Children’s Vulnerability Related to Chlorine Exposure, Container Confusion, and Mixing Household Cleaners – Florida, 2006-2008

Acute and chronic effects of exposure to chlorine and chloramines can result in the irritation of the skin and mucous membranes, often leading to airway edema resulting in respiratory difficulties, burning in the throat, eyes and nose. Ingestion of bleach or bleach-containing products often results in adverse gastrointestinal effects. Data captured by the three centers comprising the Florida Poison Information Center Network (FPICN) between 2006 and 2008 was examined to characterize the extent of toxic effects from chlorine gas exposures related to misuse of household cleaners. A known outcome was determined in 48.4% of the 5315 cases. Of those with a known outcome, 0.2% (6) had a major effect. Children two and younger were the most frequently exposed population (22.7%). Children 19 and under accounted for 39.1% (2079), whereas children 2 and under accounted for 22.7% (1204) of the chlorine exposure population. Container confusion accounted for 12%, and mixing cleaning products accounted for 17% of the cases reviewed in 2006. The most common route of exposure in cases reviewed in 2006 was by-mouth and the most common symptom was gastrointestinal (GI). Fact sheets and educational outreach related to reducing the mixing of household cleaners, reading manufacturers safety instructions carefully, and storing the chemical cleaners safely away from children and in original containers is warranted to reduce chlorine exposures in children. Florida Public Health Review, 2012; 9, 88-94. Background In the home, exposure to chlorine gas often occurs through the improper mixing of household chemicals, whereas ingestions of bleach are usually a consequence of unsafe storage and improper use of these chemicals. Children tend to be more vulnerable to bleach exposures than adults, and account for the highest frequency and percent of incidents reported nationwide by poison centers. Container confusion, a predominant factor of accidental ingestions, occurs when a product is put into a familiar container other than the original container that results in accidental ingestion in a variety of age groups. As such, container confusion is considered a significant exposure venue in children. When accidentally or intentionally ingested, bleach products predominantly cause adverse gastrointestinal effects. As children learn by exploration of their environment, significant handto-mouth behavior is common. Likewise, confusion resulting from inedible products being placed and stored in familiar containers that previously contained edible products is a major cause of accidental ingestions. Our study suggests that children aged 2 years and younger are a prime population exposed to chlorine bleach thorough container confusion in the home when compared to other age groups. Increased selection and limited consumer knowledge of cleaning products and their exposures (Bugne, 1985) has upped the potential for poisonings and other health problems due to incorrect use, storage and incorrect mixing. Manufacturers are required to label products with information on use, caution for mixing, and toxicity danger because of the toxicity of cleaning products, although studies have suggested that few consumers actually read these labels (Nazaroff & Weschler, 2004). Bleach is one of the most common household cleaners (Tanen, Graeme, & Raschke, 1999) and contains 4%-12% sodium hypochlorite. Bleach releases small amounts of chlorine gas and hypochlorous acid (Reisz & Gammon, 1986; Tanen, et al., 1999). However, when combined with ammonia-based cleaners, chloramine gas is produced (NH3+HOCL NH2CL (chloramines gas) + HCL) (Reisz & Gammon, 1986; Tanen, et al., 1999). When bleach is mixed with acid-based cleaners, chlorine gas is formed (HOCL + HCLCL2 (chlorine gas) +H20 (tissue). Chlorine gas primarily reacts with the lung epithelial lining fluid (Squadrito, Postletwait & Matalon, 2010) creating hydrochloric acid and other damaging free radicals. Ingestion is the most common route of accidental exposure in children from container confusion or from adults that are using the product to attempt suicide. When bleach is ingested, the hypochlorite reacts with stomach acids, producing chlorine gas which causes severe gastrointestinal upset. This gas is released from the stomach and can subsequently find its way into the trachea as a portal for lung exposure (Bugne, 1985). There is a relationship be-