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Products that resemble foods and appeal to children Potential risks of accidental ingestion

1. Past cases of accidental poisoning by cosmetics & liquid household products

    The SCCS opinion states:

    6. BACKGROUND INFORMATION FROM ACCIDENTAL INGESTION POISONINGS

    6.1. General considerations

    Poison centres in various EU and non-EU countries register cases of accidental poisoning. These cases are summarised in the poison centres’ annual reports and usually include information concerning age, sex, location of exposure, acute or chronic exposure, chemical and product group classification details. Since household products are still often involved in accidental poisonings despite preventive management measures introduced by regulators or manufacturers, the European Chemical Industry Council CEFIC (Europe) funded a two and a half year project (Sept 2006-Feb 2009) called DeNaMic (Description of the Nature of the Accidental Misuse of Chemicals and Chemical Products) (Wyke et al. 2009). This project aimed to provide an overview of the nature and extent of injury from chemicals and chemical products in Europe and detail the circumstances of how these exposures occur. However, there were some differences in compiling data from different poison centre annual reports, as the data were not reported in a homogenous way. Specific product information, such as packaging details, concentrations of ingredients, storage details and information on the cause of exposure were not reported.

    Since CPRF are a sub-set of household and personal care products, it was initially thought that information from the national poison centres or in the scientific literature would be helpful in fulfilling the mandate of this opinion. However, only a few cases following accidental intake of CPRF/CAP were reported by poison centres, mainly due to the lack of sufficient registered information to discriminate these kinds of products. There has been an “epidemic” of poisonings in the USA due to the package design and colour of a new marketed product, resembling that of a food product (Miller et al. 2006; see Annex II).

    In general, it is difficult to estimate accidental ingestions of cosmetics and liquid household products because the majority of accidental ingestions are innocuous. Indeed, many incidents of accidental ingestion are not reported to physicians if they are believed to be inconsequential. In addition, physicians and hospitals will not report cases to a poison control centre if they have had experience with similar cases and do not require further information.

    6.2. Characteristics of patients involved in accidental poisoning

    Children are more frequently involved in accidental poisoning than any other age group. Children below three years old accounted for the majority of childhood poisoning (72% of cases reported in French poison centres in 2002) (Guyodo and Danel 2004). Between 1990 and 2006, US emergency departments treated 192,288 cases of accidental injuries involving household cleaning products in children between 1 and 3 years old (McKenzie et al. 2010). Children under the age of 6 accounted for nearly 52% of the more than 2.2 million poison exposures reported in 2004 by the American Association of Poison Control Centers (Madden 2008).

    Paediatric poisonings are generally unintentional (>99% of all poisoning exposures) Toddlers are vulnerable to accidental poisoning because they are newly mobile and curious. Moreover they may mistake a brightly coloured product for candy or a beverage. The major route of exposure was oral and involved liquids for babies (less than 3 years of age) and solid products for older children (older than 13 years). Children of the age group 4 to 12 years were exposed to both liquid and solid products (Guyodo and Danel 2004).

    It is known that the home is the most common location for accidental poisoning of children. Data from UK poison centres suggest that the domestic environment is the most common location for poisoning to occur. From the total number of inquiries made to UK poison centres, the percentage of calls that concern poisoning in the home increased from 77% in 2003/2004 to 89% in 2006/2007 (National Poisons Information Service Annual Reports (UK) 2003/2004-2006/2007).

    6.3. Products commonly ingested by accident

    In recent decades, cleaning products have consistently been in the top five categories of paediatric poisoning exposure (WHO 2008a, Wyke et al. 2009) The toxic agents most often involved in accidental poisoning were pharmaceuticals and household products. Among children from birth to 3 years old, frequency of poisonings from pharmaceutical and non-pharmaceutical products is similar. The products most frequently involved in paediatric exposure cases were: cosmetic and personal care products; cleaning products; and analgesics, in descending order of frequency (Watson et al. 2005).

    Exposure to cleaning products or detergents reported to the GIZ-Nord Poisons Centre in Göttingen (Germany) between 1999 and 2008 represented 10% of all exposures recorded for all age groups (Desel and Wagner 2010). Exposure to cosmetic products represented 4.8 % of all exposures recorded (Desel et al., 2010).

    In the DeNaMic project, the data recorded by the poison centres were analysed and the potential usefulness of these data for risk assessment purposes was evaluated. A questionnaire survey of European poison centres was carried out. Questionnaires were sent to 89 poison centres in 33 countries. In the context of this survey, 16 poison centres provided a list of products and agents which are most frequently involved in the top five categories of poisonings; this information is often available in their annual reports. The results show that household cleaning agents, such as toilet cleaners and dishwashing detergents which are commonly used in homes, are most frequently involved in accidental poisonings.

