Bedside Snapshot
- Recognize
- Known or suspected product, often a child under 6
- Drowsiness, vomiting, cough, drooling or refusal to swallow
- A well-looking child can still be harmed
- Red Flags
- Stridor, drooling, seizure, coma, slow breathing, hypotension or arrhythmia. A swallowed battery is a red flag even when the child looks well.
- First Actions
- Airway and breathing first; check glucose. Call the poison center (1-800-222-1222 in the US). Bring the container.
- Key Doses
- Acetylcysteine IV 150 mg/kg over 1 hr, then 50 mg/kg over 4 hr, then 100 mg/kg over 16 hr
- Naloxone 0.1 mg/kg IV/IO (max 2 mg), per protocol
- Charcoal 1 g/kg under 1 yr; 25–50 g at 1–12 yr
- Don't Miss
- Esophageal button battery: remove promptly, preferably within 2 hr. Multiple or high-powered magnets: urgent specialist review.
- Escalate & Transport
- Pediatric ED for any airway, circulation or neurologic change
- Endoscopy team for a battery in the esophagus
- Observe per poison center; doses vary by protocol
Overview & Pediatric Differences
Toxic ingestions are a common reason children reach emergency care, and most are unintentional. Toddlers explore with their mouths, so the usual exposures are household products, medicines left within reach and small objects. Here's the key point: the product, the amount and the time of exposure decide the plan more than the child's first appearance.
Why Kids Are Different
- Small body weight: A fraction of an adult tablet can be a toxic dose for a 10 kg toddler. That is why every drug dose is weight-based.
- Mouthing and exploring: Young children swallow whole tablets, button batteries and magnets. One bite can take in a large volume of a liquid product.
- Little early warning: The child can look well after swallowing a battery or a sustained-release drug. A normal exam does not clear them.
- Airway and aspiration risk: Drowsy or vomiting kids aspirate easily. A caustic, hydrocarbon or pod exposure can injure the airway.
Poison center first: Call early for any unknown, uncertain or large ingestion. The US Poison Help line is 1-800-222-1222, and your local poison center works too. The center gives product-specific and dose-specific advice.
Recognition & Severity
What the child shows depends on the product. Use the pattern to guide your search for the product. Do not use it to rule out a toxic exposure.
| Feature | Mild or Local | Moderate | Severe |
|---|---|---|---|
| Mental status | Irritable or mildly drowsy | Lethargic or agitated | Coma or seizures |
| Breathing | Cough, gagging or choking | Stridor, slow or shallow breathing | Apnea or respiratory failure |
| Circulation | Normal | Tachycardia or hypertension | Bradycardia, hypotension or arrhythmia |
| Pupils and skin | Normal or local irritation | Miosis (opioids) or mydriasis (sympathomimetics) | Pinpoint pupils with apnea (opioids) |
| Local injury | Eye or mouth irritation | Oral or pharyngeal burns, drooling | Airway edema or esophageal perforation |
Red Flags
Act now: Stridor, drooling or refusal to swallow (a possible esophageal foreign body), seizure, coma, slow breathing, hypotension, or any arrhythmia or wide QRS. Each of these is an airway and circulation problem before it is anything else. Work the ABCs, check glucose and give naloxone per protocol. Then call the poison center.
Management by Type: Button Batteries & Magnets
Button Batteries
- Suspect early: Any of these means urgent imaging: a known or suspected battery ingestion, drooling, coughing, chest or throat pain, or refusal to swallow. A normal exam does not rule out a battery.
- Image: Plain radiographs, AP and lateral, locate the battery. On the AP film a button battery typically shows a double-halo (ring) appearance. The lateral view helps tell a battery apart from a coin. For triage advice, call the National Battery Ingestion Hotline (1-800-498-8666, 24 hours) or the poison center.
- Esophageal battery: Get it out promptly. A pediatric endoscopy team removes it, ideally within 2 hours of ingestion, per the ESPGHAN position paper. Do not wait for it to pass.
- Delayed presentation in the esophagus: Found late? If the battery is found or removed more than 12 hours after ingestion, ESPGHAN advises a CT scan to check for vascular injury before removal.
