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Pediatric and Young Adult Exposure to Chemiluminescent Glow Sticks
Robert J. Hoffman, MD;
Lewis S. Nelson, MD;
Robert S. Hoffman, MD
Arch Pediatr Adolesc Med. 2002;156:901-904.
ABSTRACT
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Background Although chemiluminescent plastic rods, commonly called "glow sticks"
or "light sticks," are typically considered to be minimally toxic or nontoxic,
published data about exposure to these products are scarce.
Objectives To test our hypothesis that exposure to chemiluminescent products is
unlikely to result in significant morbidity or mortality and to describe factors
associated with exposure by reviewing reports to our urban poison control
center of human exposure to chemiluminescent products.
Methods Pediatric and young adult exposure to chemiluminescent products reported
between January 1, 2000, and April 1, 2001, to our poison control center were
evaluated with regard to demographic group, type of product involved, circumstances
of exposure, symptoms, and management.
Results Reported routes of exposure (n = 118) included ingestion (n = 108),
ocular (n = 9), and dermal exposure (n = 1). Only patients exposed to chemiluminescent
fluid from a leaking container reported symptoms (n = 27). Symptoms were limited
to transient irritation of the exposure site, and no systemic toxicity occurred.
All adults (n = 4) inadvertently ruptured or swallowed intact light sticks
while at a dance club or dance party. Most exposure and all adult exposure
occurred on holidays or weekends.
Conclusions Most incidences of exposure to chemiluminescent products involve asymptomatic
ingestion of fluid that leaks from glow sticks or ingestion of an intact glow
stick. Symptoms occur after exposure to chemiluminescent fluid and consist
of transient irritation at the site of exposure. The clustering of reported
exposure on weekends and in dance clubs and parties coupled with a lack of
occupational or workplace exposure suggest that recreational use is a major
contributory factor. Exposure to chemiluminescent products infrequently resulted
in symptoms and the symptoms reported were minor. Exposure to chemiluminescent
products as described is unlikely to cause significant morbidity or mortality.
INTRODUCTION
ONCE A seldom-used specialty item of military personnel and outdoor
enthusiasts, chemiluminescent products have become very popular and readily
available consumer products. In particular, the use of glowing plastic rods,
commonly referred to as "glow sticks," at dance clubs and rave dance parties,
and the use of glowing plastic jewelry at festivals, parades, sporting events,
and other mass social gatherings are quite common. Typically, manufacturers
describe these items as "nontoxic" and they are considered minimally toxic
by many clinicians.1
The active reagents in chemiluminescent products are anthracene and
oxalates synthesized with dibutyl phthalate. Dibutyl phthalate has been reported
to cause anaphylaxis2 and even death when ingested
in large quantities.3 Reports of exposure to
these chemiluminescent products are scarce and their toxicities and outcomes
of exposure are essentially undescribed. In response to a dramatic increase
in the number of incidences of exposure to chemiluminescent products reported
to our poison control center, we sought to examine the characteristics and
outcomes of such exposure.
We hypothesized that exposure to chemiluminescent products is unlikely
to result in significant morbidity or mortality and that recreational use
is a contributory factor. These hypotheses, coupled with a lack of published
clinical data on exposure to chemiluminescent products warranted this examination
of circumstances of exposure, toxicity, and management of patients exposed
to these products. Since data about such exposure are lacking, current management
of exposure to chemiluminescent products is based primarily on anecdotal experience.
Further study of this issue is necessary for evidence-based management of
these increasingly common types of exposure.
DESIGN AND METHODS
This study included predominantly retrospective review of human exposure
to chemiluminescent products in patients younger than 25 years reported to
our poison control center. This study did not require and did not undergo
institutional review board review. Computerized records (Toxicall, Aurora
Springs, Colo) of all telephone reports made to our poison control center
between January 1, 2000, and April 1, 2001, were reviewed, and exposure to
chemiluminescent products were evaluated with regard to the demographic group
exposed, the type of chemiluminescent product, the circumstances of exposure,
the patient's symptoms at the time of the initial report, and the symptoms
at follow-up.
Exposure to such products was defined as for all other poisons reported
to our center. These include known or suspected contact with the product by
the following routes: ingestion, nasal inhalation, aspiration with ingestion,
ocular, dermal, parenteral, rectal, otic, vaginal, other, and unknown. Significant
morbidity was considered to be systemic toxicity, involvement of 2 or more
organ systems, or symptoms requiring hospitalization. Mortality was defined
as death attributed to exposure. Patient demographic and clinical data are
reported as numbers and percentages.
RESULTS
In total, 118 incidences of exposure involving 72 males were reported
(Table 1). These included 4 young
adults (18-25 years old), 18 teenaged children (13-17 years old), and 96 younger
children (0-12 years old). The preponderance of exposure cases involved glow
sticks (n = 106) but others involved glowing jewelry (n = 12). Ingestion (n
= 108), ocular exposure (n = 9), and dermal exposure (n = 1) occurred.
