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Many parents have questions regarding safety of toys during the holiday season.
The number one safety concern still remains, choking and toys should be chosen based on the recommended age of the child, which should be labeled on the package.
Parents should consider the age of the youngest child in the house, not necessarily the child the toy is intended for, since small parts often end up in the hands of younger siblings. Accidents from ride-on toys (such as scooters and tricycles) also pose risks to children of all ages.
Many of the recalled toys have been removed from store shelves due to lead being detected in these toys. The risk of lead toxicity occurring is considered very low, occurring through chronic or excessive exposure to lead. Discuss any further concerns with your child’s pediatrician. For further information regarding recalled toys, the U.S. Consumer Product Safety Commission website at www.cpsc.gov.
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Halloween should be a fun time for children. However, there is potential for danger. Listed below are Halloween safety tips for adults with young children.
Treats
Feed children before trick-or-treating and give them some candy from home while trick- or-treating to avoid the temptation to eat from their bags.
Inspect all treats before the kids eat them. Eat only treats in original and unopened wrappers. If wrappers are faded, have holes, tears or signs of rewrapping, throw them away. Throw away all unwrapped candy or treats
Allow your child to eat such items only if from someone you know and trust. Check fruits and homemade goodies for foreign objects that may have been inserted or injected, including pins, metal needles or razor blades. Cut fruit into several sections to check for foreign objects.
Consider giving non-edible treats such as stickers, pencil sharpeners, small toys, or pencils.
Pets
Be mindful of pets. Some treats, such as chocolate, can be poisonous to dogs and cats.
Glow Sticks
Glow sticks and necklaces are popular to help illuminate at night during Halloween. The sticks and necklaces occasionally break, or children chew them open. If the contents get on the skin, it can cause irritation and dermatitis. If the contents come into contact with the eyes it can cause severe irritation and cause the eyes to water. Oral ingestion of the contents can cause nausea and burning.
Dry Ice
Be wary of dry ice. While dry ice is a great special effect for a party, keep small pieces of it out of individual drink glasses. When swallowed, oral burns (actual tissue destruction from freezing) may occur. Immediate dilution is recommended.
Dry ice can cause frostbite if it comes in contact with the skin or mouth. Having dry ice in punch is not a problem as long as ice is not swallowed. Direct contact with the skin can also cause tissue damage. Wash skin immediately with lukewarm water. If exposure occurs call the toll-free Poison Help hotline (1-800-222-1222).
Makeup
Look for non-toxic designations when choosing Halloween makeup. Other products may contain emollient laxatives, talc or hydrocarbons which can cause problems. If any makeup is swallowed, treatment depends on amount ingested, ingredients and symptoms. Call the poison center.
If you suspect a poisoning, call the toll-free Poison Help hotline at 1-800-222-1222. All calls are fast, toll-free, and confidential.
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Don’t Let a Poisoning Spoil Your Holiday Season.
Here is a list of possible “Holiday Hazards” the Tennessee Poison Center believes you should know about to keep your children safe during the holidays. If you think someone has been poisoned, call the toll-free Poison Help hotline right away at 1-800-222-1222. All calls are toll- free and confidential. Interpreters are available as well.
ALCOHOL
Even small amounts of alcohol can have significant medical effects on children. Watch where you leave your half full glass of holiday “cheer”. Denatured alcohol also is found in many gifts, such as perfumes and colognes. The nice fragrance often attracts a child to drink a product.
CHRISTMAS TREE GARLAND, TINSEL, ICICLES, etc.
If eaten, these decorations should not cause a poisoning; however, they can cause blockage in the stomach or intestines.
CHRISTMAS TREE ORNAMENTS
Made of thin metal, plastic, wood, glass, etc., are of great concern for their potential to cut or obstruct the mouth or stomach if eaten. However, the dry paint or coloring on these objects is usually not a source of poisoning. Any foreign object which is swallowed could potentially cause serious harm.
JERULSALEM CHERRY
The Jerusalem cherry is considered to be a poisonous plant and should be kept out of the reach of children. It is unclear how many of the brightly colored fruit would have to be eaten to produce problems, but Tennessee Poison Center can give advice on the treatment for a child who has eaten the berries.
MISTLETOE
Certain varieties of mistletoe contain substances which have been reported to cause serious effects on the nervous system, blood pressure, and the heart. Mistletoe berries have the greatest potential for causing problems, although the entire plant is poisonous. Keep mistletoe out of the reach of children and pets. Promptly call Tennessee Poison Center for further information if you suspect a poisoning.