- Battery beyond the esophagus: Asymptomatic and seen within 12 hours? ESPGHAN advises monitoring, with a repeat X-ray in 7 to 14 days if the battery has not passed. When the diagnosis is delayed, endoscopy and CT should be considered even in asymptomatic children, to look for esophageal and vascular injury.
- While waiting for endoscopy: Honey or sucralfate may bridge the wait for an ingestion up to 12 hours old. Honey is only for children 12 months and older (see the warning below). Neither may delay endoscopy.
- After removal or passage: Keep watching for weeks. Fever, hematemesis, melena, stridor, cough or a change in voice can mean a delayed fistula or perforation. Sentinel bleeding is an emergency. Re-evaluate it urgently.
Never induce vomiting. Flushing a battery with fluids is off the table. Nothing goes in by mouth, apart from honey for children 12 months and older when the criteria in step 6 are met, or sucralfate. The receiving team or poison center makes that call.
Honey, for a child 12 months and older only: On the way to the emergency department, the dose is 2 teaspoons (10 mL) every 10 minutes. The conditions: the battery was swallowed within 12 hours, the child can swallow, and it does not delay transport or endoscopy (National Capital Poison Center guidance). Under 12 months, honey is a no-go because of infant botulism. Sucralfate is the substitute, as the team directs.
Magnets
Swallowed magnets are a hazard of their own. In its 2015 clinical report on foreign-body ingestion, NASPGHAN says button batteries and high-powered magnets carry more potential for severe morbidity and mortality than most other foreign bodies. Two or more magnets, or one magnet with metal, can pull toward each other across the bowel wall. The outcome can be perforation, obstruction or fistula.
- Image: obtain AP and lateral radiographs to count the magnets and locate them.
- Single magnet: An asymptomatic child may be watched with serial imaging, per pediatric specialist advice. Most pass.
- Multiple magnets or magnet plus metal: Urgent pediatric surgical or gastroenterology review is needed, even if the child looks well.
- Location: Within reach of the endoscope (esophagus or stomach): endoscopic removal. Beyond endoscopic reach, or with abdominal pain, vomiting, bleeding, fever or peritonitis: surgery.
Magnet pairs or magnet plus metal: Refer urgently. Do not treat it as a routine passage.
Management by Type: Detergent Pods & Edibles
Laundry Detergent Pods
Pods are concentrated, and the film breaks down when it meets moisture. The Valdez 2014 National Poison Data System series covered children younger than 6 years (2012 to 2013). Children younger than 3 years made up 73.5% of exposures. Ingestion was the main route, and 102 children (0.6%) needed tracheal intubation. Vomiting, coughing or choking, eye injury and drowsiness are the common effects. In a small child, pods can cause severe CNS depression, respiratory failure and coma.
- Eyes: irrigate continuously with water or saline for at least 15 minutes, and check for corneal injury. Call the poison center for ongoing eye symptoms.
- Skin and mouth: remove contaminated clothing, wash skin, and rinse the mouth. Give nothing by mouth until airway status is clear.
- Airway: watch for cough, choking, drowsiness and aspiration during vomiting. Suction the mouth and position the child on the side if vomiting. Do not induce vomiting.
- Monitor: repeat the neurologic and respiratory check. Bring the container to the receiving team.
Edibles and Cannabis Products
Cannabis edibles, the gummies, chocolates and baked goods, are a growing cause of pediatric exposure. A toddler who eats one is most often drowsy, irritable or unsteady, or has low tone. Most cases are mild. Respiratory depression and coma do occur in young children. Treatment is supportive: airway, breathing, glucose, temperature and observation, plus a poison center call.
Key point: A drowsy toddler who ate an edible can look like a seizure or sepsis. Check glucose, write down the product, and do not assume the cause is infection.