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Age and Type of Exposure to Chemiluminescent Products*
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Only patients exposed to an open container that leaked chemiluminescent
fluid developed symptoms (n = 27). These symptomatic patients experienced
irritation at the site of exposure, most commonly involving the mouth or throat
(n = 13), eye (n = 9), and skin (n = 1). Four children exclusively experienced
nausea (n = 1), emesis (n = 1), or dysgeusia (n = 2) after ingestion.
Twelve patients reportedly swallowed an intact glow stick and none had
symptoms at the time of reporting or during follow-up. All adults had inadvertently
ruptured or swallowed an intact light stick while dancing at a dance club
or dance party and none developed symptoms. Approximately half of exposure
incidences (62/118) occurred on public holidays or during the weekend, defined
as after 5 PM Friday and before 9 AM the following Monday. All adult exposure
occurred during these periods.
Eighty-five percent of exposure cases were reported from the home (n
= 100), 14% reported from health care facilities (n = 16), and 1% reported
from schools (n = 2). No incidences of workplace or occupational exposure
were reported.
COMMENT
Exposure to glow sticks and related chemiluminescent products is an
increasingly common phenomenon. At the time this study was concluded in April
2001, the cases of chemiluminescent product exposure reported to our poison
control center had increased 3-fold relative to January 2000, the earliest
month included in the study. Prior to conducting this study, the nature of
exposure at dance clubs and dance parties and the clustering of exposure on
weekends led us to hypothesize that recreational use of these products was
a major contributory factor to exposure. This is congruent with data from
the most comprehensive publication on the subject: in the 6-month period from
June 1993 to December 1993, 23% of all cases of exposure to chemiluminescent
products reported to an urban poison control center occurred on the Fourth
of July holiday weekend.4 In our study, the
clustering of exposure incidences on holidays and weekends, the occurrence
of all adult exposure at dance clubs and dance parties, and zero incidences
of occupational or workplace exposure supported the notion that recreational
use is a contributory factor. At this time, the only well-identified circumstances
of exposure are children at home and adults at dance clubs or dance parties.
All types of poisoning should be considered preventable, and this is particularly
true for poisoning resulting from recreational activities.
The clinical effects of reported exposure cases were fortunately minor.
Nearly all types of exposure were by ingestion (92%), although ocular and
dermal exposure were also noted. Most exposure involved intact glow sticks
and these types of exposure never resulted in symptoms. Only patients exposed
to broken glow sticks or broken glowing jewelry developed symptoms. In total,
only 23% of patients with exposure developed symptoms. Although the number
of cases of ocular and dermal exposure was small, all resulted in symptoms.
Symptomatic patients experienced irritation at the site of exposure
soon after it occurred. Irrigation of the exposure site or dilution by means
of oral intake of fluids was the sole means of decontamination and treatment.
A small subpopulation of children experienced minor nonspecific symptoms of
nausea, dysgeusia, or emesis, which seemed to indicate local irritation of
the gastrointestinal tract after ingestion.
Although many asymptomatic or minimally symptomatic patients did not
have follow-up data collected after the initial contact with the poison control
center, there were no cases of symptoms lasting longer than several hours
or recurrence of symptoms after initial cessation. All patients in this study
either remained at home or were evaluated in a health care setting and discharged
after brief observation. No patient in this study required laboratory evaluation
or hospital admission. No patient developed any systemic symptom.
By far, most patients with exposure were children, with adults comprising
only 3% of exposure cases. This statistic identifies the pediatric population
as being at the greatest risk of exposure, suggesting that pediatricians as
well as emergency physicians should have an understanding of the toxicity
of chemiluminescent products and the management of exposure to these products.
Additionally, this suggests that education and prevention efforts be directed
toward parents and children.
Nearly all chemiluminescent products involved were glow sticks and a
small number were glowing jewelry. Of note, no patient exposed to an intact
product, even if it was an ingested intact glow stick, developed symptoms.
We believe that the number of swallowed intact glow sticks was higher than
noted herein. The nature of our computerized patient records allows all types
of exposure to easily be classified as "ingestion"; however, reporting a patient
swallowing intact products requires additional data entry by manually typing
a narrative of such, which may not occur in all cases.
Glow sticks are commonly available in several sizes, ranging from cylinders
approximately 10 to 15 cm in length and 1 to 1.5 cm in diameter to smaller
cylinders approximately 2 to 2.5 cm in length and 0.3 cm in diameter. No patient
was known to have ingested a larger-sized glow stick. Although it is unlikely
to occur based on the size of these objects, ingestion of a large glow stick
may present a mechanical problem not noted in this study. Unfortunately, the
smaller glow sticks are particularly marketed as an accessory to be held in
the mouth, typically at dance clubs and dance parties. No patient in this
study who ingested an intact glow stick experienced aspiration or airway obstruction,
although the possibility of such an occurrence cannot be ignored.