POINSETTIA
There is considerable disparity in reports regarding the potential danger of the different varieties of poinsettias. Tennessee Poison Center, based on the review of evidence from many sources, believes that serious poisonings probably do not occur from eating parts of the domestic varieties of poinsettia. It is possible for children who plays with the leaves of this plant to rub their eyes and experience redness and local irritation to the eyes and skin. Rarely have cases of upset stomach been reported from ingestion of the plant.
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Toxicology Question of the Week
February 19, 2018
What is the Tide Pod Challenge?
We have had many requests for information about tide pods. There are two age groups that are exposed-the toddlers and the teenagers. Unfortunately, bad things can happen to either group. ds
The Devil’s Gusher AKA Tide Pod Challenge
Epidemiology
In 2017, poison centers reported 10,570 laundry pod exposures involving children less than 5yr old. Laundry detergent pods have a higher probability of complications than liquid detergent exposures. Approximately one fourth of cases were related to storing the pods inappropriately.
Now that 2018 is here, a new social media phenomenon called the “Tide Pod Challenge” is causing an increase in cases in adolescents. No, these young adults are not doing their laundry; teens across the country have been uploading videos of themselves ingesting a laundry detergent pod in order to gain views on their social media page.
Anatomy of a Gusher
Ingredients are often more concentrated in the laundry pod form than the liquid detergent form. The basic composition of laundry detergent includes: anionic surfactants, alkaline builders, non-ionic surfactants, polymer, and propylene glycol encased under pressure in a water-soluble membrane covering that dissolves with liquid contact. It has a pH range of 6.8 to 7.4.
Common Scenario
Ingestion is the most common route with symptoms of upset stomach, nausea, vomiting, coughing, choking, wheezing, and mucosal irritation. Most children and teens do well and do not require further treatment other than thoroughly rinsing that mountain spring odor out of their mouth, oral liquid trial, and observation at home for worsening or new symptoms. Your GI physicians can rest easy with the risk of esophageal stricture being very unlikely and routine evaluation with endoscopy is not currently recommended unless clinically indicated.
Scenarios of Concern
Respiratory distress with hypoxia can occur with aspiration of the detergent or with a foreign body occluding the airway. Aspiration can occur a few ways, the pod can become lodged into the posterior pharynx placing it under pressure, the water-soluble casing then dissolves, and the contents gush into the airway causing aspiration. The casing itself can also be aspirated occluding the airway; and although the covering is water soluble, it takes time for the body’s secretions to dissolve the casing completely.
More commonly, due to the pressure within the laundry pod, saliva weakens the membrane and when a drooly toddler bites down with their gummy bite, laundry soap shoots into the back of their throat. This frightens them, and causes aspiration of the soap to occur. Laundry detergent is also a surfactant; once aspirated, it coats the lungs, not only preventing oxygen exchange, but potentially causing chemical burns to the lung tissue. This scenario has resulted in many children requiring intubation and ventilation, and has even resulted in death in many children across the country.
Just because it has Downy does not mean it is a downer. CNS depression has also been seen with the exact mechanism being unknown; yet it has been seen in up to 8% of cases. The literature shows that patients with altered mental status and respiratory symptoms often required intubation.
But that’s not ALL (pun intended), ophthalmic exposure can lead to corneal abrasions; where as, dermal injuries from prolonged exposure to the skin causing second degree and even third degree burns have been reported even after the family has “washed off” the detergent.
The Tennessee Poison Center refers in all children who present on initial call with persistent cough, difficulty breathing, or lethargy / CNS depression post laundry pod ingestion.
Take Home Points
While “The Tide Pod Challenge” is making headlines for teens, exposure is mostly seen in children < 5years old.
Almost 1/4th of pod exposures were related to inappropriate storage; therefore, prevention starts with educating families on keeping harmful substances stored safely high and out of sight.
Vomiting is the most common symptom reported, and it does not necessarily warrant a trip to the ED.
If aspiration is suspected, patients should be seen in an emergency room for difficulty breathing and respiratory support.
A clinical picture of altered mental status and suspected pulmonary injury can potentially require intubation.
For skin exposure, removal of contaminated clothing and thorough decontamination with copious amounts of water is required to prevent chemical burns.
Ophthalmic exposure requires copious irrigation and should be evaluated for corneal abrasions.
Hopefully, you have Gained some insight on this toxicology trend! Any questions, contact your friendly neighborhood toxicologist at 1-800-222-1222
This Question was prepared by Robert Stewart, MD
I am interested in any questions you would like answered in the Question of the Week. Please email me with any suggestion at donna.seger@vanderbilt.edu
Donna Seger, MD
Medical Director
Tennessee Poison Center
Poison Help Hotline: 1-800-222-1222
The Question of the Week is available on our website: www.tnpoisoncenter.org
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Toxicology Question of the Week
January 24, 2018
What are the dangers of button batteries?
