Ama, a two-year old girl, was brought to the Cardio Centre accompanied by her distraught mother. The child's appearance was pathetic at best. Looking dry and haggard with saliva drooling from her mouth, the bones in her temple showing through her dry skin and the hollow look in her eyes, one wondered if this was a case of child neglect. But no, this was no such case. The mother settled down and told her story. Ama had been a well-cared-for and playful child. Six weeks prior to this clinic attendance, she had been playing in the neighbour's house. Feeling thirsty, she reached for the 'water' stored in a soft drink bottle in the neighbour's kitchen and helped herself. After a few gulps, she realised this was a case of mistaken identity. Her mouth and throat 'burned with fire' literally. Her cry attracted the neighbour's attention who seeing the soft drink bottle in the child's hand realised to her horror what had happened - the bottle contained caustic soda solution for the domestic manufacture of soap! Ama was sent to a nearby clinic unable to swallow solid food. Some first aid measures were administered and she was later sent on to the regional hospital emergency department. She was admitted and placed on intravenous drips of fluid and some medications but by six weeks, although the pain in her mouth and throat had subsided, her inability to swallow was total. She had lost weight markedly and was a pale shadow of the vibrant playful child she had been. Her diagnosis was an easy one; the proposed treatment, however, entailed two major operations some three months apart, both requiring one to two weeks of hospitalisation. "How could this happen to my child," the mother asked. "Well, it happens to many children as well as adults," came the reply. The mother shook her head in disbelief wondering how such a fate could befall a child whose only "crime" was an attempt to quench her thirst. It would take her a while to grasp the problem of corrosive burns of the oesophagus (gullet). Ama's case is indeed not unique. At the National Cardiothoracic Centre where such patients ultimately come for definitive treatment, the cases seen may well represent the tip of the iceberg. Not all those exposed to such corrosives end up here. The most severe injuries end up at the Cardio Centre; the less severe injuries are managed in other hospitals. At the Cardio Centre, an analysis of all such cases seen from January 1991 to December 2006 has been made. A total of 55 cases of corrosive burns of the oesophagus underwent surgery between 1991 and 1999 (a period of nine years). Of this number, 19 were children between one and 12 years of age. Thirty-six were 13 years and older. Between January of 2000 and December 2006, a period of seven years, the total number of cases coming to surgery had risen to 71. More alarming was the fact that more than half of this number (37 in fact) were children aged 10 years and below, almost double the figure for the period 1991-1999. Even more disturbing, 20 of the 37 (54 per cent) were between the ages of one and three years. Three agents were largely responsible for these oesophageal burns - caustic soda, acid solutions from vehicle batteries and unidentified herbal preparations. Virtually all ingestion in children were accidental and the agent was caustic soda solution mistaken for water or a refreshing soft drink in homes where the solution was stored for making soap. The majority of the ingestion in adults were acid solutions taken deliberately with suicidal intent. Some adults also ingested caustic soda accidentally. When corrosive burns resulted from herbal preparations, the herbs had been bought from mobile street vendors for the treatment of common febrile ailments and had been taken with the intent to cure a fever. Why such injuries are on the increase particularly in children is difficult to tell for sure. It may be because more people now seek medical care than previously. A real increase in the number of such injuries cannot be entirely ruled out however. The records show that the most susceptible group is represented by children, especially those between the ages of one and three years. What can be done to prevent such needless and entirely avoidable injuries? Must we as it were "sin and then pray for grace to abound"? Worldwide experience suggests a multi-disciplinary approach is most effective. Health care personnel cannot do it all; the problem is much bigger.' Several approaches may be helpful: Education Increasing public awareness of this prob¬lem is an obvious antidote. Parents and caretakers should be aware of the risks posed by caustics and their ingestion. Several caustic agents are common in homes including the caustic soda for soap-making, household deter¬gents, dishwasher solutions, drain cleaners and the like. These should be stored in their proper containers and kept out of reach of children and unsuspecting adults. The practice of decanting such solutions into commonly available bottles only increases the likelihood of the case of mistaken identity and should be utterly discouraged. The philosophy of "Never touch or taste without asking" must be embraced by all. Some countries have adopted one week in every year to focus on Poison Prevention Education for the citizens and have obtained gratifying results. Enactment and enforcement of appropriate laws Appropriate legislation protects all citizens through the rule of law. It is amazing how freely one may obtain such caustic agents. In this country, caustic soda is sold on the open market as one would sell salt or sugar. Interestingly, caustic soda is not infrequently mistaken for sugar. One of our patients on returning home from school hungrily took several spoonfuls of this "sugar" and added it to his 'gari', dissolved the mixture in water and helped himself to what turned out to be "a meal of fire". The mother had bought the powder in the market and was yet to dissolve it for soap making. Laws that restrict the availability of such substances are appropriate. It should be clearly defined what category of people may obtain such agents and what precautionary measures the buyers must exercise to qualify for the right of purchase. Packaging and design Proper packaging facilitates identification. With appropriate warning symbols attached, would-be victims may be alerted to the possibility of injury. Certainly, the sale of caustic agents in a packageless manner should be condemned. It should be required of producers to apply proper and safe packaging techniques to reduce the likelihood of accidental ingestion. Another useful technique is the control of the concentration of the agent in the package. Low concentrations should be required of producers of caustics so that in the event of accidental ingestion, the injury would be less than otherwise. This again goes to show how dangerous it is to dispense the agent in solid form to the unsuspecting public - very high concentrations are likely to be involved with accidental ingestion and injuries will be correspondingly severe. Economic incentives and penalties The last proposed measure is the use of economic incentives (tax breaks, exemptions, discounts) for desired behaviour by manufacturers and consumers and penalties (mainly fines) for undesirable acts. Manufacturers can be afforded tax relief for promoting safer features on their products, and unsafe products can be made less affordable. Fines levied through failure to comply with safety legislation can also serve as an incentive to safer behaviour. These measures may help reduce the number of innocent children and adults who are subjected needlessly to such risks and have to go through complicated surgical procedures to salvage an otherwise normal swallowing mechanism. Ama had her first operation which entailed placing a feeding tube into the stomach; the other end of this tube was exteriorised. This enabled administration of a fluid diet as well as water into her stomach. It built her up nutritionally and prepared her for the second and more extensive operation 12 weeks later. She literally blossomed after the first operation as her starving little body took in the supply of nutrients. She was back in three months for the second operation. In this operation, part of her large bowel was removed and used to fashion a new oesophagus. One end of this new gullet was joined to her stomach while the other end was tunnelled to reach her throat. The newly constructed gullet required a week of rest to heal but it was all joy afterwards when young Ama swallowed normally again. In all, it had been a five-month ordeal of inability to eat or drink, of denial of the pleasure of taste despite the stimulating aromas in the home environment. It had been the endurance of two major operations in the space of three months in a two-year old and the attendant financial implications. As mother and child walked out of the hospital overjoyed, health care personnel shared their joy but at the same time wondered "Need this be?" Source: Daily Graphic