**1. Introduction**

122 Complementary Pediatrics

Zeltzer, L.K., Dolgin, M.J., LeBaron, S., & LeBaron, C. (1991). A randomized, controlled

Zeltzer, L.K., Tsao, J.C.I., Stelling, C., Powers, M., Levy, S., & Waterhouse, M. (2002). A

Vol.25, No.5, pp. 430–437, ISSN 0885-3924

*Pediatrics*. 88, pp. 34–42. ISSN 0031-4005

ISSN 0885-3924

patients with advanced cancer in Korea. *Journal of Pain and Symptom Management,* 

study of behavioral intervention for chemotherapy distress in children with cancer.

phase I study on the feasibility of an acupuncture/hypnotherapy intervention for chronic pediatric pain. *Journal of Pain and Symptom Management*, 24, pp. 437–46. ,

> It has been estimated that worldwide about 5 million people (adults and children) are bitten by snakes every year (Kalantri et al., 2006), and 50,000 die according to data from the World Health Organization (Schaper, de Haro, Desel, Ebbecke, & Langer, 2004). However, it is well known that events related to snake bites are under-reported, especially in the author's country possibly because snakebites are not a very relevant cause of mortality. Nevertheless, they are a serious cause of morbidity, especially in children. Under-reporting of this important health issue can be blamed on the fact that the population is not well informed about snake classification causing them to not provide accurate information to healthcare personnel when a patient is taken for medical care after a snake attack. Children do not react to snake bites in the same way as adults. In children, this event is always more severe since they are exposed to a larger amount of venom per m2 of body surface (De la O Cavazos 2006). A small child is more vulnerable to a given volume of venom than a larger individual (Hodge III & Tecklenburg, 2006) Also, there will be different presentations including neurotoxicity, myotoxicity, renal failure, edema, bleeding due to activation of clotting proteins, and intravascular hemolysis, because different kinds of snakes have different types of venom that cause different symptomatology. (Jeng & Glader, 2004).

> On the other hand, there is very little information for primary care physicians and pediatricians and most of the time it is outdated. Hence, the need for a reliable source of information in the event of a snake bite in pediatric patients that is updated, easy to find and well-structured in a way physicians find it easy to read and to easily and rapidly translate it into clinical practice to assure a fact-based, accurate treatment and prompt recovery with the least possible amount of sequels.

#### **2. Epidemiology**

Snakebites are seriously under-reported all over the world. We currently do not have trustworthy studies or statistics to asses this problem. What we do have is information that can guide us and inform us about the most affected areas and the most common presentation. For example, studies such as the one by Ruiz Molina and cols. show not only a

Snake Bites in Pediatric Patients, a Current View 125

In the world there are over 2,500 snake species described, of these, only about 350 are considered poisonous and dangerous for humans. These 2,500 snake species are divided into 15 families and the following have enough species to be relevant or dangerous (Government of Canada, n.d.): Colubridae, Boidae, Viperidae, and Elapidae or Hydrophiidae. Just as we have countries where venemous snakes are a major health issue because of the large number of species they harbor, we also have countries where venemous snakes are virtually non-existent (except for imported snakes), such as New Zealand, Cuba,

In this chapter, we are going to be focusing on the snakes most commonly found in the Americas, more specifically in North America (the United States and Northern México), These snakes are from the Elapidae and the Viperidae families such as the pit viper, the rattlesnake, the water moccasin, and the copperhead, since they are responsible for about 99% of the cases reported. The coral snake, which can also be found in North America, is

Fig. 1. Diagram that shows the fifteen families of snakes in the world. The families marked

A very important part of the process of providing the best medical care available resides in the identification of the snake. Important as this is, it is recommended not to go after the snake to try to identify it or kill it. We need to remember that most snakes only attack when they feel menaced in the first place, thus, going after a snake after it has already attacked would put us in more danger, risking a second bite or a first bite in a different person. If we are in an advantageous situation (adequate lighting, such as broad sunlight, regular, flat

in red contain the most important and dangerous snakes in America.

Haiti, Jamaica, Puerto Rico, Ireland, Polynesia, Hawaii and the polar regions.

responsible for only 1% of the cases, along with the exotic imported species.

**3. Snake identification** 

higher incidence in men (2.5:1) but also a reasonably high incidence in pediatric population between the ages of 11 and 16 (39.3%), followed closely by even younger children ages of 6- 10 (32.1%). This may be related to the fact that in several under-developed tropical countries where snakebites represent a major health issue children take part in agricultural activities or are attacked due to their innate curiosity, which in turn, makes them victims more easily than adults. Snake bites remain a public health problem in most countries. This is especially true in countries where agricultural activities are predominant, since this is one of the occupations more often affected by snakebites (Chippaux, 1998). Once we get hold of he few statistics we have, we face a new problem: the disparity in the epidemiological data. This reflects different grades of reporting. The more industrialized the country, the more reliable the statistics are. Sadly, snake bites are a problem related to low-income countries that have frail health systems and a lower rate of reporting. Also, morbidity and mortality have low rates and are well documented in first-world countries, probably because of the health facilities and availability of newer and better treatments. This is yet another argument to sustain that snake envenoming is a disease of the underdeveloped countries. In the few studies we can relate to, a negative association between snakebite deaths and government expenditure on health services has been found. Because of this, mortality is highest in these countries, since the population has no access to proper and adequate treatment and the government is not able to provide it because they are just not capable of dealing with the financial burden of snakebites (Harrison, Hargreaves, Wagstaff, Faragher, & Lalloo, 2009).

In México, an average of 20 deaths per year are reported. However, very few accidents are reported in communities most at risk. These communities also have little access to health services. In fact, about 27 000 cases of snake envenomation and more than 100 deaths per year occur in México. Between 1994 and 1996, the Mexican Social Security Institute (IMSS) reported 1 961 venomous snake bites; thirty percent of patients were children. In the IMSS report, the age group most affected was 15 to 44 years, with 51.4% of cases. The immense majority of poisonings occurred between June and October and 70-90% of these bites were located in the legs.


Table 1. Areas most commonly involved in snakebites.

For years, it has been accepted that snake attacks occur in the field and men are the most affected, but in the study by Sotelo-Cruz it was found that there is no predominance in gender and while it is true that most of the children attacked were from rural areas, these attacks occured nearby their living places in some cases even within their home. The seasons of the year when more attacks were reported were summer and autumn. This is because the summer season in these countries lasts nearly six months. The time of day when most of the attacks happened ranges from 2:00 and 7:00 p.m., although 12.7% of the attacks happened during the night, the injury site was located in the legs in 78.1% of cases (Sotelo 2004).
