r

The Nontoxic Ingestion

HOWARD C. MOFENSON, M.D., F.A.A.P.*

JOSEPH GREENSHER, M.D., F.A.A.P.**

There are one quarter of a million tempting products into

which the toddler can sink his newly erupted teeth.
A nontoxic ingestion, for the purposes of this paper, occurs when the
victim consumes a nonedible product, which mayor may not produce
symptoms. No chemical agent is entirely safe and none should be con-
sidered entirely harmful. All agents can produce a significant degree of
undesirable effects if a sufficiently great concentration is allowed to
come in contact with a biologic mechanism.
The National Clearinghouse for Poison Control Centers reported
63,000 ingestions in 1965 in children under 5 years of age. In the same
year, a study of 11,763 families in 28 cities, involving 16,650 children
under 5 years of age, revealed 2630 ingestions or 15.7 ingestions per
100 children. The number of children in the United States under the age
of five at the time of this study was estimated to be 19.9 million, giving
an extrapolated incidence figure of 3 million ingestions. These data
suggest that only 1 in every 50 ingestions is reported and that the major-
ity of ingestions are innocuous. 6
Ingestions are not reported by parents if they are thought to be
inconsequential or the product is believed to be innocuous. If a physician
is consulted, he will not report to a Poison Control Center an ingestion
that he has had experience with, and about which he requires no infor-
mation. This lack of reporting is sad because valuable information about
acute toxicity in human subjects is lost. Until sufficient information on
human toxicity reaches the national clearinghouse, much of our knowl-
edge must be based on the vague variable LD50 in animals.
The nontoxic ingestion serves as a warning of inadequate super-
vision or of an improper and unsafe environment, which should be
corrected before a tragic toxic ingestion occurs. It also serves as a human

':'Director, Poison Control Center, and Attending Physician, Department of Pediatrics,

Nassau County Medical Center, East Meadow; Attending Physician, Department of
Pediatrics, Nassau Hospital, Mineola, New York
':":'Associate Director, Poison Control Center, and Associate Attending Physician, Department
of Pediatrics, Nassau County Medical Center, East Meadow; Attending Physician,
Department of Pediatrics, Nassau Hospital, Mineola, New York

Pediatric Clinics of North America- VoL 17, No, 3, August, 1970 583
584 HOWARD C. MOFENSON, JOSEPH GREENSHER

test of the toxicity of a product. The importance of knowing that a

product is nontoxic is that overtreatment is avoided and, more important,
the victim and parents are not placed in the jeopardy of a panicky auto-
mobile ride to the physician or nearest hospital.
In 1968, Meadowbrook Hospital Poison Control Center received
8967 reports of the ingestion of inedible products by children under 5
years of age. Only 558 had to be examined in the emergency room and
only 58 required hospitalization.
The first rule in receiving a report of an ingestion, after obtaining
the phone number, is to determine the correct spelling of the product.
An excited informant can make "Drene" sound very much like "Drano."
A clue to the toxicity of some products may be obtained from a
"signal word" on the package. This is not completely scientific, but
serves to alert the public and physicians to the potential toxicity. The
Federal Hazardous Substance Labeling Act of 1960 suggests that the
manufacturer of any potentially toxic household product include on the
label the words "Caution," "Warning," or "Danger," according to the
degree of toxicity of the product. The significance of the "signal word"
used in the labeling of pesticides is explained in Table 1.

Table 1. "Signal Word" Labeling of Pesticides':'

GOSSELIN
TOXICITY LD:;u ORAL
CATEGORY SIGNAL WORD NUMBERS (mg. per kg.) HOUSEHOLD MEASURE

4 No label 1-2 5000 Pint or more

3 Caution 3 50-5000 Ounce to pint
2 Warning 4 50-500 Teaspoon to ounce
1 Danger-Poison 5-6 >50 Taste to teaspoon

':'Based on federal Insecticide, Fungicide and Rodenticide Act of 1947 and Gosselin,
R. E., J.A.M.A., 163:1333, 1967.

