Today's guest blogger is Blair Thornley, PharmD, CSPI, a pharmacist at the Poison Control Center at the Children's Hospital of Philadelphia.

A 2-year-old boy was brought to the Emergency Department after tasting some of his mom's cotton candy-flavored liquid nicotine that had been left out on the kitchen counter. The child vomited several times at home, and was noted to be unsteady on his feet. Upon arrival at the ED, he had a rapid heart rate and appeared lethargic. Shortly after, he experienced two seizures. The boy was intubated to protect his airway, and given treatment to stop the seizures. Within six hours, he was back to normal and went home.

Calls to poison centers regarding liquid nicotine are becoming more common given the increasing popularity of electronic cigarettes. In 2014, poison centers across the country received 3,783 calls regarding liquid nicotine exposures. This is an increase of almost 1300 percent over the 271 calls received in 2011! One teaspoon of liquid nicotine could be lethal to a child, and smaller amounts can cause severe illness, often requiring trips to the emergency department, according to a statement from the AAPCC.

So what are e-cigs exactly? The basic idea behind them is that a heat source is applied to liquid nicotine, vaporizing it, and allowing the user to inhale it. It has been promoted as a healthy alternative to smoking. Although at this point, there is not a lot of data to back up this claim. In addition, there is no regulation on packaging or oversite of product integrity.

While helping manage exposure calls, one of the biggest issues I've noticed is that the labeled concentration of the nicotine in the product is often unclear. This makes it more difficult to determine an approximate amount ingested. In addition, the actual amount of nicotine compared to the labeled amount might be off. Last year, a study found that 35 of 54 nicotine containing fluids from the United States had nicotine concentrations that deviated by more than 10 percent from the label. As an example, one product labeled as containing 18mg/ml of nicotine, actually contained nearly twice that amount (34mg/mL).

Another issue is availability. Cigarettes and other tobacco products can only be bought with a valid ID, but these products can be purchased easily at local head shops, at gas station counters, or even online. Many of the products often have brightly colored or cartoon-like labels with flavors that usually appeal to kids like chocolate and fruity gumballs. And worse yet, they are often NOT in child resistant containers.

The FDA has the authority to regulate all tobacco products and therapeutic nicotine devices (such as gum, patches, and inhalers). These regulations help promote appropriate product labeling and packaging, oversite of manufacturing processes, restriction of sales, and promotion of product safety. The FDA is currently considering whether to require warning labels and child-resistant packaging for liquid nicotine. Based on the data collected by the American Association of Poison Control Centers, it seems that FDA regulations that support child-proof packaging, and more standardized labeling would be extremely helpful in preventing further exposures.

In the meantime, try not to use these products in front of the children, and make sure they are kept locked away or stored on a high shelf when not in use. It is also important to continue to raise awareness about the dangers of these products throughout the community, and educate parents about how to keep these out of the hands of their children. As always, if an exposure does occur, you can contact us at the Poison Control Center (1-800-222-1222), where pharmacists and nurses are on staff 24 hours a day to help assess the risk of toxicity.

For more information, check out this helpful infographic on liquid nicotine exposures from Children's Safety Network and AAPCC's website for updates on reported exposures to these products.

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