Pediatric ethanol intoxication
Pediatric patients with alcohol intoxication require emergent assessment in the emergency department (ED). Patients should be seen immediately upon arrival and placed on a monitor (telemetry) for frequent assessment of vital signs. Patients should receive immediate stabilization if necessary, including intravenous (IV) access, IV fluids, and laboratory and radiologic studies as necessary. These may include serum ethanol level, urine drug screen, fingerstick blood glucose level, CBC, and any radiographic studies that are clinically warranted (including advanced head imaging such as CT). Like adults, some pediatric patients will present obtunded and require emergent endotracheal intubation for airway protection. Pediatric patients may accidentally drink large volumes of alcohol, which puts them at risk for overdose. These patients will require intensive care unit (ICU) hospitalization.
Onset of central nervous system (CNS) depression is rapid, usually within 15 minutes of ingestion. Hypoglycemia may take longer to develop, but serum glucose must be regularly monitored (every 60 minutes) for the entire length of time of the alcohol intoxication. In children, 2-4 mL/kg of 25% dextrose solution is usually administered. A maintenance infusion of dextrose-containing IV fluids is often required.
Habitual alcohol use by children and adolescents is often associated with underlying psychiatric illness.
Alcohol use is a major contributor to the leading cause of pediatric death (trauma). Patients presenting as intoxicated should be evaluated for traumatic injuries.
Pediatric ethanol intoxication is a toxic reaction to ethanol that occurs in children and adolescents following unintentional or intentional ingestion of alcoholic beverages or household products containing alcohol, such as hand sanitizer, mouthwash, cough and cold medicine, perfume, aftershave, and certain foods and beverages (eg, vanilla extract, certain energy drinks). Ethanol exposure can also occur through skin absorption, eye contact, and inhalation. Although not common, intentional intoxication of an infant or child by a caregiver has been reported. Pediatric suicide attempt by alcohol overdose has also been reported.
Even a small quantity of ethanol can induce intoxication in toddlers and children. Ethanol intoxication can induce a severe reaction including altered mental status, bradycardia, hypoglycemia, hypothermia, hypotension, coma, seizures, respiratory depression, and even death. Other signs and symptoms of ethanol ingestion include lethargy, drowsiness, slurred speech, nystagmus, ataxia, eye irritation, nausea, vomiting, conjunctival injection, oral irritation, cough, abdominal pain, hematemesis, polyuria, hypovolemic dehydration, and a sweet, fruity odor to the breath.
Older children and adolescents may intentionally consume alcoholic beverages or products with a high concentration of alcohol on their own or with their peer group. These children and adolescents are at greater risk for habitual alcohol consumption, binge drinking, sexual assault, violent behavior, suicidal thoughts, pregnancy, poor academic achievement, motor vehicle accidents, and death by overdose.
Management calls for immediate emergency treatment. Patients may present with a crisis of hypoglycemia, hypothermia, hypovolemia, coma, obstructed respiration, or other life-threatening condition. Beyond this, supportive care is recommended. It is not advised to perform gastric emptying or use activated charcoal on children for ethanol ingestion alone.
The patient may require treatment for related physical injuries such as burns, fractures, bruises, and signs of child abuse and sexual assault. Use of ethanol products with the intention of self-harm calls for consultation with mental health professionals.
Children of an increasingly younger age are consuming alcohol, and many adolescents have difficulties with alcohol intoxication, self-poisoning, and/or dependence. These problems extend beyond the United States, and the World Health Organization (WHO) has identified alcohol consumption as one of their health priorities.
It is crucial that any recognition or suspicion of abuse or neglect be followed by immediate reporting to appropriate authorities to safeguard the child from further injury. To report suspected abuse in the United States, the clinician should contact their state or local Child Protection Services (CPS) agency. The national number, 1-800-4-A-CHILD, is available to help locate the regional department. If unsure whether to report, consultation with other health care professionals or CPS is recommended to help determine if the incident is reportable. It is important to remember that the duty to report requires only a reasonable suspicion that abuse has occurred and not certainty.
T51.0X1A – Toxic effect of ethanol, accidental (unintentional), initial encounter
287166006 – Accidental poisoning with ethyl alcohol
Differential Diagnosis & Pitfalls
- Opioid use disorder
- Major depressive disorder
- Bipolar disorder
- Antisocial personality disorder (see personality disorders)
- Borderline personality disorder
- Benzodiazepine withdrawal
- Opioid withdrawal syndrome
- Hepatic encephalopathy
- Metabolic derangement (eg, hyponatremia, hypomagnesemia)
- Diabetic ketoacidosis
- Adrenal crisis / Addison disease
- Infectious diseases (eg, sepsis, meningitis, encephalitis)
- Essential tremor
- Exacerbation of underlying seizure disorder (epilepsy)
- Trauma (eg, intracranial hemorrhage, traumatic brain disorder)
- Intoxication from other substance (eg, cocaine, amphetamines)