Hand Sanitizer for Your Kids: Medical Miracle or Bad Idea?

Hand Sanitizer for Your Kids: Medical Miracle or Bad Idea?

Everybody loves a pancea, or  cure-all. So far, medical science is still looking for one. In the meantime, hand sanitizers have been elevated in the public mind to the closest thing we might consider as a prevent-all.  Indeed, it is a fact that the proper use of hand sanitizers greatly reduces the possibility of contagion and spread of a number of diseases between patients in medical facilities, amongst family members, and for children who spend time in school and childcare settings.  That is a good.

The followup question is a little tougher.  “What is the downside?” you might ask as you rub a dollop of Purell into your hands before you touch your dirty keyboard, “Are hand sanitizers bad for you?”

First, consider this: Hand sanitizers began to appear in schools, workplace and healthcare related settings early in the last decade. Early on these cleansers were touted as an effective alternative to soap and water handwashing by experts in infectious disease. Following the arrival of H1N1 in 2009, their use took off, and Americans spend something like $117 million on these products yearly.  Since, federal and state authorities have invested heavily in curricula for hand hygiene programs in schools and in daycare settings. As a result, trained toddlers know to walk up to a dispenser and properly apply sanitizer to their little paws before joining a classroom.

What is the goal here?  Medically speaking, we are trying to interrupt vectors of transmission of fomites between individuals. Put more plainly, hand sanitizers zap bugs that cause coughs, colds, and other misery passed in body fluids, like boogers or saliva, from one kiddo to another.

When the work, they work…for a bit

Hey, technique matters. A variety of studies and comments online will testify that well over 95% of ‘germs’ (read that as bacteria and viruses) are eliminated when a child applies a sufficient amount of  suitable product for a certain amount of time. The Centers for Disease Control (the CDC) recommend alcohol-based sanitizers that contain more than 60% of ethyl or isopropyl alcohol. Sanitizers with less alcohol may be ineffective.  We can’t have those pathogens laughing at us, can we?  What’s more, an individual has to apply enough sanitizer gel to allow for a moist rubbing for 20 seconds or so.  Littler kids, the under sixes, may need some help to get their hands all clean and to do it right. Basically, you can’t cut corners: insufficient goop, or a five second rub and wipe on the shirt won’t get the desired bug kill.

Alcohol based hand sanitizers smite bacteria and viruses by lethally damaging the materials in their cell walls or viral capsules respectively.  On the upside, this mechanism of action appears to elude all foreseeable avenues by which these micro-organisms could develop resistance. On the downside, in taking out the bad germs, a handwasher also kills the so-called ‘healthy flora’, or bacteria that naturally live on our skin. This may predispose to rashes or irritation, but poses little risk of dinging one’s immune system in any meaningful way.

Here’s the thing: even when good technique is applied, the protective effect of the hand sanitizer is fleeting.  A survey done recently showed adult Americans believed their hand sanitizers protected them for up to an hour after use. Truth is, the alcohol has essentially evaporated before half a minute is up; and the true protective window lasts more like two minutes.  This is not to say it is without benefit! If a ‘just washed’ child has neutralized a strep bacterium on his fingers before he picks up a toy on the schoolroom floor, then a good preventive deed has been done.

Triclosan bears special mention. It is an antimicrobial product that is in use in a number of deodorant soaps, gelled handsoaps, and household and industrial cleaners. It is not an additive in any alcohol based product about which I am aware (eg Purell), but it is touted as a beneficial ingredient to keep our living spaces ever more germ free.  Triclosan works by crippling the cell wall synthesis of gram negative and gram positive bacteria. Unlike alcohol based products, it may offer a greater potential (heretofore not seen outside the lab) for fostering bacterial resistance.   Government regulation has drawn up short in restricting triclosan’s use, but I’d urge someone shopping soaps to use products without it. Superbugs–those that develop resistance to antimicrobial therapy–are something we need like a hole in the head.

