Reported Adverse Health Effects in Children from Ingestion of Alcohol-Based Hand Sanitizers — United States, 2011–2014

Hand sanitizers are effective and inexpensive products that can reduce microorganisms on the skin, but ingestion or improper use can be associated with health risks. Many hand sanitizers contain up to 60%–95% ethanol or isopropyl alcohol by volume, and are often combined with scents that might be appealing to young children. Recent reports have identified serious consequences, including apnea, acidosis, and coma in young children who swallowed alcohol-based (alcohol) hand sanitizer (1–3). Poison control centers collect data on intentional and unintentional exposures to hand sanitizer solutions resulting from various routes of exposure, including ingestion, inhalation, and dermal and ocular exposures. To characterize exposures of children aged ≤12 years to alcohol hand sanitizers, CDC analyzed data reported to the National Poison Data System (NPDS).* The major route of exposure to both alcohol and nonalcohol-based (nonalcohol) hand sanitizers was ingestion. The majority of intentional exposures to alcohol hand sanitizers occurred in children aged 6–12 years. Alcohol hand sanitizer exposures were associated with worse outcomes than were nonalcohol hand sanitizer exposures. Caregivers and health care providers should be aware of the potential dangers associated with hand sanitizer ingestion. Children using alcohol hand sanitizers should be supervised and these products should be kept out of reach from children when not in use.

In 2005, the annual rate of intentional alcohol hand sanitizer exposure was 0.68 per 1 million U.S. residents (95% confidence interval [CI] = 0.17–1.20) (4). During 2005–2009, this rate increased, on average, by 0.32 per 1 million per year (95% CI = 0.11–0.53; p = 0.02) (4). Young children, including infants, are more likely to develop complications from alcohol intoxication than are older children and teens. Younger children have decreased liver glycogen stores, which increase their risk of developing hypoglycemia, and have various pharmokinetic factors, which make them more susceptible to developing toxicity from alcohol (5–9). To characterize pediatric alcohol hand sanitizer exposures in the United States, data reported by poison centers in all states to NPDS among children aged ≤12 years during January 1, 2011–December 31, 2014 were analyzed. Analyses were stratified by age group (0–5 years and 6–12 years). Hand sanitizer exposures were defined as a poison center call reporting an exposure to either ethanol-based or isopropanol-based sanitizer solutions (alcohol hand sanitizer exposure) or a nonalcohol sanitizer product (nonalcohol hand sanitizer exposure). Calls reporting co-exposures to other agents were excluded to minimize confounding effects.

Descriptive statistics were compiled for exposed children’s age, year and season of exposure, intentionality of exposure, route of exposure (ingestion, inhalation, dermal, or ocular), reported health effects (e.g., drowsiness, eye irritation, nausea, vomiting, etc.), and outcome,^† and were compared for alcohol and nonalcohol hand sanitizers and age group. An exposure was coded by poison centers as unintentional if it was considered to be accidental or inadvertent. Deliberate exposures, because of deliberate misuse or abuse for example, were considered intentional. An exposure was considered to have resulted in an adverse health effect if at least one symptom (e.g., abdominal pain, nausea, vomiting, etc.) was reported. Categorical data comparisons were performed using the chi-square test or, when cell sizes were <5, Fisher’s exact test. Significance was defined as p<0.05. Statistical software was used for the analysis.

During 2011–2014, a total of 70,669 hand sanitizer exposures in children aged ≤12 years were reported to NPDS, including 65,293 (92%) alcohol exposures, and 5,376 (8%) nonalcohol exposures (Table 1). The number and percentage of each type of reported exposure was similar during each of the 4 years. Overall, 64,488 (91%) exposures occurred in children aged ≤5 years, and 6,181 (9%) occurred in children aged 6–12 years. There was no association between sanitizer type and year. Among all children, ingestion accounted for approximately 95% of reported exposures, including 97% of exposures among children aged ≤5 years (97.0% alcohol and 96.3% nonalcohol exposures) and 74% among children aged 6–12 years (74.0% alcohol and 72.0% nonalcohol exposures). A higher percentage of older children (aged 6–12 years) had intentional exposures to alcohol hand sanitizers (866; 15.0%) than to nonalcohol hand sanitizers (40; 8.0%) (p<0.001). This association was not found in younger children (aged ≤5 years). Ocular exposures to hand sanitizers were more common in older children (24.8% overall, 24.4% alcohol, and 29.0% nonalcohol) than among younger children (3.0% overall, 3.0% alcohol, and 3.2% nonalcohol). Although there was no seasonal variation in reported exposure to either hand sanitizer type among younger children, exposure frequency among older children was lower for both hand sanitizer types during the summer months (Figure).