The volume of a swallow has been calculated to be 0.21 ml. per kg., a
figure that may be helpful on occasion to evaluate the amount ingested.
A swallow of water in a child aged 11f2 to 3 years is 4.5 ml. 10 Another
important property that must be considered in oral toxicity is the emetic
activity of ingested substances. Since rodents are customarily used to
determine the LD50 and rodents do not vomit, this defense mechanism
of humans has been overlooked when comparing rodent LD50 to human
toxicity.
The emetic properties of some products are listed in Table 2.6 These
are the minimum doses in dogs and are not strictly applicable to man.
The authors' experience with these agents suggest that if emesis is not
produced by the ingestion itself, it is unlikely that a toxic dose has been
ingested.
On the basis of a review of the literature and the authors' experience,
some of the frequently ingested household items and their harmful
ingredients and general toxicity are listed in Table 3. The items in
Table 3 have been grouped by the authors into an arbitrary classification
for more convenient and detailed discussion.
THE NONTOXIC INGESTION 585

Table 2. Emetic Properties

ORAL LD50 EMETIC DOSE TIME

TYPE OF PRODUCT (gm. per kg.) (gm. per kg.) (Minutes)

General purpose granulated cleaner 3-7 0.1 -0.8 1-4

General purpose liquid cleaner 5.5-7 0.12-0.25 1-4
Bleach (liquid) sodium hypochlorite 17 0.25 1-2
Toilet soap 7-20 5.00 120-180
Table salt 3.5 0.25 1-3
Syrup of ipecac 8.5 0.45 20-40

Table 3. Frequently Ingested Common Household Items

Usually nontoxic
Adhesives (most)
Ballpoint pen inks
Bathtub floating toys
Battery (dry cell) (1/5 MLD of mercury chloride)
Bubble bath soaps (detergents)
Candles (beeswax or paraffin)
Caps (toy pistol) (potassium chlorate)
Chalk (calcium carbonate)
Cigarettes or cigars (nicotine)
Cosmetics (most)
Contraceptive pills
Crayons (marked A.P., C.P.)
Dehumidifying packets (silica or charcoal)
Detergents (most - not electric dishwasher)
Deodorants
Fish bowl additives
Golf ball (fluid core can cause mechanical injury)
Ipecac syrup
Matches (potassium chlorate)
Mucilage and paste
Paint - indoor (less than 1 per cent lead)
Pencil- (lead-graphite and coloring)
Play-Doh and Modeling clays
Polaroid picture coating fluid
Porous-tip ink-marking devices (felt tip markers)
Putty (less than 2 or 3 oz.)
Sachets (essential oils and powder)
Shampoos (liquid)
Shaving creams (soap, perfume, menthol)
Silly putty (silicones and 1 per cent boric acid)
Soaps (may cause vomiting)
Sweetening agents (Saccharin, cyclamate)
Teething rings (water- ?sterility)
Thermometer (mercury)
Toothpaste
Vitamins with or without fluoride
Writing ink (blue, black) (ferrous sulfate, tannic acid, gallic acid)

Table continued on following page.

586 HOWARD C. MOFENSON, JOSEPH GREENSHER

Table 3. Frequently Ingested Common Household Items (Continued)

Sometimes toxic (in large amounts or if taken deliberately)
PRODUCT TOXIC INGREDIENT TOXIC MANIFESTATIONS

Aerosol spray Freon Myocardial sensitization

After shave lotions Alcohol Hypoglycemia, intoxication
Airplane glue Toluene Hypoglycemia
Alcohol drinks Ethyl alcohol Gastrointestinal irritation
Antiseptics Hexachlorophene 3
per cent (over 1 oz.)
Mercurochrome Relatively nontoxic
Merthiolate Relatively nontoxic
Bleach (household) Sodium hypochlorite Esophageal and gastrointestinal
irritation
Bleach-mixed with bowl Chlorine Pulmonary irritation
cleaner or ammonia
Body conditioners Alcohol Hypoglycemia, intoxication
Candy laxatives Phenolphthalein Enteritis
Colognes Alcohol Hypoglycemia, intoxication
Deodorizer cakes p-dichlorobenzene or More than 1 teaspoonful-
naphthalene methemoglobinemia and
hemolytic anemia
Model cement Toluene Central nervous system de-
pression
Nail polish remover Acetone Gastrointestinal irritation and
central nervous system depres-
sion
Plastic cement Toluene Central nervous system depression
Suntan preparations Alcohol Hypoglycemia, intoxication
Talc Magnesium silicate Aspiration pneumonia