Management by Type: High-Risk Single-Dose Exposures
A few drugs and products can seriously harm a toddler after one or two doses, or after a small volume. The table lists the common ones. Call the poison center for every exposure on this list. Treat the airway, breathing and circulation first.
| Exposure | Main Risk | First Step |
|---|---|---|
| Sulfonylurea (glipizide, glyburide, glimepiride) | Prolonged or recurrent hypoglycemia | Check glucose now and repeat often; IV dextrose; octreotide for recurrence per toxicology |
| Calcium channel blocker (amlodipine, verapamil, diltiazem) | Hypotension, bradycardia, shock | Call the poison center now; see the Beta-Blocker and CCB Toxicity page |
| Beta-blocker | Bradycardia, hypotension, hypoglycemia | Check glucose; treatment per toxicology; see the Beta-Blocker and CCB Toxicity page |
| Clonidine and other imidazolines | Deep sedation, bradycardia, apnea | Airway and breathing first; check glucose and heart rate; observe per poison center |
| Opioids, including buprenorphine and methadone | Respiratory depression; long-acting drugs can re-sedate | Ventilate; naloxone per protocol, with a lower start if the child is not apneic; observe; see the Opioid Overdose page |
| Tricyclic antidepressants | Seizures, QRS widening, arrhythmia | Read the QRS; sodium bicarbonate for QRS 100 ms or longer; benzodiazepine for seizure; see the Sodium Channel Blocker page |
| Flecainide and other sodium channel blockers | Wide QRS, arrhythmia, hypotension | Same as tricyclics: bicarbonate, seizure care and monitoring; see the Sodium Channel Blocker page |
| Methyl salicylate (oil of wintergreen) | Salicylism, metabolic acidosis, pulmonary edema | Check glucose, blood gas and level; bicarbonate per protocol; see the Salicylate Toxicity page |
| Camphor | Seizures; aspiration of oil | Benzodiazepine for seizure; do not induce vomiting; call the poison center |
| Antimalarials (chloroquine, hydroxychloroquine) | Seizures, QRS widening, hypotension, sudden arrest | Cardiac monitoring; urgent toxicology call; early airway control; treat seizures and QRS widening per toxicology (watch potassium, since bicarbonate can worsen hypokalemia) |
| Iron | GI injury, shock, metabolic acidosis | Call the poison center; charcoal does not bind iron; antidote per toxicology |
| Caustics (drain cleaners, alkaline and acid products, and pods) | Burns to mouth, airway and esophagus; perforation | Airway first; no vomiting, no charcoal, no neutralizing; eye irrigation for at least 15 minutes; poison center decides on dilution |
| Hydrocarbons (kerosene, lamp oil, gasoline) | Aspiration pneumonitis | Do not induce vomiting; no charcoal; chest radiograph if symptoms; poison center |
| Nicotine e-liquid | Rapid vomiting, tachycardia, seizure, collapse | Call the poison center now; small volumes of concentrated liquid can be serious in a toddler; watch closely |
| Acetaminophen, including combination products | Delayed liver injury; the level is not valid before 4 hours | Draw the 4-hour level; acetylcysteine per the nomogram or poison center; see the Acetaminophen Toxicity page |
Do not wait for symptoms: Many of these drugs cause harm within 1 to 2 hours of ingestion. Some, the sustained-release and cardiac-active products, act late. The poison center sets the observation length.
Medications & Dosing
Doses vary by protocol; follow local protocols and medical direction. In children, dosing is weight-based. The table flags any exception.
| Drug | Dose & Route | Max | Notes |
|---|---|---|---|
| Acetylcysteine IV (acetaminophen overdose; 5–40 kg, three-bag regimen) Acetylcysteine |
150 mg/kg IV over 1 hr, then 50 mg/kg over 4 hr, then 100 mg/kg over 16 hr Diluent by weight band (label): 5–20 kg: 3, 7 and 14 mL/kg; 21–40 kg: 100, 250 and 500 mL |
300 mg/kg over 21 hr; continue until stopping criteria are met |
Start per the acetaminophen nomogram or poison center advice (see the Acetaminophen Toxicity page). Under 5 kg has not been studied: call the poison center or toxicologist. Patients 40 kg or less use the three-bag regimen; reduce total volume for fluid restriction or under 40 kg (label). For 41 kg or more, see the Acetylcysteine page. |
| Naloxone (opioid overdose with respiratory depression) Naloxone |
0.1 mg/kg IV/IO, ventilate first Repeat every 2–3 min to effect IM or IN per local protocol (see the Naloxone page for device and route doses) |
Max 2 mg/dose (adult dose); no fixed total |
Protocols often start at 0.1 mg/kg. The FDA label starts at 0.01 mg/kg IV, then 0.1 mg/kg if the response is inadequate. A lower start is reasonable when the child is not apneic, to reduce agitation or withdrawal if buprenorphine or fentanyl is suspected. Ventilation with visible chest rise comes first. |
| Activated charcoal (adsorbable drug only; single dose, not routine) Activated charcoal |
Under 1 yr: 1 g/kg PO or NG 1–12 yr: 25–50 g PO or NG (fixed amount) |
50 g per dose (1–12 yr) |
Use only within about 1 hour, only for an adsorbable agent, and only with a protected airway. Charcoal does not bind iron, lithium, alcohols or metals. Do not give it after caustic (including pod) or hydrocarbon ingestion, or when a battery or other foreign body is in the esophagus. Aspiration is the main risk. Use multiple doses only on toxicology direction. |
Charcoal and airway: A drowsy or vomiting child needs a protected airway before any charcoal goes in. Sorbitol-containing products are not for children under 32 kg or under 1 year (label).