Button batteries are small, shiny, and resemble candy which makes them very attractive to children. These tiny batteries can fit into a child’s nose and ears and can easily be swallowed. Larger diameter button batteries such as the 20 mm lithium coin cell batteries are about the size of a nickel. These batteries are becoming more popular because they last longer and have a slim shape that fits easily into compartments. Uncharged or “dead” batteries still have the potential to create enough electrical charge to cause harm.
Button batteries cause damage to tissues by generating an external electrolytic current that hydrolyzes tissue fluids and produces hydroxide at the negative pole. Due to the narrow diameter of a small child’s throat, an ingested button battery can become lodged and burn a hole in the esophagus in two to four hours. If this occurs, severe bleeding, injury requiring surgical repair, or death can occur. Other complications include vocal cord paralysis and months of feeding tubes and endotracheal tubes. When placed in the ear, damage to the ear canal and tympanic membrane can occur, and can result in hearing loss and facial nerve paralysis. Placement in the nose can cause nasal mucosal injury and septal perforation. Unwitnessed lodging of button batteries in any location results in delayed diagnosis and carries the greatest potential for greater injury.
When button batteries are swallowed and lodged in the esophagus, a child may not experience any immediate symptoms. This can make it difficult to assess whether a child may have ingested a battery and delays treatment. Once the battery starts to burn the esophagus, symptoms can manifest as common illnesses such as fever, coughing, wheezing, vomiting, drooling, and loss of appetite. Chest pain can also occur when a button battery is swallowed which can be indicative of it being lodged in the esophagus.
Tennessee Poison Center recommends X-ray imaging as soon as possible. Timing is crucial and should not wait until symptoms occur. The x-ray distinguishes a button battery from a coin, as the battery appears to have a halo shape as opposed to a solid circle. The x-ray also determines the location of battery. If the battery is in the esophagus, endoscopic removal is necessary. If the button battery is in the stomach or intestines, it will pass without intervention.
For further question or concerns about button batteries, call and speak with a specialist at the Tennessee Poison Center 1-800-222-1222 or the National Battery Ingestion Hotline at 1-800-498-8666.
Resources:
Button Battery Injuries in Children: A Growing Risk. Healthychildren.org. https://www.healthychildren.org/English/safety-prevention/at-home/Pages…. Updated February 2, 2017. Accessed November 27, 2017.
More information for patients can be found here: Poison Control - National Capital Poison Center: https://www.poison.org/articles/button-batteries
This Question was prepared by Lindsey Parks, PharmD Candidate of 2019, Lipscomb University College of Pharmacy and Nena Bowman, PharmD, DABAT, Managing Director of the Tennessee Poison Center
I am interested in any questions you would like answered in the Question of the Week. Please email me with any suggestion at donna.seger@vanderbilt.edu
Donna Seger, MD
Medical Director
Tennessee Poison Center
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Question of the Week
January 12, 2017
What are the concerns when “Snow Globes” break?
Snow Globes have long been thought of as a pretty winter decoration – interesting for young and old to watch.
The contents are:
1) Plastic or calcium carbonate
2) Water
Toxicity may come from salmonella organisms in the water, especially when they are manufactured in China or other countries where water supply may be contaminated.
3) Ethylene Glycol (may be added)
Four of 11 Snow Globe manufacturers companies reported the use of Ethylene Glycol (13% to 20%) during manufacturing. Four companies reported the use of distilled water (an algaecide was added to one).
A cat died following exposure to a Snow Globe that contained Ethylene Glycol. Although leakage (or breaking) a Snow Globe may be a potential risk to pets, risk to humans is small due to the small amount of fluid and dispersion of the fluid.
Call Tennessee Poison Center for any concern of potential exposure at 1-800-222-1222.
This Question prepared by: Rhonda Daugherty, RN, CSPI (Certified Specialist in Poison Information) Tennessee Poison Center
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Question of the Week
January 26, 2016
Do you DEWshine?
This past week, the poison center was involved in the care of 4 teenagers from Robertson County who drank Mountain Dew mixed with racing fuel (so called Dewshine). Racing fuel (used for drag racing) is almost 100% methanol. There were two deaths.
It is difficult to determine the incidence of this practice in Tennessee. Clearly, it is a practice of which we need to be aware.
According to the internet (a very reputable source we all know) Mountain Dew and Sun Drop are favorites to mix with corn liquor (better known to most as Moonshine) in the Appalachians.
