When consumers reach for over-the-counter (OTC) eye drop solutions and nasal sprays, they are usually unaware that the relief they seek from eye redness or nasal congestion is elicited by the imidazoline derivatives present in their topical OTC product of choice. These products that contain imidazo-lines are marketed under a variety of names, including popular product brands like Visine and Afrin. Topical products that contain imidazolines frequently are regarded as innocuous staples of household medicine cabinets and, in fact, generally are sold without child-resistant closures. Nevertheless, when ingested accidentally by children, the imidazoline agonists contained in these products can cause a number of adverse events and serious harm. Adverse effects from accidental ingestion of these topical products by small children range in severity and include nausea, vomiting, diarrhea, dizziness, somnolence, hypothermia, tremors, blurred vision, muscle flaccidity, difficulty breathing, hypertension followed by hypotension, bradycardia, seizures, central nervous system (CNS) depression, coma, and death (U.S. Food and Drug Administration [FDA] Reporting System; cases from this database can be obtained through Freedom of Information [FOI] request). Literature reports describing accidental pediatric exposure after ingestion of topical OTC products containing imidazolines were published as early as 1948.5 A recent FDA review of the adverse events reported to the Agency between January 1985 and November 2011 identified 57 cases of accidental imidazoline ingestion by children (see the case illustration in the Figure). In addition, the U.S. Consumer Product Safety Commission (CPSC) published a Notice of Proposed Rulemaking in which they describe 12 cases from published literature and 172 cases from the Children and Poisoning system of accidental pediatric ingestion of imidazolines reported between 1948 and 2010 (the Children and Poisoning System represents a subset of National Electronic Injury Surveillance System: Cooperative Adverse Event Surveillance System [NEISS-CADES] records regarding pediatric poisoning, chemical burn, or ingestion).
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