And this brings us to the purported dangers of alcohol based hand sanitizer use. There was a bit of fanfare a few years ago regarding the ingestion of hand sanitizer by toddlers and preschoolers on the web. A series of apocryphal emails seemed have, well, gone viral regarding a series of children gulping the stuff, and suffering the ill effects of alcohol poisoning on the one hand, or death…depending on the version in your inbox.  Happily, that was mostly bunk. Mostly.

For the most part, the biggest complaint about hand sanitizers is skin irritation. Adults who work in educational, food service, or health care settings–and who tend to use a great deal of the stuff–can testify to the irritation and redness that can result from hand sanitizer (over)use. Some adults and kids tend to react more easily to the stuff and must either a) slather with a moisturizer if irritation arises, b) consider using sanitizer more sparingly, and go to tried and true soap and water.  If a rash gets really mad and raw, it might require a checkin with your child’s clinician to give it a looksee.

Parents and caregivers should also beware of a false sense of invulnerability against maladies when using hand sanitizers. Like just about anything, hand sanitizers have their limits. They are extremely effective against most bacteria. However, imperfections in their application have lead to outbreaks of illness even when they are in use. In particular, the spread of E. coli infections have occurred in a number of states around petting zoos, even when hand sanitizer dispensers where available and utilized by patrons.  Common sense is still called for: if there is an icky or slimey encounter with another sick playmate, you may want to clean up afresh.

Further, hand sanitizers do not necessarily prove effective in eradicating all sources of illness. A number of reported instances have occurred where hand sanitizers in medical facilities suffered outbreaks of the dreaded Norovirus (that delightful GI bug heard about in cruise ships that causes a nasty diarrheal and stomach flu) in spite of widepsread use of sanitizing gels by staff.  And so, if in hand sanitizer we trust, we must do so with caveats.

And lastly, what about the risk posed to children for toxicity or ingestion?

Rightly, people worry.  Little kids do get curious about what the aromatic gel in the bottle tastes like. In an oft- quoted study from 2005-2006, some 17,000 potential toxic exposures were reported to Poison Control Centers in the US. Of these, the vast majority (~9,000) had few or no symptoms. Notably, there were no major medical problems reported in any of the cases, and nor any deaths.  Effects of alcohol toxicity are pretty hard to miss: vomiting, nausea, headache, slurred words.  In more severe cases, children may appear sedated or be difficult to arouse.  In either case, or if there is a question, a prompt call to a poison control center , or calling 911 becomes the next thing to do.

To understand how much of an sanitizer a child would have to consume to experience toxic effects of from an ethyl alcohol-based product, the Texas Poison Control Network sums it up nicely:

A hand sanitizer pump dispenses approximately 2.5 mL of liquid.  If one pump of a 62% ethanol-containing hand sanitizer was ingested by an average 2 year old weighing 15 kg (33 lbs), a blood alcohol level of 17.3 mg/dL would be expected, considerably below a toxic level of 80-100 mg/dL.  The same child would have to drink approximately 4-5 teaspoons of the sanitizer to produce toxic effects requiring medical attention.  Clearly, more than a lick of hand sanitizer would be necessary to produce significant toxic effects.

Put succinctly: a child would have to drink a lot, and quick! The alcohol rubbed onto skin is well on its way into the atmosphere within minutes.

The Bottomline:

Wash your and your children’s hands regularly. This a good idea, and may be the singlemost effective thing once can do to prevent the spread of infectious diseases that no one needs. Parents can and should use an alcohol based sanitizer themselves, and with their children. I believe alcohol based hand sanitizers work best when used some of the time, and in conjunction with good soap and water handwashing.

And, for those parents with children under six–the Curious George sort of crowd– apply sanitizers with close supervision. For the safety of kids (and pets!), keep the containers of the stuff up and away–with other medications, cleaners, etc– from grimy, exploring hands and minds or mouths.

So, here’s to a healthy season, and clean livin’!

photo above by gauncyp

Cartoon below by me

Hand Sanitizer for Your Kids: Medical Miracle or Bad Idea?

Jack Maypole, MD has plenty of material to work from. He is director of Pediatrics at the South End Community Health Center and he is director of the Comprehensive Care Program at Boston Medical Cent ...read more


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