Monitoring, Reassessment & Disposition
| Parameter | Target | Notes |
|---|---|---|
| Airway and breathing | Protected, normal respiratory effort | Watch for aspiration during vomiting; reassess after each dose of an antidote |
| Mental status | Alert or at baseline | Use the same scale each time; new drowsiness is a trend, not a fixed finding |
| Glucose | Within the local target | Check when the child is drowsy, seizing or has an unexplained change |
| Heart rhythm | No new arrhythmia | Monitor when a cardiotoxic drug, a hypotensive child or a wide QRS is present |
| Temperature | Normal | Fever or hyperthermia is a toxidrome sign, not a routine finding |
Observation and Disposition
- Observation time: Time starts at ingestion. For each product and amount, the poison center or toxicologist sets the length. Sustained-release products and drugs with cardiac or CNS effects need longer watching. A child who looks well at the first check is not cleared early.
- Discharge: Only when the poison center or toxicology has a plan, the exam is normal, and a caregiver can return or call.
- Admit or transfer: any airway, circulation or neurologic compromise, any battery in the esophagus, any multiple-magnet or magnet-plus-metal ingestion, any high-risk drug from the table above, or any uncertain exposure with symptoms.
Pitfalls & Safety Checks
| Pitfall | Consequence | Prevention |
|---|---|---|
| Normal exam with a swallowed battery | Delayed esophageal injury | Image any suspected battery; remove an esophageal battery promptly |
| Honey or sucralfate used as the plan | Delayed removal | Use only while waiting for endoscopy, never to replace it per the ESPGHAN position paper |
| Honey given to a child under 12 months | Infant botulism | Honey only for children 12 months and older; sucralfate or nothing by mouth otherwise, as the team directs |
| Charcoal for a caustic, hydrocarbon, iron or lithium exposure | Charcoal does not help and can obscure endoscopy or add aspiration risk | Check the agent before giving charcoal; discuss with the poison center |
| Charcoal given to a drowsy child | Pulmonary aspiration | Protect the airway first; use only with a poison center plan |
| Adult dosing for a child | Overdose | Use the weight-based or label pediatric dose; check the mg/kg math |
| Missed second product | Delayed treatment | Ask about all containers in the home and any pills taken from another person |
| Treating the product, not the child | Missed hypoglycemia or sepsis | Check glucose and temperature; treat the airway and circulation first |
Most dangerous error: A battery in the esophagus gets watched when it should be removed. The window is hours, not days.
Special Populations
Neonates and Infants
- Under 5 kg, acetylcysteine dosing has not been studied. Bring in the poison center or toxicologist early.
- Under 1 year, charcoal is 1 g/kg. Aspiration risk peaks in this group.
Toddlers and Preschoolers
- Most exposures here are unintentional. Pods and batteries are common at these ages.
- Ask caregivers to bring every container in the home, including the product the child took and any packaging.
Adolescents
- Intentional ingestion is possible, so screen for self-harm and safety per local protocol. Do not assume a single product.
- Adolescent dosing may follow adult protocols, by weight and size. State the dosing weight used.
