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Small toys contained in chocolate eggs—good or bad surprise?
Vol. 96 (2002) 955^956
CASE REPORT
Small toys contained in chocolate eggsFgood or bad surprise? RAINER KEHRT, BODO NIGGEMANN, SIEGFRIED KLAUE AND ULRICH WAHN Department of Paediatric Pneumology and Immunology, Charite¤ Campus Virchow-Klinikum, Humboldt University, Berlin, Germany
Injury from foreign bodies is a well-known cause of childhood morbidity and even mortality (1,2). Sweets containing toys with small parts may present a serious choking and aspiration hazard to children under 3 years of age. In Germany and other European countries, small plastic toy components are often sold together with confectionery, e.g. contained in a chocolate shell. According to the European Community Directive concerning the safety of toys, packaging containing edible items together with small toys which might be dangerous for children under three years of age must carry the warning ‘‘Not suitable for children under three years.’’ To assess the potential dangers of small toys marketed with confectionery, we performed a national cross-sectional questionnaire survey, including 500 (90%) paediatric clinics, 1300 (25%) paediatricians in practice, and placed an advertisement with the questionnaire in the newsletter of the German Association of Paediatricians. The response rate of clinic and practice was 39 and 25%, respectively.The advertisement lead to 5 returns. A total of 35 cases were reported. In all cases, the foreign body was a small toy or part of it. In 34 of the cases, the origin of the toys was a kinder surprise chocolate egg and in 1 case a magic bag. 3 (9%) of the small toys were located in the ear, 9 (26%) in the nose, 5 (14%) in the pharynx, seven (20%) in the lungs, and11 (31%) in the gastro-intestinal tract (Table 1).The incorporation of toys was mostly observed by parents.Overall 5 (14%) complications were reported: 4 children su¡ered from marked obstruction of the upper airways due to a small toy in the pharynx, while 1 child had a pneumonia because of intrabronchial localisation. There were no fatalities. The age of the affected children ranged from 8 months to 10 years (medReceived 5 November 2001, accepted in revised form 11 March 2002. Correspondence should be addressed to: Dr Rainer Kehrt, Department of Paediatric Pneumology and Immunology, Charite¤ Campus Virchow-Klinikum, Augustenburger Platz 1, D-13353 Berlin, Germany. Fax: +49-30 - 450 566 931; E-mail: [email protected]
ian 36 months). 2 (6%) were younger than1year,15 (43%) 1 and 2 years, 14 (40%) 3^5 years, and 4 (11%) 6 ^10 years old. None of the children was handicapped. Since the feedback to our questionnaire with onethird returns seems to be low, we assumeFaccording to the majority of the respondersFthat the non-responders do not remember any incident. Nevertheless, according to the present results, small toys marketed with confectionery constitute a potential risk especially for children under 5 years (3). In comparison to other accidents with foreign bodies, which are mainly caused by aspiration of peanuts and ingestion of coins, foreign body injuries caused by small toys marketed within chocolate eggs are rare. However, the common product warnings are not su⁄cient for the protection of the risk group. In addition, more than half of the children concerned were 3 years or older. Since there are no rules specifying the nature and appearance of the warning, there is usually no indication of the nature of the risk. Parents or other consumers therefore may misinterpret the label as information about the age group the toy is intended for, rather than as a warning. An American study demonstrated a change of purchasing behaviour induced from speci¢c warnings (4). In difference to Europe, the legislature of the United States of America bans from interstate commerce any toy or other article intended for use by children younger than 3 years that presents a choking, aspiration, or ingestion hazard because of small parts (5). In August 1997, the US Consumer Product Safety Commission (CPSC) was recalling approximately 5000 kinder surprise chocolate eggs illegally imported into the United States (6). CPSC considers the toys within the eggs to violate CPSC’s small parts regulation with respect to children under 3, and therefore, the kinder surprise chocolate egg is not allowed to be marketed in the United States, although no injuries involving these toys are reported so far.
