Snake bite mortality in children: beyond bite to needle time MP Jayakrishnan, MG Geeta, P Krishnakumar, TV Rajesh, Biju George Government Medical College, Kozhikode, Kerala, India Correspondence to Dr M P Jayakrishnan, Government Medical College, Kozhikode 673008, Kerala, India; mp.jayakrishnan@gmail.com Received 3 May 2016 Accepted 18 October 2016 To cite: Jayakrishnan MP, Geeta MG, Krishnakumar P, et al. Arch Dis Child Published Online First: [ please include Day Month Year] doi:10.1136/ archdischild-2016-311142 ABSTRACT Objective To study the clinical characteristics and predictors of mortality from snake bite envenomation in children. Design Prospective observational study with a one-group cohort design. Setting Paediatric intensive care unit of a tertiary care hospital in South India. Subjects The study cohort consisted of 145 children (55 girls and 90 boys) <12 years of age with snake bite envenomation. Methods Demographic and clinical details were recorded in a semistructured pro forma. Children were treated with polyvalent antisnake venom (ASV) as per WHO protocol. Details of treatment, complications and outcomes were recorded. Univariate analysis was done to identify statistical significance, and those variables found to be significant were analysed using binary logistic regression. Results Russell’s viper was the most common offending snake followed by hump-nosed pit viper. Features of haemotoxicity, neurotoxicity and combined haemotoxicity and neurotoxicity occurred in 68 (47%), 39 (26.9%) and 9 (6%) children, respectively. Acute kidney injury (AKI) occurred in 36 (25%) children. The mortality rate was 10.3%. On univariate analysis, nocturnal bites, severe leucocytosis on day 1, AKI, capillary leak syndrome and a need for more than 20 vials of ASV were significantly associated with mortality. On multivariate analysis, only severe leucocytosis on day 1 (OR 35.29; 95% CI 1.37 to 911.89) and AKI (OR 35.05 95% CI 1.74 to 706.93) were found to be independent predictors of mortality. Conclusions This study has identified two hitherto unrecognised risk factors—severe leucocytosis on day 1 and capillary leak syndrome. These findings need to be taken into consideration when planning management strategies for snake bite envenomation in children. INTRODUCTION There has been considerable improvement over the last few years in the management of envenomation due to snake bite, and the protocol recommended by the WHO has resulted in standardisation across settings in Southeast Asia. 1 In 2009, snake bite was categorised as a ‘neglected tropical disease’ by the WHO, and antisnake venom (ASV) was included in the list of essential drugs. 1 However, it is still an important cause of mortality and morbidity world- wide, and at least 20 000 deaths are reported each year. South Asia, Southeast Asia and sub-Saharan Africa have been affected the worst, with the highest number of bites and related mortality occurring in India. 2 Globally, most cases of snake bite envenomation are caused by species of Elapidae and Viperidae. The major species of venomous snakes in India are the Russell’s viper, common krait, Indian cobra and the saw-scaled viper. Other species like the hump- nosed pit viper (HNP) are encountered in certain geo- graphical regions in South India and Sri Lanka. In the Indian subcontinent, haemotoxicity has been described only with viperine bites, whereas elapid bites cause neurotoxicity. Bites by the Russell’s viper can cause combined haemotoxicity and neurotoxicity. 1 Data regarding the epidemiology of snake bite are often unreliable, since most bites occur in rural areas, where medical facilities are not easily access- ible and many of the victims seek care from trad- itional healers. Hence, the actual numbers are likely to be much higher than what hospital records would suggest. Most studies on the epidemiology and predictors of mortality involve adults. 3–6 The million-death project on snake bite mortality reported about 45 900 annual snake bite related deaths in India, with the most deaths occurring in the age group of 5–14 years. The study found that mortality due to snake bite envenomation varies across different states. 7 However, data from the state of Kerala were not included in this study. A hospital-based study from Kerala reported 635 patients admitted with snake bite, with 219 cases of envenomation during a period of 1½ years. 3 The present study was undertaken to outline the clinical characteristics of snake bite envenomation in children and to identify the predictors of mortal- ity. The setting was the Paediatric Intensive Care What is already known on this topic? ▸ Snake bite envenomation is an important cause of mortality in children. ▸ Acute kidney injury, haemotoxicity, anaemia and prolonged bite to needle time are predictors of mortality in snake bite envenomation in children. What this study adds? ▸ Severe leucocytosis on day 1 is an independent predictor of mortality in snake bite envenomation in children. ▸ Capillary leak syndrome is associated with high mortality in children with snake bite envenomation. Jayakrishnan MP, et al. Arch Dis Child 2016;0:1–5. doi:10.1136/archdischild-2016-311142 1 Original article ADC Online First, published on November 2, 2016 as 10.1136/archdischild-2016-311142 Copyright Article author (or their employer) 2016. Produced by BMJ Publishing Group Ltd (& RCPCH) under licence.