2017-18 HSC Section 3 Green Book

S. A. ARONOW ET AL.

one day and no long-term clinical sequelae were re- ported. (20) In another case study, Babl described an 11- month-old boy who presented after hair relaxer ingestion with inspiratory stridor when crying, but with a normal EGD 15 hours after ingestion and no clinical sequelae (21). Therefore, our analysis of the combined published cases revealed only 1 of 213 cases with greater than grade I esophageal mucosal injury and no apparent clini- cal sequelae. In this retrospective cohort study at a large metropoli- tan tertiary care hospital, we found hair relaxer ingestion to be the most common caustic ingestion over an 11-year period. Gastrointestinal mucosal injury progressively de- creased moving distally from the oro-pharynx to the stomach. While symptoms were common at presentation, no clinically significant esophageal or gastric mucosal injuries were identified. Consistent with our endoscopic findings, there were no adverse clinical sequelae ob- served during follow-up. When our data were combined with those from all prior published studies, we found that hair relaxer ingestion had a relatively benign clinical course (1,10–12,16). Our findings are consistent with previous studies in that patients who ingest hair relaxer are younger than those ingesting other caustic substances and cases are equally distributed by gender. In all studies, 100% of patients were of African- American ethnicity. This is not surprising given that these products are marketed to this population. Our study, as well as prior studies, has found that symptoms at presentation are not predictive of mu- cosal injury (4–6). Despite the elevated pH of these products, which sug- gests that mucosal injury might be expected, we found that hair relaxer ingestion was associated with a benign clinical course very different from the course of other substances with similar pH (22). While the known toxic effects in patients ingesting such alkaline substances as drain cleaner make it essential to directly visualize their upper GI tract to assess the extent of mucosal injury, hair relaxers have not been associated with gastrointestinal mucosal injury leading to adverse clinical sequelae. Be- cause hair relaxers burn immediately on contact with the lips and oropharynx, further intake may be inhibited, thus sparing the esophagus and stomach. The viscous nature of the hair relaxer cream may also impede swal- lowing. Together, these factors may limit the volume in contact with esophageal and gastric tissue. Conse- quently, presentation with drooling, lip and oral burns is very common, whereas the esophagus and stomach are spared. Our current standard of care is to admit any child with a suspected caustic ingestion (excluding household bleach), perform esophagoscopy within 12 to 24 hours DISCUSSION

(the full extent of damage may not be visible earlier than this) (13,23), and observe for adequate oral intake before discharge. We have found an extremely low prevalence of significant upper GI mucosal injury following hair relaxer ingestion. We suspect that the small risks of en- doscopy may outweigh the risks of hair relaxer ingestion itself (24,25). There are a number of limitations in our study. First, the study was retrospective and data were collected by chart review. Second, adverse clinical outcomes were defined as return visits, an outcome that may be con- founded by limited access to medical care in this urban population (26). Finally, even after combining all avail- able data, the statistical power to identify clinically rel- evant GI mucosal injury, a relatively infrequent outcome, may be limited. We also only reviewed the patients ad- mitted to the hospital. In our institution, since Pediatric Gastroenterology is consulted by the emergency room for all potential caustic ingestions, we doubt that many children who ingested hair relaxers were discharged home directly from the emergency room. The evidence to date suggests that ingestion of hair relaxers does not pose a significant risk of severe esoph- ageal injury and that upper GI endoscopy may not be warranted as routine in this setting. Although a prospec- tive multicenter registry of hair relaxer ingestions with appropriate clinical follow-up is necessary, meanwhile, this study and the current literature suggest that such patients can be managed conservatively, with overnight observation, evaluation for adequate oral intake, and re- ferral for endoscopy only if symptoms persist. CONCLUSION 1. Forsen JW, Muntz HR. Hair relaxer ingestion: a new trend. Ann Otol Rhinol Laryngol 1993;102:781–4. 2. Christesen HB. Epidemiology and prevention of caustic ingestion in children. Acta Paediatr 1994;83:212–5. 3. Litovitz TL, Klein-Schwartz W, White S, et al. 2000 Annual report of the American Association of Poison Control Centers Toxic Ex- posure Surveillance System. Am J Emerg Med 2001;19:337–95. 4. Gaudreault P, Parent M, McGuigan MA, Chicoine L, Lovejoy FH. Predictability of esophageal injury from signs and symptoms: a study of caustic ingestion in 378 children. Pediatrics 1983;71: 767–70. 5. Gorman RL, Khin-Maung-Gyi MT, Klein-Schwartz W, et al. Ini- tial symptoms as predictors of esophageal injury in alkaline cor- rosive ingestions. Am J Emerg Med 1992;10:189–94. 6. Crain EF, Gershel JC, Mezey AP. Caustic ingestions. Symptoms as predictors of esophageal injury. Am J Dis Child 1984;138:863–5. 7. Squires RH, Jr., Colletti RB. Indications for pediatric gastrointes- tinal endoscopy: a medical position statement of the North Ameri- can Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr 1996;23:107–10. 8. Gryboski J. Traumatic Injury. In: Walker A, Durie P, Hamilton R, Walker-Smith J, Watkins J, eds. Pediatric Gastrointestinal Disease. Hamilton, Ontario: B.C. Decker Inc, 2000:351–377. REFERENCES

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