Writing Material
Inks of the blue or black variety contain ferrous sulfate, tannic acid,
and gallic acid and are not toxic. Red ink may be toxic in doses of 1 m!.
per kg., and green and purple inks contain aniline dyes which are
hazardous if taken in large amounts. Ballpoint pen ink contains carbitol
10 per cent or diethyl glycol, both of which have an estimated lethal dose
of 30 gm. The amount available in the ink cartridge does not represent a
hazard.
Pencils of the lead variety contain nontoxic graphite. Colored
pencils may contain toxic pigments, but the small amounts are not
hazardous. Indelible pencils contain triphenylmethane dye which can
cause local pain, edema, and necrosis at the site of a puncture wound and
may require surgical debridement. They are not systemically toxic.
Ink eradicators contain sodium hypochlorite and are discussed
under "Bleaches."
Crayons are mixtures of stearic acid and paraffin colored with
harmless pigments. If they are marked C.P., A.P., or C.S. 130-46, in
accordance with regulations of the Bureau of Standards, they are non-
toxic and do not contain more than 0.05% lead, arsenic, and other toxic
material. Red and orange crayons are the only harmful colors and if
they are not identified by the letters A.P., C.P., or C.S. 130-46 they may
contain para reds which can form paranitraniline and produce cyanosis
and methemoglobinemia. 7
Chalk contains calcium carbonate and kaolin or occurs naturally as
limestone and is not toxic. Colored chalk is also nontoxic.
Porous tip ink marking devices are of low toxicity by ingestion.
THE NONTOXIC INGESTION 587
Toiletries and Laundering Agents
Cosmetic preparations for skin use are relatively safe unless large
amounts in excess of 5 gm. per kg. are ingested. Baby product cosmetics
are very innocuous; in the neighborhood of 15 gm. per kg. is the toxic
ingested dose. Talcum powder can be aspirated and produce symptoms
that resemble those of bronchiolitis. 9
Soaps are salts of fatty acids and alkalies. They may cause vomiting.
Medicinal soaps contain such a small amount of antibacterial agents
that they do not present an additional hazard. Bubble bath soaps are
detergents and dilution with bath water mitigates their minimal toxicity.
They can cause a gastrointestinal upset and dysuria (from contact, not
ingestion) in young female children. Detergents for light duty dish
washing and baby clothes, all-purpose sudsing products for laundry and
general use, and low sudsing detergents made especially for washing
machines are of low toxicity. They contain anionic surfactants, fatty
acid amides, sodium tripolyphosphates, tetrasodium pyrophosphate,
sodium a-phosphate, sodium metaphosphate, sodium silicate, sodium
sulfate, and sodium carbonate, all of low-order systemic toxicity. They
may cause mild mucous membrane irritation, resulting in gastro-
enteritis. Liquid household detergents are also of low toxicity. The
addition of bleaching agents and enzymes to the detergents does not
increase their toxicity. Electric dishwasher detergents, however,
possess a higher pH and are capable of causing serious injury to the
oropharyngeal, esophageal, gastric, and respiratory tissues. Their
ingestion should be considered as an alkali ingestion. 2 • 4
Bleach is sodium or calcium hypochlorite, 3 to 6 per cent for house-
hold use and 10 per cent for washing machines. In the past, the fatal
dose was listed as 15 to 30 ml. A recent study of 129 children who in-
gested Clorox revealed no significant esophageal injury and routine
esophagoscopy was not recommended. 13 Ink eradicators contain sodium
hypochlorite and do not cause harm.
Liquid shampoos are composed of detergent and soap and are non-
toxic, but dry shampoos may contain carbon tetrachloride and isopropyl
and methyl alcohol, which are very toxic.
Deodorants contain aluminum salts and antibacterial agents and
are not hazardous. Suntan preparations contain ethyl alcohol, brucine
sulfate, and organic solvents. Large amounts can lead to alcohol intoxi-
cation. Tooth paste is nontoxic, but large amounts of stannous fluoride
can cause vomiting.
Tobacco and Matches
Cigarettes and cigars contain nicotine, which is potentially very
harmful but which is not readily absorbed from ingested tobacco, and
protective vomiting frequently occurs. One cigarette contains 10 to 18
mg. of nicotine with the toxic dose being 1 mg. per kg. Werner reported
on 355 Swedish children who ingested tobacco with only very mild
symptoms. 16 There is almost no nicotine in cigarette ash.
Matches contain potassium chlorate. The heads of20 safety matches
contain 220 mg. A 1 year old could consume 20 books before toxicity
would occur. Caps for toy pistols also contain potassium chlorate in a
588 HOWARD C. MOFENSON, JOSEPH GREENSHER

