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Revista chilena de pediatría

versión impresa ISSN 0370-4106

Rev. chil. pediatr. vol.90 no.5 Santiago oct. 2019

http://dx.doi.org/10.32641/rchped.v90i5.1017 

ORIGINAL ARTICLE

Characterization of the phone-calls made to a poison center related to household and cosmetics products exposition in pediatrics

F. González1  3 

C. Retamal1  3 

L. Sílva1  3 

P. Cerda2  3 

P. Medel2  3  6  7 

S. Solari4  6 

R. Mellado1  5  6 

J.C. Ríos1  3  4  6 

1 Pharmacist, Chile.

2 Nurse, Chile.

3 Centro de Información Toxicológica, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile.

4 Departamento de Laboratorios Clínicos, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile.

5 Departamento de Farmacia, Facultad de Química y Farmacia, Pontificia Universidad Católica de Chile, Chile.

6 Unidad Docente de Farmacología y Toxicología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile.

7 Departamento del Adulto y Senescente, Escuela de Enfermería, Pontificia Universidad Católica de Chile, Chile.

Abstract:

Introduction:

Household cleaning products and cosmetics are necessary for daily life and widely used by the population. However, their use may not be risk-free, especially when they are not used or stored as recommended. It is important to characterize exposures, as this is useful for developing stra tegies to reduce morbidity, mortality, and health costs associated, especially in the child population.

Objective:

To describe reports associated with household cleaning products and cosmetics exposure in patients under the age of 12, reported to the Poison Information Center of the Catholic University of Chile (CITUC).

Patients and Method:

Descriptive cross-sectional study of phone calls to CITUC during 2016. The analyzed variables were age, sex, product, caller, caller and incident location, ex posure circumstances, exposure route(s), symptoms, and severity from manual records and from the WHO’s electronic record software ‘INTOX Data Management System’.

Results:

3,415 cases met the inclusion criteria. Children under the age of five represented 91% of the exposures, and 58.5% were male. 99.4% were accidental exposures, and 98.6% occurred at home. Family members (57%) and health personnel (42%) made the calls. 68.3% of the patients had no symptoms after exposure. The four products with the highest incidence were household bleach (27.6%), floor cleaners and polishers (13.1%), dish soap (7.9%), and perfume/cologne (5.8%). The main exposure route was by ingestion (89.4%).

Conclusions:

Household cleaning products and cosmetics are common causes of exposures especially in children under the age of five. Although these products have a low morbidity and mortality rate, it is important to educate the population to prevent possible poisonings in the child population.

Keywords: Toxicology; clinical toxicology; household cleaning products; cosmetics; poison center

Introduction

The use of household cleaning products and cos metics is common in everyday life and provides count less benefits for consumers, however, their use may not be risk-free if they are not used and stored according to manufacturers’ recommendations. The potential risk in these situations will depend on the inherent hazard of the ingredients contained in the products and the exposure context.

According to the 2016 annual report of the Ameri can Association of Poison Control Centers (AAPCC), the top three most frequently occurring categories related to human exposures are: painkillers, cleaning products, and cosmetics1. In the same study, it was ob served that exposures in children under 12 are mostly accidental. This probably occurs due to errors in the use and/or storage of these products, which genera tes risk conditions in the pediatric population. In the national context, the Toxicology Information Center of the Pontificia Universidad Católica de Chile (CI- TUC) receives more than 34,000 calls per year, where the main agents involved are medicines for human use (58.1%) and household products (14.6%)2.

In cleaning products, the supplier provides the consumer, through the label, all the necessary infor mation on the use, storage, and risk associated with the products, and in some cases, on a voluntary basis, a toxicology emergency telephone number. That’s why users have access to the CITUC telephone number in cases of exposure to these substances.

Exposures to these agents are reported voluntarily by the user or patients exposed to the Center, who communicates to request advice and technical recom mendations on how to proceed in these situations.

According to this background, it is important to characterize the exposures to cleaning and cosmetic products in the pediatric population, to determine the associated symptoms and the level of severity that the exposures represents. The availability of these data is relevant when implementing strategies to reduce mor bidity, mortality, and costs associated with these expo sures.

