Child Health ALERT

Volume 15 A Survey of Current Developments Affecting Child Health Care July/August 1997

Cyclospora From Imported Berries:
Another Food-Borne Illness To Worry About

Four very recent reports from the U.S. Centers for Disease Control and Prevention (CDC) indicate that we now have to add a new illness to the growing list of diseases that can be transmitted by certain food products. In an unusual series of three reports in the CDC's weekly health bulletin over just two months, federal health officials describe hundreds of adults and children from various states who developed a relatively serious and prolonged intestinal infection caused by a parasite called Cyclospora.

Fresh berries, particularly raspberries, were believed to be the source of the Cyclospora parasite, and preliminary evidence indicates that the contaminated berries came from Guatemala and possibly Chile. Cases of cyclosporiasis (as the disease is called) occurred during April and May of this year, and new cases of the illness are continuing to be reported to CDC, with the most recent ones occurring only a few weeks ago. (Centers for Disease Control and Prevention: Morbidity & Mortality Weekly Report, May 23, 1997, pp. 451-452; May 30, 1997, pp. 461-462, & June 13, 1997, pp. 521-523)

In a more detailed report published at the same time, government researchers describe almost 1,500 cases of cyclosporiasis reported last year (1996) from 20 states. Of these, about 3% occurred in children. Most patients had diarrhea, weight loss, loss of appetite, and fatigue, as well as gas, abdominal pains, and cramps. At least half the patients also had other symptoms, such as muscle, joint, or body aches, fever, and headache. The illness lasted at least two weeks in more than half the patients. Only about 1% of the patients were hospitalized, and there were no deaths.

In tracking down where these patients might have gotten their illness, the researchers found that about half the people had attended 55 different social events held during May and early June last year, and raspberries were served at the vast majority of these events. In most cases, the source of the raspberries was traced to Guatemala, though it was unclear how the berries might have become contaminated.

The researchers point out that before last year, most North American cases involving Qyclospora infection were in overseas travelers, but in just the last two years large numbers of cases among non-travelers have come to attention. The illness is described as long-lasting and intermittent (with times when patients might feel better followed by times when they are ill again). It takes an average of a week after eating contaminated berries for symptoms to begin, and the symptoms are the result of the parasite invading cells of the small intestine. Fortunately, cyclosporiasis is treatable with antibiotics. (Herwaldt BL et al: New England Journal of Medicine, May 29, 199 7, pp. 1548-1556)

COMMENT: There is a "good news/bad news" aspect to these reports. The good news is that Cyclospora infection was neither fatal nor serious enough to require hospitalization in most cases; further, the large majority of 1996 cases occurred in adults, not children. The bad news is that cyclosporiasis is not your average case of stomach flu, since symptoms tend to be more severe, longer lasting, and weight loss is a common problem. Further, we're not sure that we can take much reassurance from the fact that only 3% of the 1996 cases occurred in children, since most of those people seem to have been exposed to the parasite at social gatherings and we don't know how often children may have attended those events and eaten the contaminated berries.

In fact, we would bet that children are far more frequently infected by Cyclospora than the current cases would suggest, and those who care for children should be alert to ways of preventing the infection in the first place and recognizing it when it does occur. Prevention at this time means avoiding berries grown in Guatemala, Chile, and perhaps other countries, so it's important to carefully check berry packages for the country of origin. Whether the risk of illness is serious enough to avoid eating any berries unless you know where they were grown is debatable, but given the number of social events where berries were served and people became ill, that would be our approach. Unfortunately, washing berries may offer little protection, since the parasite can easily be missed in the crevices of some berries, especially raspberries.

Recognizing a case of cyclosporiasis is not simple, since many of the symptoms are the same that would occur with other illnesses, such as stomach flu. However, the Centers for Disease Control recommend that this condition should be suspected in anyone with a prolonged case of diarrhea, and health care providers should request specific testing for Cyclospora by the laboratory. Until authorities figure out how to prevent contamination of berries by Cyclospora, prevention and early detection will be the primary ways to avoid and treat infection by this troublesome parasite.

