What is ‘juuling’?

A Juul e-cigarette (bottom) and a similar-looking Juno device (top), with a pen for scale.

A Juul e-cigarette (bottom) and a similar-looking Juno device (top), with a pen for scale.

Looking similar to a USB flash drive and easily hidden, Juul electronic cigarettes have rapidly grown in use among teenagers. Dubbed by some the “iPhone of e-cigarettes,” Juuls are so popular that “juuling” has become a verb, a particular type of “vaping,” the word used to describe e-cigarette use in general.

Like other e-cigarettes, Juuls consist of a mouthpiece, a reservoir for liquid nicotine solution, a heating element and a battery. E-cigarettes come in many forms, from slim “vape pens” to palm-sized rectangular “box mods,” with a wide range of customized devices on display across the internet. Juuls are easy to use, helping to make them the top brand of e-cigarette—they account for 55% of overall sales—and they are also easy to hide, making them popular among high school and even middle school students, raising concerns among school systems across the country.

E-cigarettes do not contain many of the known cancer-causing ingredients found in traditional cigarettes, which may make them a less harmful choice for adults who already smoke, although it is unclear at this point whether they are an effective way to help people quit. Meanwhile, as of 2016, vaping as a fad had introduced more than 750,000 teenagers who had never smoked to nicotine, a highly addictive substance.

While some e-cigarettes have nicotine-free versions, this is not the case with Juuls, which have some of the highest nicotine concentrations on the market. In addition to the potential for addiction, this also makes it easy for teens to overuse. Many calls to the NNEPC related to e-cigarettes involve teens and adults who have become sick from overusing these products, experiencing symptoms such as headache, upset stomach and anxiety. On top of this, many teens may not realize Juuls contain nicotine. A recent study found that nearly 2 in 3 teens and young adults who used Juuls did not realize that all Juuls contain nicotine.

The long-term effects of e-cigarette use won’t be known for some time, but there is strong evidence that introducing addictive substances to teens’ developing brains can make them more susceptible to other addictions later in life. One study has also found that teens that use e-cigarettes are more likely to transition to traditional cigarettes, as well.

It’s important for teens to understand the risks related to e-cigarette use. The surgeon general’s office and the CDC have produced a tip sheet for parents to get the conversation started about nicotine use.

If someone is feeling sick after using e-cigarettes or tobacco products, call the poison center right away at 1-800-222-1222, chat online or text POISON to 85511.

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Is it safe to use Orajel or Anbesol for teething?

Baby with teething toysThe FDA has strengthened its warnings about benzocaine, a medication used to numb pain that is included in some over-the-counter teething products. Though it’s rare, swallowing benzocaine can cause a dangerous condition called methemoglobinemia, in which not enough oxygen is carried in the blood.

The latest FDA warning states that benzocaine products should not be used in children younger than 2 years. It also calls on manufacturers to stop marketing benzocaine products for teething and to add a warning about methemoglobinemia to the product label.

What are some ways that you can relieve your child’s teething pain, without using numbing medications like Orajel or Anbesol?

  • Gently massage your child’s gums.
  • Give your child something firm and cool to chew on. Make sure it is clean, and large enough that they can’t choke on it, and supervise them closely. Some possibilities are a chilled teething ring or pacifier; a cool, wet washcloth; a chilled cucumber or carrot; or hard, unsweetened teething crackers. Avoid using frozen items. They may be too hard or uncomfortably cold.
  • Comfort and distract your child. Sing a favorite song, read a book, rock your child, or gently message them. Breastfeeding can also help.
  • If your child is in a lot of discomfort, your doctor may recommend giving them some over-the-counter pain-relieving medicine, such as acetaminophen (Tylenol) or ibuprofen (Motrin or Advil).  Always check with your child’s doctor before giving medication, and carefully follow the directions on the product label.

If you have given your child an over-the-counter medication that contains benzocaine, or if you have question about the risk of using these products, call the poison center at 1-800-222-1222 chat online or text POISON to 85511.

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Antidote management & antidote chart

The Northern New England Poison Center is your local resource for antidote management. Our poison specialists and toxicologists are available 24/7 to assist health care professionals in the medical management of patients who require a specific antidote or antivenom. We also help health care facilities determine which antidotes to stock, and can assist in finding antidotes or suggest other options in the case of a shortage.

NNEPC Antidote Chart ThumbnailTo help hospital staff make stocking decisions about antidotes, in May 2018 we released the NNEPC Antidote Chart. This tool lays out many of the more common antidotes the poison center may recommend in treating poisoned patients, explaining what each antidote is used for, the dosing parameters, and how much is generally needed on hand to treat a patient initially. Not every hospital will require every antidote listed in the chart, and the poison center is available to help determine your hospital’s needs by calling 1-800-222-1222.

To help make these assessments, the NNEPC conducts a periodic hospital antidote survey to find out which antidotes each hospital in the region regularly stocks. Your participation is crucial to helping the poison center determine where to send patients, or where to obtain an antidote that is not stocked by every hospital.

