Alarming Surge in Liquid Nicotine Toxicity in Kids

Drs Robert Glatter and Ryan Marino discuss the hidden dangers, symptoms, interventions, and urgent need for awareness in this alarming public health issue with nearly 7000 reported incidents.
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Robert D. Glatter, MD: Hi. I'm Dr Robert Glatter, medical advisor for Medscape Emergency Medicine. Joining me today is Dr Ryan Marino, an emergency physician, medical toxicologist, and addiction medicine specialist at Case Western Reserve University School of Medicine.
Welcome, Dr Marino. It's really a pleasure to have you join us.
Ryan Marino, MD: Hi, Dr Glatter. Thanks for having me.
Glatter: Today's topic is the toxicity of liquid nicotine, and it's something that's been very important, especially since the CDC put out a report several months ago looking at the cumulative exposure from 2022 in the mid-year toward 2023 and the number of exposures - there were nearly 7000. The thing that caught my eye was that almost 90% of these exposures were in children under the age of 5, which to me was a significant wakeup call. I know that the proportion of children exposed to liquid nicotine has been increasing, but this is something that seems like a real public health concern, if not an emergency. I wanted to get your take on this report.
Marino: This was a report based on poison center calls. There are a couple of things to mention here. We've seen exposures to nicotine and calls to poison centers about nicotine increasing steadily over the past number of years. This is a pretty significant increase year-on-year, and it correlates to the liquid nicotine and vape market that we're seeing in this country.
One thing that I do want to mention about these data is that because these are poison center data, people have to call this in and it's self-reported, so it's probably an undercounting and underestimate of actual nicotine exposures. The real number is probably going to be even higher than what we're seeing here.
Nicotine Toxicity - Signs and Symptoms
Glatter: What are the signs and symptoms that a child has a significant exposure? What are the things you look for? What's the history? How do you approach a pediatric patient?
Marino: The most important thing is if someone reports that they think their child was exposed to nicotine, that's going to be the best clue because the symptoms can be nonspecific. Early on, you can get pretty mild symptoms. The most common presenting symptoms that you would see, especially in the emergency department, are going to be gastrointestinal symptoms, including nausea, vomiting, and diarrhea. You can get a sympathomimetic-looking picture like adrenergic stimulation with tachycardia, hypertension, diaphoresis, and those kind of things. We really worry because this can progress to things like bradycardia, hypotension, depressed level of consciousness, and even coma and respiratory failure. Kids can get respiratory paralysis from nicotine poisoning on the far end of the spectrum.
Glatter: With the liquid nicotine vial itself, you may ask a parent, "How much do you think your child might have been exposed to?" What's a quick way that you estimate this in a child who vomited once and looks okay clinically? What determines whether you observe that child for another 4-6 hours? How are you determining the degree of exposure in terms of milligrams of nicotine?
Marino: That's a good question and it can be really tough. I don't know that there is necessarily a good answer in terms of the exact dose and a correlation to symptoms. This is something that is still debated in the literature, but we tend to think, for a small child or toddler, ingestion of one cigarette would merit observation for at least several hours. A cigarette can contain probably 12 mg of nicotine. The liquid nicotine in vaporizer products, refill cartridges, and those kinds of things can have up to 20 mg/mL nicotine.
Very small amounts can contain significantly more than even an ingestion of a cigarette, which we used to teach. The unregulated products can have even more than that and can be more concentrated, and that's something that is not seen infrequently. That does make it more concerning with this liquid nicotine exposure. Anyone who's symptomatic, I think, has kind of bought themselves at least a several-hour observation in the emergency department, with 6 hours probably being the general cutoff. Certainly, there is a low threshold to admit for significant symptoms or any signs of progression.
The one good thing about nicotine - which maybe is not really a good thing - is that it is rapidly absorbed and should have pretty rapid onset of effects after ingestion. It's not like you would be expecting significant delay in your presentation or progression of symptoms. Again, because it is very rapidly absorbed, there's not really much time to intervene before it can get into the body.
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