Aluminium phosphide poisoning in children: repeated lessons unheeded in Pakistan

Dear Editor, In our paediatric emergency department, we have recently received multiple children with aluminium phosphide (ALP) poisoning who had no chance of survival. Each presentation followed the same sequence: a child who was well hours earlier, a family unaware that the fumigation tablet in their home was lethal, and a resuscitation team arriving too late to alter the outcome. By the time phosphine-induced cardiotoxicity is established no intervention in the clinical arsenal can reverse the process. Failures of regulation, labelling, and public awareness are the main causes of such tragedies. ALP remains freely available, inexpensive, and unlabelled across Pakistan, with a reported mortality of 72.41% in documented cases [1, 2]. Despite repeated published warnings over the past decade, children continue to die from a preventable exposure. In 2010, Hirani and Rahman described three siblings exposed in Karachi; two died, and one survived after cardiac support [3]. In 2022, Jamali and Siddiqui reported three sisters admitted following domestic fumigation; one was brought dead, two required PICU care for arrhythmias, pulmonary oedema, and reduced ejection fraction [4]. In 2026, we continue to observe the same sequence: vague gastrointestinal symptoms that progress insidiously to myocardial dysfunction, arrhythmia, and multi-organ failure are observed. Sajjad MM, Shahzad H, Tariq A. Deliberate ingestion of aluminum phosphide tablets as a treatment for dyspepsia. J Coll Physicians Surg Pak. 2023;33(5):600. doi:10.29271/jcpsp.2023.05.600 Jan S, Khan MA, Anwar S, et al. Demographic and clinical profiles and mortality of aluminium phosphide poisoning cases in Khyber Pakhtunkhwa Province, Pakistan. Gomal J Med Sci. 2021;19(1):11-18. doi:10.46903/gjms/19.01.1052 Hirani SAA, Rahman A. Aluminium phosphide poisoning: a case report. J Ayub Med Coll Abbottabad. 2010;22(4):221-222. Jamali A, Siddiqui E. Phosphine gas poisoning in children: a case series study from tertiary health care center of Karachi, Pakistan. J Pak Med Assoc. 2022;72(Suppl 1):S72-S76. Agrawal VK, Bansal A, Singh R, et al. Aluminum phosphide poisoning: possible role of supportive measures in the absence of specific antidote. Indian J Crit Care Med. 2015;19(2):109-112. doi:10.4103/0972-5229.151021 the underlying mechanism [5]. For the children who were not saved, the failure did not occur in the resuscitation room; it occurred earlier, when an unlabelled tablet was manufactured, sold without restriction, and placed in a family home without labelled warning. Clinical excellence cannot compensate for regulatory failure, until ALP is removed from unregulated domestic use, emergency physicians in Pakistan will continue arriving too late to a preventable tragedy.