Remember, the NNEPC Antidote Chart is only a reference and not a substitute for calling the poison center. Each patient and circumstance is unique, and we urge you to contact the NNEPC at 1-800-222-1222 for consultation and assistance in dosing individual patients.

The NNEPC’s state educators—Rebecca Miller (Maine), Laurie Warnock (New Hampshire) and Gayle Finkelstein (Vermont) have been contacting hospitals in the region to deliver complimentary copies of the antidote chart to pharmacy and ED staff and to discuss other ways the poison center can be a resource for you. To arrange a meeting, email your state’s educator (link in the name above). You can also download the antidote chart or order a physical copy at cost through our website.

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Get rid of your expired medications on Saturday, April 28

The U.S. Drug Enforcement Administration is holding a prescription drug take-back day this Saturday, April 28, 2018, from 10 a.m to 2 p.m. at locations across the country. You can use this free, no-questions-asked service to get rid of medications that have expired or that you no longer need. Visit the DEA’s website to find a collection site near you.

Safely getting rid of your medications helps keep children and pets from getting into them, and medication take-back events can help prevent medications from getting into the water supply.

To coincide with this take-back event, the FDA this week posted a redesigned page dedicated to medication disposal.

Also check out the medication disposal video below, put together a few years ago by University of Vermont students in collaboration with the NNEPC’s Vermont educator.

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Alert: Adulterated “spice” in Chicago area

The Chicago area has seen a significant number of cases of people using synthetic cannabinoids (spice, K2, fake weed, etc.) that have been adulterated with brodifacoum. This is a rat poison that can cause profound and prolonged anticoagulation with unmeasurable INRs and clinically significant bleeding.

These patients have required 100s of milligrams of vitamin K and this needs to be continued at high doses as an outpatient as well. It is not clear if all of these have been identified via screening or with bleeding.

There have been at least 2 deaths so far. In the past few days, there were some cases/products identified in Maryland as well.

The NNEPC sees a fair amount of what is described as “spice” although we don’t really know what that actually means. It’s hard to know exactly what chemicals make up that particular “spice”—there is no quality assurance in illicit drug production.

These patients are treated similarly to a warfarin overdose but they can be anticoagulated for a very long time and outpatient therapy can be prolonged. Compliance may be difficult in this population as well.

As far as we know there have not been any cases in Maine, New Hampshire or Vermont, but we need to be alert to the possibility as it is not unexpected that this could end up here.

Please don’t hesitate to call the NNEPC at 1-800-222-1222 with any questions.

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Brushing up on fluoride for kids and adults

What are the benefits of fluoride?

Fluoride is a naturally occurring mineral that can help prevent tooth decay by strengthening the enamel of your teeth. It is added to most types of toothpaste, as well as many other dental products, such as mouthwash. It is also added to the public water supply in many areas to help support dental health. Dentists sometimes prescribe fluoride supplements, such as tablets, especially for people who do not get fluoride from their water.

Should children use fluoride?

Fluoride is beneficial for dental health for people of all ages. As of 2014, both the American Dental Association and the American Academy of Pediatrics recommend using fluoride toothpaste beginning with a child’s first tooth. This will help prevent cavities, which is important for your child’s overall health and development.

Can fluoride be poisonous?

Fluoride is safe when used properly, and swallowing small amounts is not harmful.

Swallowing too much fluoride at once can irritate your stomach.

Regularly swallowing too much fluoride for a long time—such as having too much fluoride in your well water for several years—can lead to a condition called fluorosis. Dental fluorosis develops in children before their baby or adult teeth are fully formed, and causes streaks or spots on the teeth. It is usually not harmful to overall health. Skeletal fluorosis, which affects the bones, is not common in the United States.

A smear of toothpaste and a pea-sized amount
American Dental Association photo showing a smear of toothpaste for children under 3 years old (left) and a pea-sized amount for children 3-6 years (right).

How can I use fluoride safely?

For young children, follow the American Dental Association’s guidelines for tooth brushing:

  • For children up to 3 years old, use just a smear of fluoride toothpaste—about the size of a grain of rice.
  • For children age 3 to 6, use a pea-sized amount
  • Watch young children when they brush to make sure they spit out rather than swallow the toothpaste.

Store toothpaste and other dental products up high, out of the reach of young children. Keep them separate from medications and food to prevent accidental poisonings.

When using dental products, carefully follow the directions from your dentist or on the product label.

What about training toothpaste?

While some companies still make training toothpaste or other fluoride-free toothpaste for young children, the American Dental Association strongly recommends using small amounts of fluoride toothpaste as described above. Fluoride-free toothpaste will not help prevent cavities. Using a smear amount of fluoride toothpaste to brush your child’s teeth is safe, even if your child accidentally swallows the toothpaste.

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Why you should keep products in their original containers

“Keep products in their original containers.” Whether it’s a medication, a cleaner or an automotive product, this is one of our top tips for preventing poisonings, because mistakes are easy to make!

Windshield washer fluid and antifreeze
Keeping automotive products like windshield washer fluid and antifreeze in their original containers can help prevent poisonings. Photo by Paul Cooper, used under Creative Commons 2.0.

