Tricks and Treats and a Visit to the ER

In the 1980’s, my mother used to make me wait to eat my Halloween candy until she could sort through it for needles. Sound like an urban legend? Well it is…almost! Due to media sensationalism by Ann Landers, Dear Abby, and even the New York Times urban legends of malicious candy tampering ran rampant during my youth.

Take, for example, that plump red apple that Junior gets from a kindly old woman down the block. It may have a razor blade hidden inside. The chocolate candy bar may be a laxative, the bubble gum may be sprinkled with lye, the popcorn balls may be coated with camphor, the candy may turn out to be packets containing sleeping pills… wrote Judy Klemesrud on October 28th, 1970 in “Those Treats May Be Tricks” for The New York Times.

Very few stories of candy tampering were ever determined to be true and the majority were speculations spurred by fear. There are, however, other dangers lurking in the streets during Halloween. The following is what you will most likely see in your ED on October 31st, and what you can preventatively counsel for this week.

1. Pedestrian injuries
The National Highway Traffic Safety Administration and the Centers for Disease Control reported that for 1975-2002, Halloween was one of the 3 deadliest days of the year for pedestrians with Halloween being the deadliest day of the year for specifically children on foot. The majority of these injuries involved motor vehicle accidents.
Prevention: Wear bright, reflective costumes or add strips of reflective tape to improve visibility. Do not wear masks or other costume components that obscure vision. Do not drink and drive.

2. Falls resulting in orthopedic injuries, head injuries, and soft tissue injuries
Again, Halloween is the deadliest day of the year for children on foot and though most critical injuries involve MVA’s, serious injuries can occur from simple falls as well. Take for example ICD-10 code W22.02- Walked into a lamppost.
Prevention: Make sure the costumes aren’t so long that a child is in danger of tripping. Do not wear masks or other costume components that obscure vision. The AAP also cautions to make sure that shoes fit well.

3. Choking
Prevention: Cargivers will hopefully evaluate for choking hazards on Halloween costumes or in treats and take proper precautions. However, if they don’t, a child may come to your ED choking, remember PALS procedures for FB removal, including finger sweep, back blows/chest thrusts, and the Heimlich maneuver. A free review can be found on WebMD. baby choking

4. Dermatitis following novelty face/body paints
The FDA recommends checking their “Summary of Color Additives” prior to purchasing face paints, however on my review of this site, I found it to be unhelpful. In addition to coding for dermatitis for this ED visit, you may also choose to add R46.1- Bizarre personal appearance.
Prevention: Test an area of skin with the paint a few days prior to assess for any reaction and only use paints as directed. If a child does present to your ED with dermatitis secondary to make-up, thoroughly wash and remove any paint from the body and recommend supportive care with mild fragrance free soaps and moisturizers until the rash resolves.

5. Burns
A Halloween costume should have the designation of “Flame Resistant.” But even then, the US Consumer Product Safety Commission warns that this doesn’t mean that the clothing cannot burn.
Prevention: Minimize costumes made with flimsy materials and with billowing sleeves and skirts as well as obviously avoiding flames. Of course, do not forget to counsel on burn-type frost-bite injuries following dry ice encounters, consider W93.02- Inhalation of dry ice.

6. Licorice
For those licorice-lovers over 40, the U.S. FDA warns against excessive black licorice ingestion in your Halloween goodie bags. Black licorice contains glycyrrhizic acid that has a mineralocorticoid effect causing renal excretion of potassium. Consuming multiple 2oz bags of black licorice every day for 14 days or longer can result in hypokalemia, muscle weakness, arrhythmias, hypertension, and edema.
Prevention: Do not eat obscene amounts of licorice.

7. Gastric distension and hyperglycemia with or without emesis secondary to excessive candy eating
Well, my PubMed search did not have any evidence to support such presentations or treatments. But based on clinical experience, this child will be ok. Consider R10.84, generalized abdominal pain…but don’t bother searching for “chocolate” – the only listing you will find will be “chocolate cyst”.
Prevention: Chocolate candy bar mini’s are an average of 60-90 calories each – don’t eat too many of them!

Angela Lumba-Brown MD, FAAP

Angela Lumba-Brown MD, FAAP

Clinical Assistant Professor Pediatric Emergency Medicine at Stanford University School of Medicine
Angela's research focus is in pediatric traumatic brain injury and recent research has been in therapeutic intervention for concussion. She the director of PEMNetwork.
Angela Lumba-Brown MD, FAAP
Angela Lumba-Brown MD, FAAP

Angela Lumba-Brown MD, FAAP

Angela's research focus is in pediatric traumatic brain injury and recent research has been in therapeutic intervention for concussion. She the director of PEMNetwork.

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