concentration of 4 mg. per cap, so that a roll of 50 contains the same

amount as a book of matches and would not be harmful. 1. 3
Medicinals
Merthiolate and mercurochrome are organic mercury compounds
which are not well absorbed and rarely produce intoxication. Hexa-
chlorophene acts like phenol and is relatively innocuous unless large
amounts are ingested. The fatal dose is 2 gm., but the usual preparations
have only a 1 to 3 per cent concentration. Candy laxatives that contain
mainly phenolphthalein are relatively nontoxic. The catharsis they
produce usually subsides in 3 days. Vitamins are nontoxic in amounts
usually available. There is only 1 mg. of fluoride per tablet or 10 drops,
which represents no additional hazard, since the fatal dose of fluoride is
50 to 225 mg. per kg., or 5 gm. in an adult.
Contraceptives of the hormonal type have been reported to produce
almost no toxicity. A 1962-65 report from the National Clearinghouse of
962 ingestions listed only 40 producing nausea and vomiting, even after
the ingestion of 21 pills.
Ethyl alcohol is fatal in doses of 6 ml./kg. of 100 per cent alcohol if
ingested in 1 hour's time. This represents 500 to 1000 ml. of whiskey in
an adult. Since alcohol is rarely of high concentration in any medicinal
product, it is not considered a significant hazard. B • 15
Sweetening agents such as saccharin or cyclamate may produce
loose stools in amounts over 5 to 7 gm., but no acute systemic toxicity.
Thermometers contain metallic mercury, which oxidizes too slowly
to yield mercury ions for absorption from the intestinal tract and is not a
hazard. A small danger exists from the broken glass. 5
Syrup of ipecac in a 1 ounce dose is not toxic. It contains twice
the parenteral dose of emetine for a 1 year old child. Fluid extract of
ipecac is 14 times as potent as syrup of ipecac and has produced fatalities.
Single tablets of medication, even of adult dosage, in the authors'
experience, will not produce significant toxicity if ingested by a child.
Miscellaneous
Paints contain a large variety of potentially toxic metallic com-
pounds, but these are too slowly absorbed to be of consequence. The ill
effects of an ingestion are caused by the petroleum distillate vehicle.
Dried indoor paint contains less than 1 per cent lead and is safe. Out-
door paints have large amounts of lead, and repeated ingestions can
cause lead intoxication. A paint chip of outdoor paint the size of a finger-
nail has 100 mg. of lead, which is 200 times the safe single daily dose.
Any ambulatory child with pica who has lived in a house built before
World War II for more than 3 months should be investigated for chronic
lead poisoning. The emulsion type latex base paints are not seriously
toxic in doses of less than 5 ml. per kg.
Dry cell batteries of the flashlight type contain 1/5 of the MLD of
mercuric chloride for a child and are considered nontoxic. Mercury
batteries contain 5 gm. of mercuric oxide and could produce toxicity if
the casing is broken. The fatal dose of mercuric oxide is 100 to 700 mg.
THE NONTOXIC INGESTION 589
Toluene has an estimated fatal dose of 50 gm. if ingested. It is
unlikely to produce toxicity if a tube of model cement, airplane glue, or
plastic cement is bitten into. Glue sniffing concentrates toluene up to
200 parts per million, which is 50 times the maximum allowable concen-
tration in industrial plants.
Teething rings and bathtub floating toys contain water, glycerin,
or mineral oil. Rarely there may be an oil with a kerosene odor present
which, if aspirated can cause chemical pneumonia. The toxic dose of
glycerin and mineral oil is in excess of 2 gm. per kg., which makes the
toxicity negligible. Imported items may contain pathogenic organisms
in the fluid.
Candles contain paraffin and beeswax and are nontoxic. Paraffin
toxicity is in excess of 2 gm. per kg.