Glow sticks are extremely common items used at dance clubs and dance
parties. We surmise that use of glow sticks in such settings may involve particular
risk factors, including holding glow sticks in mouth while dancing, concomitant
use of drugs and alcohol that may impair cognition, and consumption of ecstasy
(MDMA), a common adverse effect of which is bruxism,5
for which users may seek relief by chewing on glow sticks.
Industrial data report dibutyl phthalate as capable of causing severe
morbidity and mortality. The quantities of this toxic reagent in glow sticks,
glowing jewelry, and other chemiluminescent products is minimal and these
products should not be presumed to have the same toxicity as industrially
used dibutyl phthalate.
Based on the results of this study and our clinical experience, we consider
unintentional exposure to chemiluminescent products, such as that discussed
here, unlikely to result in symptoms in the absence of a broken or leaking
container. In this study, ingestion of small, intact glow sticks never resulted
in symptoms, although we acknowledge the potential for airway complications
or complications that may result from ingestion of a larger glow stick.
Oral, ocular, or dermal exposure to liquid from chemiluminescent glow
sticks and similar products may result in symptoms but the nature of these
symptoms is transient irritation at the site of exposure. If necessary, treatment
of topical exposure should consist of irrigation, and treatment of oral exposure
and ingestion should consist of irrigation or dilution. In our study, these
agents acted as a local irritant rather than as a systemic toxin. Since exposure
to the small amounts of fluid that leak from these products does not seem
to result in systemic toxic reaction, routine administration of activated
charcoal after unintentional exposure is not necessary.
The limitations of this study include its retrospective nature, reliance
on patients, caregivers, and clinicians to contact or consult our poison control
center after exposure, and the inability to confirm that any reported exposure
directly involved the chemiluminescent products of interest. Although we cannot
declare that exposure to chemiluminescent products is free of potentially
serious consequences, our data demonstrate that reported exposure to such
products is unlikely to result in significant morbidity or mortality.
| What This Study Adds
The reagents in chemiluminescent products have been reported to cause
significant morbidity and even death, but reports of exposure to these products
are scarce. Unfortunately, most data on these toxins are relative to industrial
uses and chronic toxic reactions, and to our knowledge, no scientific evaluation
of exposure to chemiluminescent products exists in published form. Thus, current
management of exposure to chemiluminescent products is based primarily on
anecdotal experience. Further study of this issue is necessary to provide
data that allow rational, evidence-based management of these cases. To our
knowledge, this study is the most thorough review of exposure to chemiluminescent
products ever published. It provides epidemiologic information as well as
relevant information about the symptoms, management, and outcomes. These data
give clinicians information that may assist in the prevention and medical
management of patients exposed to chemiluminescent products.
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AUTHOR INFORMATION
Accepted for publication March 14, 2002.
This study was presented in part at the XXI International Congress of
the European Association of Poisons Control Centres, Barcelona, Spain, May
17, 2001, the American College of Emergency Physicians 2001 Research Forum,
Chicago, Ill, October 16, 2001, and the American Academy of Pediatrics 2001
National Conference and Exhibition, San Francisco, Calif, October 22, 2001.
Corresponding author: Robert J. Hoffman, MD, 455 First Ave, Room
123, New York, NY 10016 (e-mail: rjhoffman{at}pol.net).
From the Maimonides Medical Center, Brooklyn (Dr R. J. Hoffman) and the New York
City Poison Control Center, New York (Drs R. S. Hoffman and Nelson),
NY.
REFERENCES
1. Poisindex System 2000: dibutyl phthalate. In: Rumack BH, Rider PK, Gelman CR, eds. Poisindex System.
Englewood, Colo: Micromedex Inc; 2000.
2. Gall H, Khler A, Peter RU. Anaphylactic shock reaction to dibutyl-phthalate-containing capsules. Dermatology. 1999;199:169-170.
PUBMED
3. Occupational Safety & Health Administration. Occupational safety and health guideline for dibutyl phthalate. Washington, DC: Government Printing Office; 1999.
4. Keys N, Erickson T, Lipscomb J. Glow compound exposure [abstract]. J Toxicol Clin Toxicol. 1995;33:488.
5. Stephenson CP, Hunt GE, Topple AN, McGregor IS. The distribution of 3,4-methylenedioxymethamphetamine "Ecstasy"-induced
c-fos expression in rat brain. Neuroscience. 1999;92:1011-1023.
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Poison control center protocols
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AAP News 2002;21:224-224.
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