Overall, 8,219 (12%) patients had at least one reported symptom, including 7,703 (12%) children who ingested alcohol products, and 516 (10%) who ingested nonalcohol products. Adverse health effects were more likely to be reported for alcohol hand sanitizer exposures (p<0.001). The most common adverse health effects for both hand sanitizer types were ocular irritation (2,577; 31.4%) and vomiting (1,872; 22.8%). Conjunctivitis (862; 10.5%), oral irritation (782; 9.5%), cough (705; 8.6%), and abdominal pain (323; 3.9%) were also reported (Table 2). Rare health effects included coma (five), seizures (three), hypoglycemia (two), metabolic acidosis (two), and respiratory depression (two). Those rare effects occurred more frequently among children with alcohol hand sanitizer exposures, but the differences were not statistically significant when the rare health effects were analyzed individually. Alcohol hand sanitizers were significantly associated with worse outcomes (compared with no effect outcomes) when both age groups were analyzed (p = 0.02). Approximately two thirds (66%) of children with exposures were not followed to determine outcome (Table 2). Among patients who were followed (23,828), exposure to alcohol hand sanitizers had no reported effect in 17,441 (85%) of the younger children. In contrast, 1,005 (50%) of the older children had no reported effect to alcohol hand sanitizer exposure. No deaths were reported.

Corresponding author: Cynthia Santos, krx8@cdc.gov, 770-488-3418.

¹Division of Environmental Hazards and Health Effects, National Center for Environmental Health, CDC; ²Emory University School of Medicine, Atlanta, Georgia; ³Office of Public Health Preparedness and Response, CDC.

References

1. Mrvos R, Krenzelok EP. Pediatric ingestions of hand sanitizers: debunking the myth. Pediatr Emerg Care 2009;25:665–6. CrossRef PubMed
2. Miller M, Borys D, Morgan D. Alcohol-based hand sanitizers and unintended pediatric exposures: a retrospective review. Clin Pediatr (Phila) 2009;48:429–31. CrossRef PubMed
3. Rayar P, Ratnapalan S. Pediatric ingestions of house hold products containing ethanol: a review. Clin Pediatr (Phila) 2013;52:203–9. CrossRef PubMed
4. Gormley NJ, Bronstein AC, Rasimas JJ, et al. The rising incidence of intentional ingestion of ethanol-containing hand sanitizers. Crit Care Med 2012;40:290–4. CrossRef PubMed
5. Madsen LP. Acute alcohol intoxication in children. Diagnosis, treatment and complications. Ugeskr Laeger 1990;152:2362–4. PubMed
6. Marek E, Kraft WK. Ethanol pharmacokinetics in neonates and infants. Curr Ther Res Clin Exp 2014;76:90–7. CrossRef PubMed
7. Ford JB, Wayment M, Albertson TE, Owen KP, Radke JB, Sut ME. Elimination kinetics of ethanol in a 5-week-old infant and a literature review of infant ethanol pharmacokinetics. Case Rep Med 2013; 2013:250716.
8. Tran MN, Wu AH, Hill DW. Alcohol dehydrogenase and catalase content in perinatal infant and adult livers: potential influence on neonatal alcohol metabolism. Toxicol Lett 2007;169:245–52. CrossRef PubMed
9. Lamminpää A. Acute alcohol intoxication among children and adolescents. Eur J Pediatr 1994;153:868–72. CrossRef PubMed
10. Forrester MB. Characteristics of hand sanitizer ingestions by adolescents reported to poison centers. Int J Adolesc Med Health 2015;27:69–72. PubMed

TABLE 1. Exposures to alcohol and nonalcohol hand sanitizer products among children aged ≤12 years reported to poison centers, by sanitizer type, year, age group, exposure route, and intentionality — United States, National Poison Data System, 2011–2014

*Percentage of total exposures.

FIGURE. Percentage of exposures from alcohol-based and nonalcohol-based hand sanitizer products in children aged ≤5 years and aged 6–12 years reported to poison centers, by month — United States, National Poison Data System, January 1, 2011–December 31, 2014

TABLE 2. Most common adverse health effects and outcomes experienced by children with exposure to alcohol and nonalcohol hand sanitizers, by age group — United States, 2011–2014

* The three most commonly reported symptoms per column.
^† The patient exhibited some symptoms as a result of the exposure, but they were minimally bothersome to the patient. The symptoms usually resolved rapidly and often involved skin or mucous membrane manifestations. The patient returned to a preexposure state of well-being and had no residual disability or disfigurement.
^§ The patient exhibited symptoms as a result of the exposure that were more pronounced, more prolonged, or more of a systemic nature than minor symptoms. Usually some form of treatment was or would have been indicated. Symptoms were not life-threatening and the patient returned to a preexposure state of well-being with no residual disability or disfigurement.
^¶ The patient exhibited symptoms as a result of the exposure that were life-threatening or resulted in significant residual disability or disfigurement.