Patients and Methods

A cross-sectional descriptive study was conducted. (Table 1) describes the reports included in the study that contain all the calls reported to the CITUC emergen cy hotline during 2016, associated with exposures to cleaning products and cosmetics in pediatric patients under the age of 12. A report is defined as a record in volving a victim/patient exposed to one or more agents and having one or more associated exposure route.

This exposure could generate a clinical picture that could eventually require medical treatment. CITUC also receives requests, calls where information is re quested to the center with no exposed individuals; and incidents, calls where there are three or more indivi duals exposed.

Table 1 Agent categories included in the characterization. 

The data was collected from the manual registra tion forms and from the electronic registration soft ware called ‘INTOX Data Management System’ of the World Health Organization (WHO).

The variables analyzed were sex (female, male), age (newborn: 0 to 28 days; infant: 29 days to < 2 years; preschool children: ≥ 2 years to < 5 years; primary school children: ≥ 6 years to < 11 years; adolescent: ≥ 12 years to < 17 years; adult: ≥ 18 years to < 64 years; older adult: ≥ 65 years), exposure circumstance (ac cidental, suicidal, environmental, abuse or misuse), agents involved, user, location of the user and incident, exposure routes (swallowing, inhalation, ocular, der mal, oropharyngeal mucosa, and other), symptomato logy, referral to emergency service, and severity scale score.

(Table 1) details the agents involved according to the CITUC classification.

To analyze the severity level of each case, the WHO Poisoning Severity Score (PSS) was used3,4 which clas sifies the poisoning severity through a qualitative eva luation of the morbidity associated with them, identifying risks and analyzing the clinical picture.

For this study, the scale was applied according to the symptoms reported at the time of the call to CI- TUC, which represents the severity of the time of the call and not the final condition of the patient.

The severity analysis is carried out based on the following numerical scale, where: None (PSS 0): No symptoms or signs related to intoxication, Minor (PSS 1): Mild, transient, spontaneously resolving symp toms, Moderate (PSS 2): Prolonged or pronounced symptoms, Severe (PSS 3): Severe or life-threatening symptoms, and Fatal (PSS 4): Death.

Exclusion criteria. Records associated with inci dents, requests, and reports in which the agent is not a cosmetic or cleaning product were excluded.

Statistical analysis. The results are expressed as descriptive data with the respective percentage value and frequency. For the calculation of Odds ratio, 95% CI and p-value the online software OpenEpi® was used.

Results

From January 1 to December 31, 2016, CITUC re ceived 32,146 records that include cases. Out of these, 3,415 (10.6%) were analyzed in this study. Calls to CI TUC were made mostly from home (58.5%), followed by medical institutions (40.6%). In 57% of the cases, a family member made the call, and in 42% was the health personnel. The exposure occurred mainly at home (98.6%).

Most of the individuals were men (58.5%), and 99.4% of the exposures were accidental. Regarding age, children under 5 years of age accounted for the majori ty of cases, representing 91% of the total (Table 2). Out of these, infants aged between 1 and 2 years had more reports (47.6% and 24.4%, respectively).

Table 2 Age and sex distribution of human exposure n= 3415. 

Regarding the categories of agents involved, clea ning products and related represents 77.2% of exposu res (Table 1). Within this category, household bleach is the agent with the highest incidence (27.6%), followed by floor cleaners and polishes (13.1%), dishwasher (7.9%), and fragrance/perfume with 5.8% of the cases.

Exposures to household products reported to CI- TUC were mainly related to a single agent (98.8%), however, a case may be associated with more than one product. For this reason, the values analyzed in (Table 1) correspond to a higher number than the total number of studied cases.

95.9% of the people affected were exposed through a single exposure route, while 4.1% of cases were as sociated with multiple routes. Ingestion was the main exposure route (89.4%), and the second-highest incidence was inhalation and ocular exposure, each accou nting for 1.9% of the cases (Table 3). 30.6% of those cases reporting a single route developed symptoms. When analyzing the severity level according to this variable, it was observed that in ocular and inhalation exposures, most of the patients presented symptoms, 93.8% and 58.5% respectively, unlike exposures by other routes where, in most of the cases, the patients did not present symptoms.

Table 3 Route of exposure and Poison Severity Score (PSS) n = 3.384. 

