ABSTRACT
Pill packs are novel packaging systems designed to contain multiple medications and increase medication access but are not child-resistant and increase the risk of pediatric ingestions. We present two pediatric ingestion cases suspected to involve pill packs. Case 1 describes a 19-month-old male presenting to the Emergency Department with altered mental status and unsteady gait after a suspected clonidine and buspirone ingestion. The patient's father reportedly received his medications in mail delivery "baggies". Case 2 involves a 21-month-old female presenting to the Emergency Department with unsteady gait. During an extensive workup we eventually found a clonazepam metabolite in her urine. A family friend supervising the patient at the time reportedly received medications through mail delivery in "plastic packs". Emergency physicians should be alert to this packaging system as these products contain multiple medications, potentially increasing injury risk and obfuscating diagnosis. Manufacturers, regulatory agencies and public health authorities should assess and reduce the dangers these products pose to children.