For example, every year we receive dozens of calls about people accidentally drinking automotive products that were placed in drink bottles. It’s a mistake that adults are just as likely to make as kids.

Maybe you were out of windshield washer fluid and your friend poured some of theirs into a sports drink bottle for you. Or perhaps you needed to drain off some antifreeze and collected it in a soda bottle. If they’re not in the original container, these products can easily end up in your mouth instead of your car!

If for some reason you have to keep a product in a drink bottle or some other container, peel off all the original drink labeling, make sure you clearly mark what is in the bottle, and store it up high, out of the reach of children and pets, with the cap on tight. Always store products in a separate area from any food or drink.

Always put products away as soon as you are done using them to prevent poisonings among young children. Remember that a bad smell is not enough to keep a kid from drinking something.

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Ways the poison center helps school nurses

The poison center is a great resource for school nurses. Not only does the poison center offer quick, expert treatment advice for possible poisonings of students and staff, it also can answer questions about a wide variety of medications and other products. The poison center provides educational materials and programming, as well as in-person education.

The Northern New England Poison Center receives about 500 calls a year from school nurses in Maine, New Hampshire and Vermont. Here are just a few of the situations the poison center helped school nurses with in the past couple years:

  • Photo of a school hallway by Henry de Saussure Copeland
    School hallway photo by Henry de Saussure Copeland. Creative Commons 2.0.

    A 6-year-old boy ate sumac berries found near the school.

  • Four students ages 7-10 all drank some hand sanitizer.
  • An 11-year-old boy was sprayed in the eye with a water-conditioning chemical by another student.
  • A 13-year-old girl got formaldehyde in her eye while dissecting a frog in science class.
  • A 16-year-old boy accidentally took a double dose of his ADHD medication.
  • A student’s cellphone caught on fire and released fumes in the cafeteria.
  • A school bus had a potential antifreeze leak into the passenger compartment.

The poison center also helps school nurses in cases where students have abused substances or tried to harm themselves.

Besides cases of possible poisoning, the NNEPC, answers questions for school nurses about products used in the school, medications, trends in substance abuse and more. It offers lessons for use in the classroom on topics such as electronic cigarettes and caffeine, and trainings for school nurses on current poisoning topics, such as opioids and synthetic drugs of abuse.

The poison center is here for school nurses and everybody else, 24 hours a day, 365 days a year. Just call 1-800-222-1222, chat online or text POISON to 85511.

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Choosing Wisely: Toxicology

Choosing Wisely logoThe Choosing Wisely campaign, conceived by the National Physicians Alliance, provides evidenced-based and practical recommendations in a number of clinical disciplines to help patients and physicians make good decisions. The campaign focuses on clearing up misconceptions and avoiding unnecessary and costly interventions.

The American College of Medical Toxicology and the American Academy of Clinical Toxicology have created a list of 10 items that are relevant to primary, emergency, and specialty care providers regarding specific toxicological treatment and evaluation.

The Northern New England Poison Center has nurses, physicians and pharmacists ready to assist you 24/7. Let us help you choose wisely when a toxicology-related question arises, or even if you are unsure if it’s toxicology related. Call 1-800-222-1222.

Choosing Wisely, Toxicology: Ten Things Physicians and Patients Should Question
American College of Medical Toxicology and American Academy of Clinical Toxicology

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Stay safe this Halloween

Jack-O'-Lantern
Jack-O’-Lantern by William Warby. Creative Commons.

For many of us October means Halloween—picking out costumes, carving pumpkins, and maybe dipping into the candy stash a little too early!

While a little spookiness is part of the fun, none of us want anything actually scary to happen. Follow these tips for a fun and safe Halloween:

  • Dress trick-or-treaters in brightly colored costumes made of flame-resistant materials. Add reflective tape to costumes or trick-or-treat bags to make sure your child is visible after it gets dark.
  • If you use makeup, test it on a small area of skin first. Keep an eye out for skin irritation or an allergic reaction, such as a rash or itching. If this happens, remove the makeup right away with soap and water. Remove all makeup before bedtime to prevent skin and eye irritation.
  • Keep an eye on kids playing with glow sticks. They can break and sometimes children chew them open. The insides of a glow stick can irritate the skin and eyes and cause an upset stomach.
  • Bring along your own candy to give your children while trick-or-treating so they will not eat candy you have not inspected from their bags.
  • Inspect all treats before kids eat them. Only eat treats that are in their original, unopened wrappers. Throw out candies with wrappers that are faded, have holes, tears or signs of rewrapping.
  • Keep candy, such as chocolate, away from dogs and other pets. It can be poisonous to them.
  • Keep candle-lit jack-o-lanterns off doorsteps and out of the way of foot traffic. They can be a fire hazard for trick-or-treaters with long or flowing costumes.
  • Keep dry ice out of drinking glasses. Dry ice can cause frostbite if it touches your skin or mouth.

Most importantly, always supervise your child, and remember you can call the poison center at any hour at 1-800-222-1222 or chat online if your child chews on or swallows something that may be harmful.

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