956
RESPIRATORY MEDICINE
TABLE 1. Foreign bodyinjuries (n=35) due to smalltoys containedin chocolate eggs.The cases are listed according to location of the foreign body
Number Age (months) Range Median Removal Spontaneous Instrumental Endoscopic In-patient
Ear
Nose
Pharynx
Lung
Gita
3 (9%)
9 (26%)
5 (14%)
7 (20%)
11 (31%)
30^41 36
24-46 32
8^94 18
18^120 24
11-73 36
0 3 (100%) 0 0
2 (22%) 7 (78%) 0 0
1 (20%) 3 (60%) 1 (20%) 4 (80%)
1 (14%) 0 6 (86%) 6 (86%)
11 (100%) 0 0 4 (36%)
a
gastro-intestinal tract.
Although explicit warnings are obviously needed for things known to pose a choking hazard to children, prevention of foreign body injuries can only be e⁄cient if all those who are in charge of educating children are aware of the risk factors.
REFERENCES 1. Nixon JW, Kemp AM, Levene S, Sibert JR. Suffocation, choking, and strangulation in childhood in England and Wales: epidemiology and prevention. Arch Dis Child 1995; 72: 6–10. 2. MMWR, Morbidity and Mortality Weekly Report. Toy-related injuries among children and teenagersFUnited States, 1996. Massachusetts Med Soc 1997; 46: 1185–1189.
3. Weizman Z, Krugliak P. Toys within chocolate eggsFan ingestion hazard. Acta Paediatr 1998; 87: 478–481. 4. Langlois JA, Wallen BAR, Teret S, Bailey LA, Hershey JH, Peeler MO. The impact of specific toy warning labels. JAMA 1991; 265: 2848-2850 5. Rimell FL, Thome Jr A, Stool S, Reilly JS, Rider G, Stool D, Wilson CL. Characteristics of objects that cause choking in children. JAMA 1995; 274: 1763–1766. 6. U.S. Consumer Product Safety Commission. CPSC and Kreiner Imports announce the recall of Kinder chocolate eggs containing toys. Release # 97–172. Office of Information and Public Affairs, Washington, 1997.
CASE REPORT
Small toys contained in chocolate eggsFgood or bad surprise? RAINER KEHRT, BODO NIGGEMANN, SIEGFRIED KLAUE AND ULRICH WAHN Department of Paediatric Pneumology and Immunology, Charite¤ Campus Virchow-Klinikum, Humboldt University, Berlin, Germany
Injury from foreign bodies is a well-known cause of childhood morbidity and even mortality (1,2). Sweets containing toys with small parts may present a serious choking and aspiration hazard to children under 3 years of age. In Germany and other European countries, small plastic toy components are often sold together with confectionery, e.g. contained in a chocolate shell. According to the European Community Directive concerning the safety of toys, packaging containing edible items together with small toys which might be dangerous for children under three years of age must carry the warning ‘‘Not suitable for children under three years.’’ To assess the potential dangers of small toys marketed with confectionery, we performed a national cross-sectional questionnaire survey, including 500 (90%) paediatric clinics, 1300 (25%) paediatricians in practice, and placed an advertisement with the questionnaire in the newsletter of the German Association of Paediatricians. The response rate of clinic and practice was 39 and 25%, respectively.The advertisement lead to 5 returns. A total of 35 cases were reported. In all cases, the foreign body was a small toy or part of it. In 34 of the cases, the origin of the toys was a kinder surprise chocolate egg and in 1 case a magic bag. 3 (9%) of the small toys were located in the ear, 9 (26%) in the nose, 5 (14%) in the pharynx, seven (20%) in the lungs, and11 (31%) in the gastro-intestinal tract (Table 1).The incorporation of toys was mostly observed by parents.Overall 5 (14%) complications were reported: 4 children su¡ered from marked obstruction of the upper airways due to a small toy in the pharynx, while 1 child had a pneumonia because of intrabronchial localisation. There were no fatalities. The age of the affected children ranged from 8 months to 10 years (medReceived 5 November 2001, accepted in revised form 11 March 2002. Correspondence should be addressed to: Dr Rainer Kehrt, Department of Paediatric Pneumology and Immunology, Charite¤ Campus Virchow-Klinikum, Augustenburger Platz 1, D-13353 Berlin, Germany. Fax: +49-30 - 450 566 931; E-mail: [email protected]