In reports associated with more than one exposure route, 50.4% of patients developed symptoms (Table 3). When comparing a single exposure route with mul tiple routes, exposure to more than one route has 2.3 times higher risk of developing symptoms (OR: 2.3; 95%CI: 1.6 to 3.2; p < 0.0001).

69.0% of the affected people showed no symp toms or signs after the exposure. Out of the patients who presented symptoms, 97.8% were classified in the severity category 1. The signs and symptoms associa ted with this severity category are mainly irritative at a mucous membrane level. 23 cases were classified in the category 2 of the severity scale, that is, moderate seve rity, in which pronounced or prolonged symptoms are presented such as tachycardia, loss of consciousness, crepitus, among others. No cases associated with PSS 3 and 4 were reported. 31 cases were excluded from the severity scale analyses since there was not enough information on the symptoms and signs associated with the exposure to the analyzed agents.

Regarding the calls made from homes, educational institutions, public space or the workplace, only 6.3% required referral to health care services. There were also 444 reports in which observation at home was indicated for a certain period of time, according to the history of each particular report, with indication to go to a health service in case of clinical manifestations previously informed by professionals from CITUC emergency center, equivalent to 21.9%.

Exposures referred to emergency services were associated to fragrance/perfume (22%), followed by floor cleaners and polishes (10.2%), and environment deodorants along with household bleach (7.9% each).

Discussion

During the study period, 3,415 cases associated with exposures to cleaning and cosmetic products were reported in individuals under 12 years of age. The high number of exposures in the pediatric population could be due to a combination of factors, such as the storage of these products at home and/or easy accessibility to them. This is reflected in the fact that most exposures occur at home and the call is made by a family member. This can also be influenced by the characteristics of the products’ packaging which, due to their striking colors and odors, attract the attention of children. If we also consider exploratory behavior and the tenden cy to take objects and put them in their mouth, this creates a scenario that could explain the incidence of reported cases1.

Children under the age of 5 were the most exposed to this products. This is consistent with the AAPCC 2016 annual report, which shows that patients in this same age group are more frequently exposed to cosmetic/personal hygiene and cleaning products1. It should be noted that within this group a higher number of ca ses was observed in patients between 1 and 2 years of age.

Of the two categories of agents analyzed in this study, the one with the highest exposure was cleaning products and related products (Figure 1). This finding relates to the AAPCC 2016 annual report, which sta tes that the first three categories of highest frequency related to human exposures are painkillers, cleaning, and cosmetic/personal hygiene products1. In the data collected by CITUC, the most frequent agents were household bleach, followed by floor cleaners and po lishes, and dishwasher. These data were similar to that observed in the study conducted by the Dr. Felix Bulnes Cerda Hospital between 2000 and 2001, where the agents most associated with exposures in pediatric patients were drugs, hydrocarbons, and bleach-based products7. This may reflect the easy access to these substances at home, therefore it is even more impor tant to educate on the proper storage of products, which ideally should be placed in an enclosed place out of the reach of children to reduce accidents.

Figure 1 Distribution by use or function of the agent n = 3.460. The differences between agent number is explained because most of reports are made by exposure to just one agent (98,8%), some reports are made by exposure to 2 or more agents. 

Exposure to these agents may eventually generate symptoms, which will vary depending on the agent, dose, and exposure route. Due to their components and concentrations, most household products have a low hazard potential8. In addition to this, the events are mostly accidental, so children are exposed to mild or moderate doses. Together, this means that the symp toms following the event are of low severity, or simply no symptoms at all. The results of our research indicate that in more than half of the reported cases the patients remained asymptomatic (PSS 0). The reports that de veloped symptoms presented mainly gastrointestinal and respiratory effects (Table 3), which coincides with other studies9.

According to the results obtained in the analysis of the exposure route, the ocular, inhalation, and der mal route were associated with greater development of symptoms.

Regarding the agents, no association with the level of severity was observed, since at all levels the presence of the same agents could be seen. Even when the cha racteristics of some products could generate a more se rious health condition, this was not identified. The de velopment of symptoms may be related to the context of the exposure, rather than to the agent itself (Table 4). Therefore, the level of severity will be determined by the inherent hazard nature of the substance, expo sure route(s), dose, duration of the exposure, among other factors.