The life threat is the methanol. Methanol has relatively low toxicity but it is metabolized to formaldehyde which is subsequently oxidized to formic acid. The conversion from formaldehyde to formic acid is very rapid and occurs within minutes. Formic acid is converted by 10-formyl tetrahydrofolate synthetase to carbon dioxide and water. Formic acid accumulates. Not surprisingly, there is a direct correlation between formic acid concentration and morbidity and mortality. Formic acid inhibits cytochrome oxidase, the inhibition increases as the pH decreases, and cellular injury occurs. Lactate is produced as formic acid interferes with intracellular respiration and promotes anaerobic metabolism. The combination of the formic acid and lactic acid can cause a life-threatening acidosis.
Ocular toxicity is caused by formic acid directly. MRI reveals edema and necrotic damage in the basal ganglia and putamen and hemorrhage in the white matter. Cause is thought to be due to failure of Na-K ATPase pump as the formic acid inhibits cytochrome oxidase.
Signs and symptoms include nausea/vomiting and CNS depression (depending on methanol dose). A latent period lasting 12-124 hours and blurred vision may occur.
Blood analysis reveals an osmolar gap (depending on the amount of methanol that has not been metabolized); an acidosis (depending on the amount of methanol that has been metabolized); and an anion gap.
Treatment is correction of the acidosis with sodium bicarbonate and administration of fomepizole which is a potent inhibitor of alcohol dehydrogenase. Prior to fometpizole, ethanol was administered but there were multiple problems with that administration. (Drunk people in the PICU/ICU can be difficult to manage). Depending on the methanol concentration and the clinical picture, hemodialysis may be necessary.
This question prepared by: Donna Seger, MD Medical Toxicologist
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Question of the Week
January 23, 2012
What does mercury have to do with beauty?
On September 2, 2011, the Texas department of health issued a news release to make the public aware of the presence of inorganic mercury in beauty creams such as Crema Aguamary. These creams are from Mexico and advertised as beauty creams, blemish removers, anti-aging creams, and skin lightening creams. This isn’t a novel idea that just started in the 21st century. Mercury has been added to soaps, creams, and ointments as an agent to bleach skin in areas of hyperpigmentation for many moons.
Unfortunately, the active ingredient of mercury is usually not listed on the label or is listed as “calomel” which is mercurous chloride; thus many users of the product may not know that they are exposing themselves to inorganic mercury. Test samples of the Aguamary face cream contained concentrations of inorganic mercury ranging from 56,000 to 122,000 parts per million (ppm) and eye cream samples contain from 239 up to 6,780 ppm Hg. The FDA tolerance level for mercury in cosmetics is 1 ppm.
Inorganic mercury can be absorbed transdermally. This can result in toxicity that may result in neurologic, neuropsychiatric and possibly renal effects. In 1996, there was a product called Crema de Belleza that was distributed in the southwest and had elevated mercuric chloride in the compound. There were cases of elevated mercury levels in children of family members who used the cream-unclear as to the route or method of exposure.In addition, there have been reports of elevated levels of mercury in infants of mothers who used these creams during pregnancy. Yikes!
This question prepared by: Saralyn Williams, MD Medical Toxicologist
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What products in the home contain ethanol?
Because concentrations in home products are quite high, ingestion of relatively small amounts may cause symptoms. Typical household items include mouthwash (15-27%), cough and cold preparations (25%), perfume and colognes (50%), aftershaves (50-90%), hairspray (25-80%). The volume needed to be ingested to cause inebriation (blood alcohol level ~100mg/dL) in a �typical 15 kg, two year old child would be 50 mL of mouthwash (20%), 40 mL of a cough/cold preparation (25%), 20 mL of a perfume/cologne (50%), 20 mL of aftershave (50%), and 15 mL of hairspray (70%) Remember that the �average volume of a swallow for a child between 2-4 years of age is about 4.5 mL.
Do you know what products contain alcohol (ethanol) in your home? Many products used on a daily basis contain ethanol as part of their normal constituents. Increasing patient awareness of these products educates and prevents accidental poisoning. Normally we think of beer, wine, whiskey and other �drinking alcohol as containing ethanol. Typical ethanol concentrations in these products are 4-6% for beer, 10-20% wine, and �hard liquors 20-50%.
Significant amounts of these products cause CNS depression along with its complications of aspiration and possibly trauma. A more common problem in young children is hypoglycemia, which may be associated with seizures, coma and death. Although hypoglycemia is more common in young children, it may also occur in older children and adults. There are reports of hypoglycemia following chronic ethanol ingestion.
If ethanol has been ingested, watch for development of CNS depression and support the patient as appropriate. Consider the potential for hypoglycemia and give glucose supplementation as indicated.
Question prepared by:
John Benitez , M.D., MPH Medical Toxicologist