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A 30-month-old child was brought to our Emergency Department with a history of accidental ingestion of nicotine solution. The mother had spotted her picking up a refill cartridge bottle and placing it in her mouth. Although she managed to snatch it away quickly she wasn't sure if the child had managed to swallow a small amount. The girl had vomited shortly after this incident but was otherwise asymptomatic. On examination the child was systemically well and all clinical observations were normal. The child's mother was unable to provide details about the amount or strength of solution in the bottle.
Toxbase was searched. There was extensive information on nicotine intoxication including smoking cessation aids like patches, gums and sprays but specific guidance on ingestion of nicotine liquid was unavailable.1 Based on the pharmacokinetic properties of nicotine (half life 24 min–2 h), the child was observed for 6 h,1 remained well and was discharged home. The parents were advised to keep the nicotine liquid in a safe place away from the child.
Our case highlights an important emerging issue related to the use of increasingly popular e-cigarettes.2 Initial devices were disposable but newer devices use refill cartridges containing liquid nicotine and battery powered vaporisers. The exploratory nature of young children and the attractive packaging of refills is a dangerous combination likely to lead to a growing incidence of accidental exposure to concentrated nicotine solution. The Centre for Disease Control and Prevention has reported a massive rise in e-cigarette liquid related calls to poison centres, from 1 per month (September 2010) to 215 per month (February 2014). More than half (51.1%t) of calls involved children under the age of 5 years old.3 To the best of our knowledge no mortality from this cause has yet been reported in children.
Early features of nicotine ingestion include burning in the mouth and throat, nausea, vomiting, confusion, dizziness, weakness and hypersalivation. Signs include tachycardia, tachypnoea, hypertension and agitation followed by bradycardia, hypotension and respiratory depression. Severe poisoning leads to arrhythmias, coma, convulsions and cardiac arrest.1 Skin or eye contact with concentrated liquid may cause irritation followed by variable absorption and systemic features may follow.
Lethal dose of nicotine has been estimated to be as little as 40 mg in adults.1 Lethal dose in children is probably much lower at approximately 1 mg/kg. Children who have ingested 0.2 mg/kg or more nicotine and are symptomatic should be referred for medical assessment.1 Nicotine liquid refills are available in various strengths ranging from 6 mg/mL (0.6%) to 36 mg/mL (3.6%). Assuming 20 drops in 1 mL solution, 1 drop of 3.6% e-juice will contain 1.8 mg nicotine. Ingestion of a few drops of concentrated solutions may be enough to cause severe symptoms in young children. For example, ingestion of one to two drops of 3.6% solution (1.8–3.6 mg) will put most children below the age of 5 years old in this category.
The risk posed by nicotine liquid to children needs to be recognised, acknowledged and acted upon by all. This includes public education and legislation to improve the safety profile of e-liquid containers. Toxbase guidance also needs to be updated.
Contributors SG was involved in the management of the case. All three authors contributed to the review of literature and preparation of the manuscript.
Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned; internally peer reviewed.
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