    The products were often characterised by their chemical and physical properties e.g. corrosive, bleach, desiccant or solvent, and nearly all poison centres listed such products in their “top five” list. Some chemicals were specifically named due to their importance e.g. sodium hypochlorite, sodium hydroxide, alcohols and hydrogen peroxide. Corrosive chemicals and detergents/surfactants were predominant: 1) due to their toxic potential and widespread use e.g. descalers, bleach, and drain cleaners; and 2) due to the widespread use in households. Other product groups which were mentioned by poison centres were pesticides, fuels, and several alcohols, which were grouped as solvents.

    Household chemical consumer products commonly ingested by children are presented in Table 2. It is possible that some of these products could be ingested by children because of their child-appealing properties. However, sufficient data are not available.

    Table 2: Household chemical consumer products commonly ingested by children (Wyke et al. 2009)

    6.4. Types of adverse effects

    There are no statistics available to estimate the burden of injuries caused by poisonings. Global data, in particular, on non-fatal outcomes of poisoning are not readily available (WHO 2008a). The epidemiology of poisoning can be studied from hospital admissions and discharge records, mortality data, emergency department records and surveillance systems, as well as from enquiries to poison control centres. Desel and co-workers reported that between 1999 and 2008, 2% of exposures to cleaning products and detergents and 0.8% of exposures to cosmetic products were considered moderate or severe (Desel and Wagner 2010, Desel et al. 2010). There were 6 lethal cases following exposure to cosmetic products, representing 0.05% of total exposure to cosmetic products and 9 cases following exposure to cleaning products and detergents, representing 0,03% of total exposure to these kind of products. Among cosmetic products, hair colouring agents were considered as the product group with the highest poisoning risks

    Concerning childhood poisoning incidents it is thought that there is substantial under- recording and under-reporting of cases. Fatalities in young children following toxic ingestions are rare (Watson et al. 2005). Most of the poisoning cases reported in children were not serious: the death rate reported by Guyodo and Danel (2004) is 0.026% of the poisoned children. In UK, less than 5% of all accidental exposures to household chemical consumer products resulted in clinical symptoms (Bateman 2003).

    In two publications (Lamireau et al. 2002, Marchi et al. 2004), clinical and epidemiological features of toxic exposures observed in 14 Italian hospitals during 2001 in children under 1 year old were reported. In most cases, non–toxic exposures, or exposures without any clinical consequences, were reported and the symptoms were rarely serious. Initial symptoms reported by parents whose children were admitted to the paediatric emergency care unit were mainly gastrointestinal (vomiting, abdominal pain) or neurological (impaired consciousness, hypotonia, ataxia, seizure), although cutaneous (rash), respiratory (dyspnoea, cough) or dysphagia were also reported in some children. On arrival at the paediatric emergency care unit, most of the digestive symptoms (essentially vomiting) had stopped, whereas cardiovascular symptoms (dysrhythmia, hypotension) were noted. Nevertheless, more than half of the children remained asymptomatic. Of the children admitted to the paediatric emergency care unit, 40% received no treatment, 10.6% had symptomatic treatment and 25.5% underwent gastric emptying (Lamireau et al. 2002).

    Many of the cases of accidental ingestion of cosmetic and household products brought to the poison centres are sent home untreated. However, on the basis of the available data on the adverse health effects by accidental ingestion of cosmetics and liquid household products, the following effects may be seen:

    Only limited data are available on adverse health effects of accidental ingestion of CPRF and CAP. However, as CPRF and CAP are subsets of cosmetic and household products, similar effects are expected.

    In the elderly, these effects may be exacerbated by underlying health status (Annex II). Both children and elderly persons are prone to aspiration, which may result in severe pulmonary manifestations.

    Aspiration of vomited material may damage the lung tissue, particularly the alveoli because of the acidity of the stomach contents. Such material can, on its own, cause inflammation of the lung tissue, but this is usually transient. However, if the vomited material contains accidentally ingested xenobiotics, such as surfactants and emulsifiers, chemical pneumonia may develop as a result of further inflammation and damage of the lung tissue. This can also be induced by aromatic oils as their low viscosity increases the chance of inhalation rather than swallowing. Chemical pneumonia is a particular problem with children and the elderly, and has resulted in deaths.

    Exposure to corrosive substances may also be of concern since minimal ingestion can cause severe oesophagogastric burns.

    Source & ©: SCCS,  Opinion on the potential health risks posed by chemical consumer products resembling food
    and/or having child- appealing properties
    , (2011),
    Background Information From Accidental Ingestion Poisonings, pp. 10-13


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