In an attempt to curtail the frequency of caustic ingestions in the pediatric population, safety labeling, packaging, and substance production are federally regulated under the Federal Caustic Act of 1927, the Federal Hazardous Substance Labeling Act of 1960, and the Safe Packaging Act of 1970 (1,2). Despite these efforts, caustic ingestions remain a significant problem in the pediatric population. The American Association of Poison Control Centers (AAPCC) compiles the Toxic Exposure Surveillance System (TESS) data in cooperation with the majority of U.S. poison centers. Although the incidence of caustic ingestions, or ingestions involving hair products, is not reported in the annual TESS report, the AAPCC estimates that more than 1,137,918 human poison 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 following 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 common. The few published studies describing the clinical or endoscopic outcome of the ingestion of hair relaxer suggest that mucosal injury is uncommon (1,5,10–13).
To further explore the relative frequency of hair relaxer ingestion, the incidence of associated upper GI mucosal injury, and the potential for adverse clinical sequelae, we examined all caustic ingestions at Rainbow Babies & Children's Hospital between 1990 and 2001.
Patients were identified by querying the hospital International Code of Diseases (ICD-9) Meta-Charms Database (Meta, Chicago, IL) for all caustic ingestions (codes 983.2, 983.9, 976.4) admitted to Rainbow Babies & Children's Hospital between January 1990 and January 2001.
Caustic ingestion was defined as the consumption of an alkaline or acidic substance capable of inducing upper GI mucosal injury. Ingestions were categorized as hair relaxer, household bleach, drain cleaner, household cleaner, or other (any caustic substance that was ingested by no more than three patients).
The pH of three brands of hair relaxer was determined using an Orion Research digital pH meter model 611.
Esophagogastroduodenoscopies (EGD) for caustic ingestions were routinely performed 12 to 24 hours following the exposure, under general anesthesia or deep conscious sedation, with a flexible endoscope appropriate to the size and the age of the child. For children less than 11 years old, either the P140 or XP20 endoscopes were chosen and for patients greater than 11 years old, the P140 or the Q140 endoscope were used (Olympus America, Inc., Melville, NY).
Lip, oral, and pharyngeal burns were defined as erythema, edema, or blistering at each respective site. The gross appearance of esophageal and gastric mucosal injury was scored by a standardized scale (8,14): Grade 0—no mucosal abnormalities; Grade 1— edema and/or hyperemia limited to the superficial mucosa; Grade 2—erosions, superficial ulcerations, hemorrhage with or without eschar; Grade 3—multiple ulcerations and/or areas of necrosis. Grades 0 and 1 have not been associated with adverse clinical outcomes. A small percentage of patients with Grade 2 mucosal injury have clinically relevant sequelae. Scarring, stricture, and perforation are most commonly associated with Grade 3 injury (1,8,10,15–17). As clinical consequences following a caustic ingestion typically become apparent within four to eight weeks, we defined adverse clinical outcome as any GI complaint evaluated during a follow-up visit recorded within that time frame (13).
Literature Review of Hair-Relaxer Ingestions
Using appropriate keywords (hair relaxer, caustic, ingestion, child, esophagus), a Medline search was performed to compile the clinical outcomes on hair relaxer ingestions published in the literature. The cohort data was combined with our study cohort and evaluated for clinical presentation, endoscopic findings, and sequelae.
Data on patient demographics, clinical presentation, endoscopic findings, and clinical outcomes were captured through retrospective chart review. We then pooled our patient cohort with all published patients with hair relaxer ingestion to more accurately estimate the frequency of significant clinical and endoscopic sequelae. Continuous variables are expressed as medians with interquartile ranges because of their non-normal distribution. Categorical variables are displayed as frequencies and percents. Mann-Whitney
U testing was used to compare continuous variables. All analyses were conducted using SAS version 6.12 (Cary, NC).
During the study period, the most common caustic ingestion was hair relaxer, which was responsible for 33 (34.4%) of the 96 total cases at our institution. Other common ingestions included household bleach (12%), drain cleaners (9%), or other detergent housecleaners (8%) (Fig. 1). The remaining ingestions (36%) included a variety of products ingested by no more than three patients. Twenty-nine of the 33 patients (88%) who ingested hair relaxer served as our study cohort. The remaining four patients were excluded, since EGD was not performed. Table 1 displays patient demographics. The median age of our cohort was 14.0 months (range 9 to 31 months). Patients who ingested hair relaxer were younger than those who ingested other agents (P < 0.001). The age distribution of ingestions was bimodal, and was consistent with previous observations of accidental ingestion among toddlers and intentional (i.e., suicide gestures or attempts) ingestion in teenagers (Fig. 2). The cohort was evenly divided in gender. All of our patients were of African-American ethnicity.
Clinical Presentation, Endoscopic Findings and Outcomes
The most common symptoms at presentation were drooling and emesis. No patients presented with respiratory symptoms. Mucosal injury was most commonly noted at the lips with decreasing frequency of injury more distally toward the stomach (Fig. 3). Six patients (20.7%) had Grade 1 esophageal mucosal injury. Five patients (17.2%) had Grade 1 gastric mucosal injury. No patients had mucosal injury greater than Grade 1 (10,15,18,19). No complications resulted from the procedure or its sedation. The median (25th–75th percentile) length of stay was 1 (1,2) day, while the median (25th–75th percentile) post-procedure length of stay was 1 (0,1) day. Eight weeks after ingestion, no adverse clinical events had occurred.
The pH of three different brands of hair relaxers ranged from 11.4 to 12. (Cream of Nature™ and Bone Strait™: ph of 12; Luster's Pink™: pH of 11.4).
Literature Review of Hair-Relaxer Ingestions
To our knowledge, six cohort studies and two case series evaluating pediatric hair relaxer ingestions have been published to date. When our data were combined with these previously published cohort data (Table 2), there were no clinically relevant esophageal mucosal injuries among the 147 of 211 patients who underwent upper GI endoscopy, and no adverse clinical outcomes were reported. In one published case report, Rauch identified a patient with a non-circumferential, second-degree esophageal burn. Resolution of symptoms occurred after one day and no long-term clinical sequelae were reported. (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 clinical sequelae.
In this retrospective cohort study at a large metropolitan tertiary care hospital, we found hair relaxer ingestion to be the most common caustic ingestion over an 11-year period. Gastrointestinal mucosal injury progressively decreased 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 observed 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 mucosal injury (4–6).
Despite the elevated pH of these products, which suggests 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. Because 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 swallowing. Together, these factors may limit the volume in contact with esophageal and gastric tissue. Consequently, 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 (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 endoscopy 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 confounded by limited access to medical care in this urban population (26). Finally, even after combining all available data, the statistical power to identify clinically relevant GI mucosal injury, a relatively infrequent outcome, may be limited. We also only reviewed the patients admitted 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 esophageal injury and that upper GI endoscopy may not be warranted as routine in this setting. Although a prospective 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 referral for endoscopy only if symptoms persist.
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