ENVIRONMENT

Insect Repellents Can Reduce The Effectiveness of Sunscreens

The ultraviolet light in sunshine, along with mosquitoes and ticks, are two different kinds of outdoor hazards, particularly in summer, and so it's not surprising for parents to use both sunscreens and insect repellents to protect their children. To see whether insect repellents might interfere with the effectiveness of sunscreens, researchers at Walter Reed Army Institute of Research and colleagues studied what happened when repellents were applied at various times after a sunscreen had been put on the skin.

They determined how well a sunscreen worked by measuring the "sun protection factor" (SPF-the same measure that sunscreens use to indicate how much sun protection they offer). Using 14 volunteers, they applied sunscreen (Coppertone Sport SPF 15) to all; on some, they then applied a repellent (containing 33% DEET, a common formula) anywhere from 15 to 105 minutes following application of the sunscreen.

When they compared the SPF effectiveness of the sunscreen, they found that those who used DEET after applying their sunscreen had an average decrease in sun protection of about one-third. Effecti~ eness "as decreased the most when the DEET was applied within one hour of applying the sunscreen.

Based on these findings, the authors "recommend that when a DEET-containing insect repellent and sunscreen are used together additional measures to protect from ultraviolet radiation should be used, such as avoiding direct sunlight during peak hours and the wearing of protective clothing and headgear." (Montemarano AD et al: Lancet, June 7,1997, pp. 1670-1671)

COMMENT: These findings are interesting, but it's important to keep them in perspective. It's hard enough to get sun protection measures incorporated into our daily routines, and trying to get parents and others who care for children to time their applications of sunscreen and DEET might result in one or both being overlooked. The fact is that the DEET reduced, but did not eliminate, sun protection by an average of about one-third, so an SPF of 15 may drop to 10. The simple solution, in our view, is to up the SPF in the first place! There's no magic in an SPF of 15, but if that's the protection that's desired, a product with 18 or more should cover most loss in effectiveness resulting from DEET.

CHILD SAFETY

Window-Cord Strangulations Of Children, 1981-1995

Before 1980, about one-quarter of all choking deaths in the United States were the result of strangulation by ropes or cords. As a result, federal laws were passed to modify products that were commonly blamed for these deaths, leading to the banning of cords on pacifiers, improvements in the design of crib toys, and recalls of various children's toys. One item, however, received little attention-window cords. Recent publicity has focused on the potential hazards of strangulation posed by windowcords, and a current study describes, for the first time, the nature of this problem.

Researchers from the U.S. Consumer Product Safety Commission (CPSC) report that in the 15 years from 1981 through 1995, 183 fatal window-cord strangulations were reported. Over 90% of the victims were 3 years of age or younger, and the vast majority were strangled by pull cords on venetiantype horizontal coverings.

In most cases, the accident occurred when the parent was the primary caretaker, and the time that the victim was left unattended was as brief as 4 minutes (and as long as 8 hours). The researchers point to recent window-cord safety campaigns as one way to reduce the risk of this potentially fatal injury among children. (Rauchschwalbe R & Mann NC: Journal of the American Medical Association, June 4, 1997, pp. 1696-1698)

COMMENT: This article provides details to document the kinds of serious hazards posed by various window cords, and reinforces the importance of the campaign, launched recently, to help consumers prevent such accidents.

SummerHint: CookThat Hamburger!

Summertime to many children means barbecues and cookouts, whether at home or at camp. For that reason it's a good time to remind readers (and for them to remind children) that they should make sure their hamburgers are well cooked. Undercooked hamburger (as well as unpasteurized apple cider) can be a source for certain kinds of E. coli bacteria, and these have caused both epidemics and isolated cases of serious and sometimes fatal illness in children. To be safe, hamburgers should be cooked so there's no pink in the middle.