Table 4 Characterization of the symptoms by agent n = 3571. 

Of the calls that were not made from health centers, only 6.3% required referral to an emergency service, indicating that fewer exposures require management by health professionals.

For consumers, the only way to communicate dangers and recommendations for the proper use and sto rage of products is through labeling, so it is important to regulate this information. This is exactly the way that consumers have access to CITUC’s telephone and may call when situations of risk occur. Although most hou sehold products are not classified as hazardous, they are not legally required to have this emergency call service. A large part of the national market for household products purchases CITUC’s toxicological emergency service to provide consumers with timely assistance in cases of incidents related to their products. This is use ful to give instructions on how to proceed initially with the individual exposed to these products and, therefo re, avoid unnecessary emergency visits and reduce the associated health costs.

This study shows that cosmetic and cleaning pro ducts and related products do not represent a high le vel of concern, however, it is necessary to strengthen among the population the necessary measures to en sure proper storage and handling of them, in order to reduce the number of exposures in pediatric patients. For this, it is essential that consumers can read and un derstand the information contained in the label atta ched to the packaging.

Ethical Responsibilities

Human Beings and animals protection: Disclosure the authors state that the procedures were followed ac cording to the Declaration of Helsinki and the World Medical Association regarding human experimenta tion developed for the medical community.

Data confidentiality: The authors state that they have followed the protocols of their Center and Local regu lations on the publication of patient data.

Rights to privacy and informed consent: The authors have obtained the informed consent of the patients and/or subjects referred to in the article. This document is in the possession of the correspondence author.

Conflicts of Interest: Authors declare no conflict of interest regarding the present study.

Referencias:

1. Gummin DD, Mowry JB, Spyker DA, Brooks DE, Fraser MO, Banner W. 2016 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 34th Annual Report. Clin Toxicol. 2017;55(10):1072-254. doi: 10.1080/15563650.2017.1388087. [ Links ]

2. Centro de Información Toxicológica de la Pontificia Universidad Católica de Chile. CITUC UC Memoria 2017. Pontificia Universidad Catolica de Chile. http://cituc.uc.cl/cituc-memoria/ . Published 2017. Accessed August 30, 2018. [ Links ]

3. Persson HE, Sjoberg GK, Haines JA, Pronczuk de Garbino J. Poisoning severity score. Grading of acute poisoning. J Toxicol Clin Toxicol. 1998;36(3):205-13. http://www.ncbi.nlm.nih.gov/pubmed/9656975. Accessed August 30 , 2018. [ Links ]

4. OMS. Escala de severidad de las intoxicaciones - IPCS/EAPCCT. 1998:2. [ Links ]

5. Sawalha AF, Sweileh WM, Tufaha MT, Al-Jabi DY. Analysis of the Pattern of Acute Poisoning in Patients Admitted to a Governmental Hospital in Palestine. Basic Clin Pharmacol Toxicol. 2010;107(5):nono. doi:10.1111/j.1742-7843.2010.00601.x. [ Links ]

6. Greenberg RS, Osterhout SK. Seasonal trends in reported poisonings. Am J Public Health. 1982;72(4):394-396. http://www.ncbi.nlm.nih.gov/pubmed/7065321.0 . Accessed August 30, 2018. [ Links ]

7. Gárate ON, Cendoya UC, Zegers CC, Fernández LE, Alfaro OJ, Díaz TM. Exposiciones a sustancias tóxicas en el Servicio de Urgencia Infantil del Hospital Dr. Félix Bulnes Cerda. Rev Chil pediatría. 2002;73(3):257-62. doi: 10.4067/S0370-41062002000300006. [ Links ]

8. Angerer J, Bernauer U, Chambers C, et al. Opinion on The Potential Health Risks Posed by Chemical Consumer Products Resembling Food and/or Having Child- Appealing Properties. 2011;(March). doi: 10.2772/31904. [ Links ]

9. Meyer S, Eddleston M, Bailey B, Desel H, Gottschling S, Gortner L. Unintentional household poisoning in children. Klin Padiatr. 2007;219(5):254. [ Links ]

Received: December 27, 2018; Accepted: April 11, 2019

Correspondence: Ríos J.C. E-mail: jriosb@uc.cl.

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