipecac is most commonlY used in children younger t h a n 5 years of age, (2) the evaluation of actual poisoning cases m a y be more clinically relevant t h a n the use of volunteers, (3) the n u m b e r of subjects evaluated was small, a n d (4) 15 m L ipecac in an adu~lt is less t h a n the currently recommended dose. T h e results of our study indicate t h a t the administration of milk does not alter the effectiveness of ipecac syrup. All children given ipecac followed by milk vomited, and the m e a n time to emesis was not prolonged compared with t h a t in the clear fluid group. In addition, the m e a n time to emesis in the milk group was c o m p a r a b l e to the m e a n time to emesis reported in other s t u d i e s ) Milk did not increase the incidence of advers e effects experienced after the use of ipecac, and the n u m b e r of patients experiencing d i a r r h e a and mild lethargy was consistent with those reported?.~~ T h e r e was a significant difference in the m e a n time to
Volume 110 Number 6
Clinical and laboratory observations
emesis with increasing volume of fluid administered, that is, the greater the volume administered the longer it took for emesis to occur. However, this observation needs further investigation, because several factors may be responsible, including age and weight of the child and the time over which the fluid is administered. Our investigation is strengthened by the large number of children in each group and the comparability in patient characteristics in the two groups studied. Furthermore, the results obtained from Rhode Island are comparable to those from Massachusetts. The analysis of cases from two independent poison centers strengthens our study by decreasing the possibility of bias inherent with a single study site. We conclude that the administration of milk does not delay onset of ipecac-induced emesis. Therefore, we believe that milk can be administered with ipecac syrup in children who have ingested a toxin.
975
2. Barkis D, Kurwahara L, Robertson W. Results of forcing fluids pre-vs-post ipecac. Vet Human Toxicol 1978;20:90-1. 3. Spigiel R, Abdouch 1, Munn D. The effect of temperature on concurrently administered fluid on the onset of ipecac induced emesis. Clin Toxicol 1979;14:281-4. 4. Uden D, Davidson A, Kohen D. The effect of carbonated beverages on ipecac-induced emesis. Ann Emerg Med 1981;10:79-81. 5. Varipapa R, Oderda G. Effect of milk on ipecac induced emesis. N Engl J Med 1977;296:11%3. 6. Varipapa R, Oderda G. Effect of milk on ipecac induced emesis. J Am Pharm Assoc 1977;17:510. 7. Grbcich P, Lacouture P, Kresel J, et al. Expired ipecac syrup efficacy. Pediatrics 1986;78:1085-9. 8. Manoguerra A, Krenzelok E. Rapid emesis from high dose ipecac syrup in adults and children intoxicated with antiemetics or other drugs. Am J Hosp Pharm 1978;35:1360-2. 9. Czajka P, Russell S. Nonemetic effects of ipecac. Pediatrics 1985;75:1101-4. 10. Chafee-Bahamon C, Lacouture P, Lovejoy FH Jr. Risk assessment of ipecac in the home. Pediatrics 1985;75:1105-9.
REFERENCES 1. Eisenga BH, Meester W. Evaluation of the effect of motility on syrup of ipecac induced emesis [Abstract]. Vet Human Toxicol 1978;20:462.
BOUND VOLUMES AVAILABLE TO SUBSCRIBERS Bound volumes of the 1987 issues of THE JOURNALOF PEDIATRICSare available to subscribers (only) from the Publisher, at a cost of $44.00 ($60.00 international) for Vol. 110 (January-June) and Vol. 111 (July-December), shipping charges included. Each bound volume contains subject and author indexes, and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram, with the Journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact The C. V. Mosby Company, Circulation Department, 11830 Westline Industrial Dr., St. Louis, MO 63146, USA/800-325-4177, ext. 351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular Journal subscription.