2017-18 HSC Section 3 Green Book

Reprinted by permission of J Pediatr Gastroenterol Nutr. 2003; 36(1):120-125.

Journal of Pediatric Gastroenterology and Nutrition 36: 120–125 © January 2003 Lippincott Williams & Wilkins, Inc., Philadelphia

Hair Relaxers: A Benign Caustic Ingestion?

*Stefanie P. Aronow, †Herbert D. Aronow, ‡Thomas Blanchard, ‡Steven Czinn, ‡Gisela Chelimsky

Work was performed at the Department of Pediatrics, Division of Gastroenterology, Rainbow Babies & Children’s Hospital and Case Western Reserve University, Cleveland, Ohio, U.S.A. *Department of Pediatrics, Rainbow Babies & Children’s Hospital, Cleveland, Ohio, U.S.A.; †Department of Cardiology, Cleveland Clinic Foundation, Cleveland, Ohio, U.S.A.; ‡Department of Pediatrics, Rainbow Babies & Children’s Hospital and Case Western Reserve University, Cleveland, Ohio, U.S.A.

ABSTRACT Background: Despite federally legislated safety regulations, caustic ingestions remain a significant problem in the pediatric population. The current standard of care for caustic ingestion includes upper gastrointestinal endoscopy in most cases. Hair relaxers are a common caustic ingestion at our institution, yet few data have been published describing the clinical or endo- scopic outcome. We explored the relative frequency of hair relaxer ingestion, the incidence of associated upper gastroin- testinal injury, and the adverse clinical sequelae resulting from these ingestions. Methods: Consecutive caustic ingestions admitted to our in- stitution between January 1990 and January 2001 were identi- fied. The data were collected through retrospective physician chart review, were analyzed, and were pooled with the existing literature to evaluate for the presence of esophageal injury. Results: 96 charts were reviewed, 29 (30%) of which were hair relaxer ingestions that underwent esophagogastroduodenos- copy; these ingestions served as our study cohort. The median In an attempt to curtail the frequency of caustic inges- tions in the pediatric population, safety labeling, pack- aging, and substance production are federally regulated under the Federal Caustic Act of 1927, the Federal Haz- ardous Substance Labeling Act of 1960, and the Safe Packaging Act of 1970 (1,2). Despite these efforts, caus- tic ingestions remain a significant problem in the pedi- atric population. The American Association of Poison Control Centers (AAPCC) compiles the Toxic Exposure Received May 13, 2002; accepted August 12, 2002. Correspondence and reprint requests to Gisela Chelimsky, Depart- ment of Pediatrics and Division of Gastroenterology, Rainbow Babies and Children’s Hospital, 11100 Euclid Avenue, Cleveland, OH 44106, U.S.A. This work was presented in part at North American Society of Pe- diatric Gastroenterology, Hepatology, and Nutrition World Congress Meeting, August 2000. BACKGROUND

age of the cohort was 14.0 months and patients were evenly divided in gender. The most common symptoms at presentation were drooling and emesis. At endoscopy, lip and oropharyngeal mucosa were most commonly affected. While six patients (20.7%) had Grade I esophageal mucosal injury and five pa- tients (17.2%) had Grade I gastric mucosal injury, none had greater than Grade I mucosal damage. No adverse clinical events were identified. When our data were combined with all previously published cohort data, the findings were similar and no adverse clinical outcomes were reported. Conclusions: Hair relaxer is the most common childhood caus- tic ingestion presenting to our large metropolitan tertiary care center. Symptoms are common at presentation. However, de- spite the high pH of these products, no clinically significant esophageal or gastric mucosal injuries and no long-term se- quelae were identified. JPGN 36:120–125, 2003. Key Words: Hair relaxer—Ingestion—Caustic—Children. © 2003 Lippin- cott Williams & Wilkins, Inc. Surveillance System (TESS) data in cooperation with the majority of U.S. poison centers. Although the incidence of caustic ingestions, or ingestions involving hair prod- ucts, is not reported in the annual TESS report, the AAPCC estimates that more than 1,137,918 human poi- son exposure cases occurred during the year 2000 in children younger than 6 years of age (3). The signs and symptoms manifested at the time of presentation follow- ing caustic ingestion are poor predictors of the extent of esophageal injury (4–6). Therefore, the North American Society of Pediatric Gastroenterology and Nutrition has recommended that upper gastrointestinal (GI) endoscopy be performed in all patients with suspected or known caustic ingestion (7). Caustic substances vary in their potential to cause injury and some substances (e.g., household bleach) are associated with a benign clinical course (8,9). In our experience, ingestion of hair relaxer, an alkaline cream (pH of 11.2–11.9) applied to hair to straighten or smooth its texture, has become increasingly

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