In the January, 1997, issue of CHILD HEALTH ALERT, we brought the problem and campaign to readers' attention, and included a free poster, made available by the Wall Covering Safety Council, which can be reproduced for posting and distribution to parents, child-care centers, and other settings where children may be at risk from looped cords used in window blinds, drapes, and shades.

Readers who wish to receive an additional copy of that 8.5 x I I inch poster should send a self-addressed, stamped business size (#10) envelope to: CHILD HEALTH ALERT, Attn: Window Cord Poster, P.O. Box 610228, Newton Highlands, MA 02461.

MEDICATION

As More People Try To Quit Smoking, More Children May Be At Risk For Poisoning With The Nicotine Patch

In recent weeks we've heard a great deal about possible major advances in reducing the hazard to children (and adults) of cigarette smoking. While the agreement worked out between tobacco companies and attorneys general from 40 states still must be approved by the U.S. Congress, the flurry of publicity surrounding the issue is bound to encourage more adults to try to quit smoking. One popular way is to use nicotine patches. These devices attach to the skin like a large bandaid and provide small amounts of nicotine through the skin, into the bloodstream, to help smokers get by without cigarettes and eventually quit entirely.

Patches were first introduced in 1992 by prescription only, but they became available over-the-counter in 1996. These delivery systems still contain active drug after they have been on the skin for the specified time, and the nicotine in the patch could be toxic to infants and toddlers who might come in contact with

them. To determine whether nicotine patches might pose such risks, researchers from 34 poison centers monitored incoming poisoning calls regarding accidental exposure to nicotine patches.

Overall, they identified 36 cases where this happened. Children ranged from 7 weeks of age to 13 years (the average age was 3 years), and the circumstances of exposure varied. In most, the child had discovered the patch, either new or discarded, or had opened a new package. In some, the patch had fallen off an adult's skin. In one instance a child mistook the patch for a Bandaid, in another the child was sucking a patch attached to its father's arm, and in still another the patch became attached to the child's pajamas in the family wash, and was then transferred to the child's skin.

Two-thirds of the children suffered no toxic effects. The five children who had symptoms after sucking or chewing the patch had gagging or a burning sensation of the mouth or tongue, vomiting of the gel, and excessive fatigue in a 7-month old who chewed a patch. By contrast. children who had the patch attached to their skin tended to be more seriously ill, including nausea and/or vomiting that often required an emergency room visit or even, in two cases, admission to the hospital. (Wooff A et al: Pediatrics, May, 1997; 99:e4 [electronic edition])

COMMENT: Once the nicotine patch became available for adult use, it was only a matter of time until poison centers accumulated these cases. The current study was conducted before the patch became available without prescription: now that it is available so readily, sales will increase, and because it no longer requires a prescription, people who use it may treat the patch more casually. The combination of wider use and casual attitudes may well pose an extra hazard to children, who can develop mild problems from chewing or sucking on new or even used patches or more serious poisoning if the patch becomes attached to their skin for more than 20 minutes or so. So the lesson is clear-nicotine patches must be effectively discarded when they are no longer being used and, like any other medication, kept away from young children.

PRODUCT RECALLS

Recalls: Rabbit Rattles ...

Right Start, Inc., of Westlake Village, Calif., is recalling 8,000 Baby's Play Sets because the yellow rabbit rattle included in the set has blue and white balls that may separate from the rattle and present a choking hazard. The sets were sold through Right Start catalogs and retail stores from September, 1994 through August, 1995 for $14.95; the company will refund $1.50 for each rattle that is returned or it will refund the full purchase price if the entire set is returned. For more information, call Right Start at (800) 710-7816.

... Swimming Vest's...