Plants
There are approximately 300,000 plants identified. In the United
States, 525 are suspected of being poisonous to animals and humans. \1
According to Lampe and Fagerstrom, plant ingestions account for 5 per
cent of accidental pOisoningsY In our community, they account for 10
per cent of the incidents of ingestion reported to the Poison Control
Center. A recent report of 1659 plant ingestions revealed only 170
patients to have had any but mild symptoms. The danger of poisoning
varies according to the degree of ripeness, the quantity ingested, the
intactness of the seed coating, the age and health of the victim, his
inherited susceptibility, his blood composition, and whether vomiting is
induced by the plant.
If material from the ingested plant is not available or cannot be
described, or if the plant cannot be identified, one should proceed on
the assumption that the plant may have been poisonous. If only 2 to 3
hours have elapsed, vomiting should be induced. 12
In our experience, plant identification is very difficult if the name of
the plant is not known to the owners. It requires consulting plant author-
ities, which is not helpful in treating the immediate problem. We attempt
to identify the plant and portion consumed in Edible Wild Plants and if
it is listed as nontoxic, we do not advise emesis. An example of the
problem faced with a plant ingestion is the yew berry; it is safe to eat, but
the seeds inside the berry may be poisonous. Books available to aid in
advising on plant ingestions include Edible Wild Plants, by o. P.
Wedsger, published by Williams & Wilkins Company, and Poisonous
Plants of the United States and Canada, by Kingsbury, published by
Prentice-Hall, Inc.

SUMMARY

The authors have compiled a list of common household products

which are frequently ingested by children and which may be considered
nontoxic unless deliberately taken in large amounts.
590 HOWARD C. MOFENSON, JOSEPH GREENSHER

An understanding of the nontoxic ingestion should prevent over-

treating and hazardous alarm on the part of physicians and parents.
Reporting of all ingestions is encouraged to help obtain more infor-
mation on the potential harmfulness of the ever increasing number of
household products.

GENERAL REFERENCES

Arena, J. M.: Poisoning. Springfield, Illinois, Charles C Thomas, Publisher, 1964.

Gleason, M. N., Gosselin, R. E., and Hodge, H. C.: Clinical Toxicology of Commercial Products.
2nd ed. Baltimore, Williams & Wilkins Co., 1963.
Gosselin, R. E.: How toxic is it? J.A.M.A., 163:1333, 1967.
Verhulst, H. L., and Crotty, J. J.: Toxicity of common household items. Bulletin of The
National Clearinghouse for Poison Control Centers, March-April 1969.

REFERENCES
1. Anonymous: Questions and answers. J.A.M.A., 197:200, 1966.
2. Arena, J. M.: Poisonings and other health hazards associated with use of detergents.
JA.M.A., 190:168, 1964.
3. Arena, J. M.: Poisoning. Springfield, Illinois, Charles C Thomas, Publisher, 1964, p. 346.
4. Cann, H. M., and Verhulst, H. L.: Toxicity of household soap and detergent products and
the treatment of their ingestion. Amer. J. Dis. Child., 100:287, 1960.
5. Cantor, M. 0.: Mercury lost in the gastrointestinal tract. J.A.M.A., 146:560, 1951.
6. Carter, R. 0., and Griffith, J. F.: The household products manufacturer's role in poison
control. Proceedings of the Conference on Poison Control, March 26-29, 1967.
7. Clark, E. B.: Poisoning due to ingestion of wax crayons. J.A.M.A., 135:917, 1947.
8. Cummins, L. H.: Hypoglycemia and convulsions in children following alcohol ingestion.
J. Pediat., 58:23,1961.
9. Hughes, W. T., and Kalmer, T.: Massive talc aspiration. Amer. J. Dis. Child., 111 :653,
1966.
10. Jones, D. V., and Work, C. E.: Volume of a swallow. Amer. J. Dis. Child., 102:427,1964.
11. Kingsbury, J.: Poisonous Plants of the United States and Canada. Englewood Cliffs, N.J.,
Prentice-Hall, Inc., 1964.
12. Lampe, K. F., and Fagerstrom, R.: Plant Toxicity and Dermatitis. Baltimore, Williams &
Wilkins Company, 1968.
13. Pike, D. G., et al.: A re-evaluation of the dangers of Clorox ingestion. J. Pediat., 63:303,
1963.
14. Shirkey, H. C.: Ipecac syrup. Its use as an emetic in poison control. J. Pediat., 69:139,
1966.
15. Toles, A. D.: Hypoglycemic convulsions in children after alcohol ingestion. PEDIAT. CLIN.
N. AMER., 12:423, 1965.
16. Werner, B.: Interviews with parents of 595 children with poisoning accidents. Inter-
national Conference of Poison Control, June 4, 1969.

Nassau County Medical Center

2201 Hempstead Turnpike
East Meadow, New York 11554