7. CONSUMER RELATED FACTORS FOR CPRF AND CAP INTAKE
Children and the elderly are more
susceptible to the
cosmetics and liquid household products because of their
behaviour and differences in some physiological
There is no universally agreed age range for what constitutes
childhood. Article 1 of the United Nations Convention on the
Rights of the Child defines “children” as persons up to the age
of 18. However, in many reports of the United Nations (UN) and
the World Health Organization (WHO), the term “children” refers
to persons up to the age of 14 years (e.g. UN 2010, WHO 2010b).
The term “infant” refers to children between the ages of 1 month
and 12 months (Berk 2009, WHO 2010c); however, other definitions
vary between birth and 3 years of age. The term “toddler” refers
to children who are learning to walk, so it is typically used
for children aged 1 to 2 years (Berk 2009), but sometimes also
up to 3 years. As children less than 6 years old are more
frequently involved in accidental poisoning than older children,
special attention will be paid to this category in the following
section. Children less than 6 months old are not considered in
this opinion because it is unlikely that they will be able to
reach CPRF/CAP by themselves.
7.1.1. Child physiology
It is generally known that in organisms of different sizes,
physiological functions such as basal metabolic rates correlate
much better with the body surface area rather than with the body
weight. This is also reflected by drug dosing; paediatric
therapy usually requires higher doses (per kilogram body
weight), compared to therapy of adults. In concordance,
susceptibility towards xenobiotics is not generally higher in
children compared to adults. However, differences in kinetics of
distinct xenobiotics in children of a specific age, especially
very young age groups, may well have the consequence that
external exposures identical to those of adults lead to
increased response due to higher ‘‘internal’’ doses (Renwick et
Numerous studies have been investigating the activity of
xenobiotic metabolising enzymes in different age groups. There
are considerable species and inter-individual differences
(Schwenk et al. 2003).
In general, the most prominent differences in toxicokinetics
are found in children less than 1 year old and especially in the
first few days and weeks of life (Scheuplein et al. 2002). By
the age of 2 years, most of the biochemical and physiological
parameters that affect toxicokinetics have reached maturation,
although differences still exist. Thus, it seems reasonable to
be extra cautious in the risk assessment of children as an
exposed group as there are differences between children and
adults in toxicokinetics (especially babies in their first
months) and toxicodynamics (especially at different stages of
development), which may render children more
susceptible to the
toxic effects of a
Particular attention should be paid to the effects on the
nervous, reproductive, endocrine and immune systems, and also on
the metabolic pathways, all of which in part develop new
functional properties during childhood (Falk-Filipsson et al.
7.1.2. Children’s behaviour
The present opinion focuses on children between 6 months and 6
years of age, as this is the group of children for which
ingestions of cosmetics and liquid household products appear to
be most likely.
Age has a strong association with accidental
ingestion and poisoning,
as with children’s injuries in general (Hillier and Morrongiello
1998). Children under the age of 1 year have the highest rates
of fatal poisonings, but non-fatal poisonings appear to be more
common between 1 and 4 years of age. The risk of poisonings
increases particularly at around 2 years of age, as young
children become more mobile and have increased access to toxins
(WHO 2008a). It is instructive to look at some general
developmental milestones of children up to 6 years of age (see
Table 3, Annex III).
Young children are particularly
especially liquids, because they are very inquisitive, put most
items in their mouths (e.g. hand-to-mouth activity) and are
unaware of consequences. The quantities involved are often small
(a mouthful/sip). The volume of a swallow is 4.5 ml for a child
aged between 18 months and 3 years, and in an adult it is 15 ml
(Jones and Work 1961; cited in Mofenson et al. 1984). A
toddler’s mouthful is approximately 9.0 ml (Ratnapalan et. al.
Children who are hungry or thirsty are more likely to
accidentally ingest products
within their reach than children who are not. The very fact that
they want something to eat or drink increases the likelihood
that they will ingest something that smells good to them
(Whitford et al. 2001).
7.1.3. Children’s environment and parental supervision
Reduced observation and supervision of children may increase
the risk of exposure and subsequent accidental poisoning e.g.
during holiday periods, festivals and other events (Amitai et
al. 2000, WHO 2008a). A good example is when meals are being
prepared. It is common for children to have free run of the
house as adults focus their attention on preparing a meal
(Whitford et al. 2001). The most significant injuries reported
following ingestions of poisons by children seem to occur as a
result of them drinking from opened containers within their
reach. There are still many cases which are related to storing
corrosive solutions in unlabelled containers or more seriously,
routine drinking bottles which other adults unknowingly give to
their children (Riffat and Cheng 2009, WHO 2008a).
In an American study that made in-home observations of safety
hazards related to burns, poisoning and falls, maternal
supervisory style, rated on dimensions of protectiveness, was an
important correlate of all types of household hazards (Glik et
al. 1993). In this study, risk perceptions of the mothers had
little influence on home hazards. In another study, maternal
perceptions of risk variables interacted with maternal safety
behaviour (Dal Santo et al. 2004). A recent study on parental
perceptions of injury risks shows that parents underestimated
scenarios with high injury/death rates and overestimated
scenarios with low injury /death rates (Morrongiello et al.
2009, Will et al. 2009).
However, direct evidence linking supervision to child injury
is scarce and more research is needed to assess the independent
contribution of this factor (independent, for instance, from
socio-economic status) to injury risk (Morrongiello
7.1.4. Socio-economic and related factors
The variable most frequently correlated with poisonings is
socio-economic status (SES). SES is a strong predictor of
observed home hazards (Glik et al. 1993), unsafe childcare
practices (Hapgood et al. 2000), fatal unintentional injuries,
and to a lesser extent, of nonfatal injuries (Cubbin and Smith
2002). In particular, unemployment and homes needing repair
appear to be risk factors for unintentional injuries at home
(Dal Santo et al. 2004, Glik et al. 1993, WHO 2008a).
There are many variables related to SES, for instance,
maternal social support, stress and coping (Dal Santo et al.
2004). Stress in the home in this context is defined as regular
changes in lifestyle demanding social re-adjustment (Eriksson et
al. 1979, Shaw 1977). More recent studies also confirmed that
risk factors for accidental poisoning in children may include
child behaviour but also stress at home, size, education and
income of the family, absence of the parents, and the
accessibility of the poisonous products (Eriksson et al. 2008,
Katrivanou et al. 2004, Soori 2001).
Although SES is the best studied predictor of different injury
risks, even affluent families do not undertake safety practices
all the time, and most of the variation in the number of safety
practices, for instance, is not explained by SES (Hapgood et al.
2000). Thus, further research is needed.