OddzOn Products Inc., of Campbell, Calif., is recalling 5,000 children's "Starfish" swimming vests because the buckles could unlatch. The vests were sold for $14 in toy, sporting goods, and gift stores from May, 1996 through March, 1997 - -Consumers should return the - vests to the place of purchase for a full refund, or call OddzOn Products at (800) 755-6674.

... Infant Swings...

Cosco Inc., of Columbus, Ind., is providing a free repair kit for over 350,000 Quiet Time infant swings. Screws connecting the metal hanger tubes and the Ushaped seat support can loosen and fall out, and infants could be injured in a resulting fall. The company has received more than 300 complaints, including 44 reports of injuries.

Supported by four white metal legs, the wind-up swing operates for about 30 minutes at a time. "Cosco Quiet Time" is printed on a label on top of the swing. The model numbers affected are 08-975 and 08-977, made from February 1, 1993 through September 30, 1995: the date codes run from 0593 through 4095. The swings were sold for S45 to S49 nationwide, beginning in February, 1993, at juvenile products and discount department stores. Consumers should call Cosco at (800) 221-6736 to receive the free repair kit.

... High Chair...

Playskool, of Pawtucket, R.I., is offering free replacement restraint bars for over 275,000 of its 1-2-3 High Chairs. The restraint bar can crack or break off, allowing an unsecured child to fall from the chair. PlayskoQ1 has -received hundreds of complaints and 40 reports of injuries resulting from children falling out of the chair. The plastic restraint bar is located at the center of the front of the seat. The high chair's tray attaches to the restraint bar. Only bars on chairs made between May, 1995 and May, 1996 require replacement, and these have serial numbers between TX51321 and TX61442. The serial number can be found on the label on the back of the seat.

The Playskool 1-2-3 High Chair was sold nationwide for about $65 at discount juvenile product and department stores. To receive a free replacement bar, call the company at (800) 555-0428 or write Playskool at P.O. Box 5659, Pawtucket, R.I. 02862 (consumers should not return the high chair to retailers).

... Teddy Bears...

The Mazel Co., of Solon, Ohio, is recalling 835 Teddy Precious Indian girl and boy stuffed bears because their Native American-style beads can detach, leading to a potential choking hazard. The 18-inch, light brown bears have brown vinyl clothing trimmed with Native American embroidery and a label sewn to the bear's foot reading "Teddy Precious". A sewn-in tag has the words "Dandee International Limited ... Made in China". They were sold at independent discount stores for $13 from July through December, 1996. Consumers should return the bears to the store where purchased for a full refund or replacement toy. For more information, call Mazel at (800) 443-4789.

... Necklaces...

Charming Shoppes Inc., of Bensalem, Penn., is recalling almost 5,000 metallic heart-shaped medallion necklaces because they contain high levels of lead. Young children could be exposed to lead by getting it on their hands (and putting them in their mouths) or by swallowing lead directly from the necklace. The necklaces were included with a blouse-and-pant set, which had a pink heart print and was available in sizes 4 through 6X. The necklace has a heart-shaped silvercolored medallion (embossed with daisies) on a dark blue string. The necklace should be returned to any Fashion Bug store for a replacement; for questions, call Charming Shoppes at (800) 4782918.

... And Lacrosse Stick Handles

STX Inc., of Baltimore, Md., is recalling as many as 9,000 older model Titanium Plus lacrosse handles because they may not be thick enough and could crack or break during play, resulting in injury to players. STX recently received three reports of lacerations blamed on this problem. The lacrosse handles were sold between January, 1994 and July, 1996 through lacrosse catalogs, specialty sporting goods stores, and at lacrosse camps. The handles in question are eight-sided titanium alloy, silver in color, and with the words "Titanium Plus" printed on the stick handle when it was new. Though the wording may have faded from use, the purchase date should help identify the affected models. Newer models, under the same name, are not subject to this recall. Consumers should call STX at (800) 848-2152 for more information.

(All reports from AAP News and Consumer Product Safety Commission, Washington, D.C.)