Suspected Maltreatment
- Repeated or unexplained ingestions, or a history that does not fit the child's findings, need a child-protection report per local law. See Child Maltreatment.
Prehospital & Transport Considerations
| Level | Typical Role in This Topic |
|---|---|
| EMT | Scene safety, airway positioning, suction, bring the container, call the poison center per protocol |
| AEMT | Glucose check, IV access, antiemetic per protocol |
| Paramedic | Advanced airway, weight-based naloxone, antidotes and seizure drugs per local protocol |
| RN (ED/ICU) | Antidote administration, charcoal decisions with poison center, observation and handoff |
| Critical Care Transport | Airway protection in transit, cardiac monitoring, weight-based infusions and antidotes per protocol |
- Bring the product: Know three things: the container, the amount and the time of ingestion. Call the poison center from the scene or en route.
- Destination: Go to a pediatric-capable ED. A pediatric ICU or endoscopy team is the right stop for an esophageal battery or a respiratory or cardiac compromise.
- Handoff: Give product, amount, time, symptoms, glucose, vital signs and any treatment given. Use your service's structured handoff.
- Doses: doses vary by protocol; follow local protocols and medical direction.
Clinical Pearls
Ask for the container: The exact product and its concentration are the single most useful fact you will get. A pod, a battery and an edible each need their own plan.
Honey is a bridge, not a plan: An esophageal battery swallowed within 12 hours may be bridged with honey (children 12 months and older only) or sucralfate while the team arranges removal. Neither one ever replaces endoscopy.
Look well is not clear: A battery or a sustained-release product can do harm while the child plays normally. Image, or call the poison center, instead of waiting for symptoms.
Drowsy toddler, check glucose: A child with an edible, a sedative or an unexplained coma gets the airway and a glucose check first. The toxicology diagnosis comes after that.
References
- Mubarak A, Benninga MA, Broekaert I, Dolinsek J, Homan M, Mas E, et al. Diagnosis, management, and prevention of button battery ingestion in childhood: a European Society for Paediatric Gastroenterology Hepatology and Nutrition position paper. J Pediatr Gastroenterol Nutr. 2021;73(1):129–136. https://doi.org/10.1097/MPG.0000000000003048
- Kramer RE, Lerner DG, Lin T, et al. Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee. J Pediatr Gastroenterol Nutr. 2015;60(4):562–574. https://doi.org/10.1097/mpg.0000000000000729
- Valdez AL, Casavant MJ, Spiller HA, Chounthirath T, Xiang H, Smith GA. Pediatric exposure to laundry detergent pods. Pediatrics. 2014;134(6):1127–1135. https://doi.org/10.1542/peds.2014-0057
- Cumberland Pharmaceuticals. Acetadote (acetylcysteine) injection, for intravenous use: prescribing information (revised July 2025). DailyMed, US National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=472f158a-5ab9-4308-8e49-1116e6ea3d39
- Dart RC, Mullins ME, Matoushek T, et al. Management of acetaminophen poisoning in the US and Canada: a consensus statement. JAMA Netw Open. 2023;6(8):e2327739. https://doi.org/10.1001/jamanetworkopen.2023.27739
- Mahan KM, Hayes BD, North CM, et al. Utility of hypertonic saline and diazepam in COVID-19-related hydroxychloroquine toxicity. J Emerg Med. 2021;60(3):359–364. https://doi.org/10.1016/j.jemermed.2020.10.048
- Chyka PA, Seger D, Krenzelok EP, Vale JA. Position paper: single-dose activated charcoal. Clin Toxicol. 2005;43(2):61–87. https://www.clintox.org/wp-content/uploads/2016/04/Position-Statement-Single-Dose-Activated-Charcoal-1.pdf
- National Capital Poison Center. Button battery ingestion: treatment guidelines and National Battery Ingestion Hotline (1-800-498-8666). Accessed October 2026. https://poison.org/battery
Medical Disclaimer
- For Educational Purposes Only: This content is intended for educational reference and should not be used for clinical decision-making.
- Not a Substitute for Professional Judgment: Always consult your local protocols, institutional guidelines, and supervising physicians.
- Verify Before Acting: Users are responsible for verifying information through authoritative sources before any clinical application.
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