Just because it's natural doesn't mean it's safe: A case of pediatric toxicity from topical and herbal remedies

Document Type

Conference Proceeding

Publication Date

9-4-2025

Publication Title

Clin Toxicol

Abstract

Background: The use of alternative medicine is an increasingly popular trend among consumers seeking holistic treatments marketed as “natural”alternatives to Food and Drug Administration (FDA) approved prescription and over-the-counter medications. However, the clinical utility of these products remains controversial due to variable potency, potential xenobiotic interactions, limited regulatory oversight, and an overall dearth of safety and efficacy data. We report a case of a 5-month-old female who presented with salicylism and coagulopathy, likely secondary to “natural”supplements. Case report: A 5-month-old female, unimmunized and born at home, presented to the emergency department with decreased oral intake and altered mental status. Presenting vital signs were HR of 204 bpm, RR 40 breaths per minute, BP 69/25 mmHg, and a rectal temperature of 36.6 °C. Due to the child's tachycardia, tachypnea, and hypotension, a broad workup was initiated. Initial laboratory evaluation revealed: Sodium 153 mMol/L, potassium 5.4 mMol/L, chloride 119 mMol/L, bicarbonate 9 mMol/L, anion gap 25, glucose 77 mg/dL, creatinine 0.77 mg/dL, ALT 50 U/L, AST 61 U/L, INR >9.36, PTT 86.8 seconds, aPTT 28.6 seconds. Beta-hydroxybutyrate was 16.6 mg/dL. Venous blood gas showed a pH of 6.98, PCO2 24.4, and lactate 12.15 mmol/L. Salicylate concentration was 31 mg/dL. Infectious and additional toxicological screenings, including acetaminophen and ethanol, were unremarkable. The patient received crystalloid fluid resuscitation, vitamin K, calcium gluconate, and urinary alkalinization therapy with sodium bicarbonate, and was admitted to the pediatric intensive care unit. Nephrology was consulted for anuria and initiated diuresis with furosemide. The salicylate concentration initially decreased to 24 mg/dL and remained stagnant with a 12-hour repeat at 25.2 mg/dL. Soon after, the patient's mother was witnessed applying a cream on the patient intended for the treatment of eczema. The mother disclosed she had been administering a natural regimen for several weeks, which included a cream containing 1% salicylic acid, baby tooth oil containing eugenol, and calendula oil rich in vitamin E. The products were discontinued, and dermal decontamination was performed. N-acetylcysteine and albumin were administered while sodium bicarbonate treatment continued. The patient's coagulopathy and salicylism resolved within 48 hours.Discussion: This case highlights the potential dangers of perceived benign “natural”remedies in pediatric patients. While this patient had a positive clinical outcome, the potential for significant morbidity and mortality nonetheless remains. Salicylic acid, particularly with chronic topical application in setting of compromised skin integrity, can lead to systemic salicylism. Literature regarding extracorporeal removal of salicylates in infants is limited. Forced diuresis is generally not recommended for toxin removal though it was performed in this case for anuria. Eugenol, (4-allyl-2-methoxyphenol), is associated with hepatotoxicity and coagulopathy, and treatment with N-acetylcysteine is supported in literature. Vitamin E, particularly in setting of vitamin K deficiency, may contribute to coagulopathy.Conclusions: Healthcare clinicians must remain vigilant in assessing alternative remedy use, particularly in pediatric patients. Chronic administration of unapproved and unregulated products can result in significant toxicity. Education of caregivers regarding the potential risks of these agents is paramount to prevent harm.

Volume

63

First Page

91

Last Page

92

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