ian 36 months). 2 (6%) were younger than1year,15 (43%) 1 and 2 years, 14 (40%) 3^5 years, and 4 (11%) 6 ^10 years old. None of the children was handicapped. Since the feedback to our questionnaire with onethird returns seems to be low, we assumeFaccording to the majority of the respondersFthat the non-responders do not remember any incident. Nevertheless, according to the present results, small toys marketed with confectionery constitute a potential risk especially for children under 5 years (3). In comparison to other accidents with foreign bodies, which are mainly caused by aspiration of peanuts and ingestion of coins, foreign body injuries caused by small toys marketed within chocolate eggs are rare. However, the common product warnings are not su⁄cient for the protection of the risk group. In addition, more than half of the children concerned were 3 years or older. Since there are no rules specifying the nature and appearance of the warning, there is usually no indication of the nature of the risk. Parents or other consumers therefore may misinterpret the label as information about the age group the toy is intended for, rather than as a warning. An American study demonstrated a change of purchasing behaviour induced from speci¢c warnings (4). In difference to Europe, the legislature of the United States of America bans from interstate commerce any toy or other article intended for use by children younger than 3 years that presents a choking, aspiration, or ingestion hazard because of small parts (5). In August 1997, the US Consumer Product Safety Commission (CPSC) was recalling approximately 5000 kinder surprise chocolate eggs illegally imported into the United States (6). CPSC considers the toys within the eggs to violate CPSC’s small parts regulation with respect to children under 3, and therefore, the kinder surprise chocolate egg is not allowed to be marketed in the United States, although no injuries involving these toys are reported so far.
956
RESPIRATORY MEDICINE
TABLE 1. Foreign bodyinjuries (n=35) due to smalltoys containedin chocolate eggs.The cases are listed according to location of the foreign body
Number Age (months) Range Median Removal Spontaneous Instrumental Endoscopic In-patient
Ear
Nose
Pharynx
Lung
Gita
3 (9%)
9 (26%)
5 (14%)
7 (20%)
11 (31%)
30^41 36
24-46 32
8^94 18
18^120 24
11-73 36
0 3 (100%) 0 0
2 (22%) 7 (78%) 0 0
1 (20%) 3 (60%) 1 (20%) 4 (80%)
1 (14%) 0 6 (86%) 6 (86%)
11 (100%) 0 0 4 (36%)
a
gastro-intestinal tract.
Although explicit warnings are obviously needed for things known to pose a choking hazard to children, prevention of foreign body injuries can only be e⁄cient if all those who are in charge of educating children are aware of the risk factors.
REFERENCES 1. Nixon JW, Kemp AM, Levene S, Sibert JR. Suffocation, choking, and strangulation in childhood in England and Wales: epidemiology and prevention. Arch Dis Child 1995; 72: 6–10. 2. MMWR, Morbidity and Mortality Weekly Report. Toy-related injuries among children and teenagersFUnited States, 1996. Massachusetts Med Soc 1997; 46: 1185–1189.
3. Weizman Z, Krugliak P. Toys within chocolate eggsFan ingestion hazard. Acta Paediatr 1998; 87: 478–481. 4. Langlois JA, Wallen BAR, Teret S, Bailey LA, Hershey JH, Peeler MO. The impact of specific toy warning labels. JAMA 1991; 265: 2848-2850 5. Rimell FL, Thome Jr A, Stool S, Reilly JS, Rider G, Stool D, Wilson CL. Characteristics of objects that cause choking in children. JAMA 1995; 274: 1763–1766. 6. U.S. Consumer Product Safety Commission. CPSC and Kreiner Imports announce the recall of Kinder chocolate eggs containing toys. Release # 97–172. Office of Information and Public Affairs, Washington, 1997.