Comprehensive Drug Screening in Pediatric Patients: Is It Worth It?
ABSTRACT & COMMENTARY
Source: Belson MG, Simon HK. Utility of comprehensive toxicologic screens in children. Am J Emerg Med 1999;17: 221-224.
In this study on toxicologic screens, belson and Simon evaluated the effect of comprehensive drug screening in pediatric patients. Using a retrospective design, Belson and colleagues determined the clinical and financial impact of 463 comprehensive drug screens performed in 444 patients. In this paper, the comprehensive component evaluated was an extensive chromato-graphic analysis performed in addition to a urine screen for drugs of abuse and a limited blood screen for common toxins (acetaminophen, salicylates, and ethanol).
The results demonstrated that 227 of the 234 positive screens (97%) were either suspected based on history or physical examination, already detected by the limited drug screen, or were deemed to be clinically insignificant. Although the remaining seven screens found previously unsuspected and undetected toxins, in no case did the results alter management. One example was finding codeine in a patient who had already been given naloxone with a good clinical response. Interestingly, the cost for comprehensive screening in this study was determined to be $16,205.
Comment by Robert S. Hoffman, MD
More than half of the approximately 2 million annual exposures reported to United States poison control centers occur in children younger than the age of 6. Nevertheless, neither severe morbidity nor mortality from poisoning is common in this age group. This low risk largely results from the unintentional nature of childhood exposures. With advancing age, however, substance abuse and suicide attempts increase the risk of poison-related complications.
When faced with an ill patient of any age, it is always important to determine whether poisoning could be responsible for the clinical problem. While history, physical examination, and rapid bedside tests will usually suffice to define the likelihood of poisoning, many clinicians request additional assistance from the laboratory. Laboratory testing can be accomplished in several ways: directed quantitative tests for suspected toxins, such as acetaminophen or theophylline; rapid qualitative urine screening for drugs of abuse by enzyme technology; or comprehensive qualitative urine screening by chromatography.
Many investigations have demonstrated an extremely limited utility for qualitative testing in adults. These tests are wrought with false-positive and negative results, and even when accurate, only confirm exposure. Since metabolites persist in the urine for days to weeks, the decisions are always clinical. Unfortunately, widespread use of comprehensive drug screening continues.
Belson et al correctly conclude that routine comprehensive toxicology testing is an unnecessary and costly endeavor in pediatric patients. I would add that routine screening of urine for drugs of abuse is also unnecessary.
However, in select cases, laboratory confirmation of clinical suspicions may be required. Specifically, when there is a suspicion of child abuse or neglect, product tampering, or attempted homicide, laboratory results may have significant legal and civil ramifications; although they rarely alter medical decision making.
Comprehensive drug screening in pediatric patients:
a. is cost-effective.
b. usually confirms what has been found during the history and physical examination or on limited drug screens.
c. is mandatory when evaluating a pediatric patient with abdominal pain.
d. is mandatory when evaluating the pediatric patient who admits to ethanol intake.
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