RECOMMENDATION ON THE RISKS OF ACCIDENTAL INHALATION OR INGESTION OF SMALL OBJECTS BY

1
RECOMMENDATION ON THE RISKS OF ACCIDENTAL
INHALATION OR INGESTION OF SMALL OBJECTS BY

• Dr Georges GARCIA-BARDIDIA
• Assisted by Odile FINKELSTEIN, Jacques BEDOUIN et
  Patrick MESNARD, technical advisors

2
DEFINITIONS

• INGESTION
• Introduction through the mouth of alimentary
  solid or liquid substances that afterwads get
  through the sophagus
• INHALATION
• Accidental (except in the case of the absorption
  through the airways in a curing purpose, of
  gaseous or liquid substances) penetration in the
  airways of solid or liquid substances (what they
  call false passage )

3
THE CONSEQUENCES OF INHALATION OR INGESTION OF
FOREIGN BODIES

• Foreign bodies that provoke  food choking  and
  fall in the airways
• Foreign bodies that follow the normal tract but
  provoke problems because they are inedible

4
THE NATURE OF THE FOREIGN BODIES

• Children under 3 80
• Peanuts 50
• Other vegetables (walnuts, hazel nuts, almonds)
  between 20 and 25
• Metallic objects (needles) decreased and
  replaced by plastic objects (15 ) tokens,
  pearls
• Other 10 à 15
• Adults
• Food represents most of the inhaled bodies (meat,
  fruits, vegetables)
• Dental protheses or fragments (dental or
  maxillofacial surgery)

5
LOCALISATION OF THE FOREIGN BODIES

• Sharp or prickly (piece of glass, needle, pin)
  respiratory distress in all the stages of the
  bronchial tree
• Round FB go through more easily. More severe
  obstruction
• Soft FB (piece of plastic, balloon fragment)
  cause of a valve phenomenon
• Metallic FB better tolerated by the bronchial
  mucosa than alimentary FB

6
SYMPTOMATOLOGY

• Hypopharynx deglutitive disorders
• Larynx asphyxia soon fatal
• Trachea slowing down of breath (whooping-cough
  like)
• Bronchial tubes symptomatology varies

7
EMERGENCY MANEUVERS (continuation)

• Moderate or even no respiratory distress calm
  down the patient, place him in a comfortble
  position but avoid mobilizing him. Avoid any
  misplaced maneuver. Call the emergency units
• Vital emergency
• Heimlich maneuver brutal intra-tracheobronchial
  suppression. Makes the air in the airway move
  powerfully enough to evacuate the FB to the oral
  cavity.

8
THE LEARNING OF FIRST AID GESTURES

• The unblocking of the airways is taught by
  registered associations or bodies (RED CROSS).
• France is lagging behind the other European
  countries (10 are trained for 30 in Denmark)
• This type of accidents takes place almost
  exclusively in home environment or sphere
• Law n 2004-811 of 13 August 2004 on
  modernisation of civil safety should help make
  schools aware of the necessity of teaching
  children the first aid gestures (experiment in
  Picardy)
• Go further and make the consumers aware (posters
  in restaurants like in the US, in cafeterias, in
  institutional and school caterings, in old
  peoples homes)

9
ESOPHAGEAL FOREIGN BODIES

• Heavv or bulky objects (coins? chicken bones)
• Blocked in the third top part of the esophagus.
  Unnoticed phase often discovered several months
  later.
• Specific risk the button cells (electronic
  toys, audiovisual aids, watchmaking). The dangers
  comes from the liberation of corrosive and toxic
  electrolytic products (mercury, zinc, silver,
  acid) damaging and sometimes perforating the
  digestive wall (several deaths in the US and in
  Japan)
• Absorption unnoticed abdominal pains, radio of
  the abdomen shows the presence of the button
  cell
• Absorption known take the child to the hospital
  for a radio to know at what level of the
  digestive tract the cell is located
• Elimination as quickly as possible by
  gastrointestinal or esophagial endoscopy

10
FATAL CASES

• Toys
• 18 months girl. Inhalation of a rubber
   super-ball  (SAMU 92)
• 9 year old girl. Inhalation of pawn of a
  RAVENSBURGER EM6 game
• Sweets
• 15 months. inhaled a multicolored drop neckladce
  (SAMU de Grenoble and a hospital doctor)
• 2 ½ year-old girl. Ingestion of a  Push-push 
  ARTIC ice-cream. Choked because the malabar was
  too deep in the airways. The product was
  immediately withdrawn from the market by ARTIC
• 6 year-old child. Food false passage because of
  the ingestion of a SHAMALLOW sweet (SAMU
  Montpellier)

11
NON FATAL CASES

• Toys
• Adult with a peashooter
• 5 year-old girl with the ball at the end of the
  string of a stuffed musical clown MOULIN ROTY.
• 30 months girl. Artifical precious gems freed
  from a tiara of a SMOBY toy called  The beauty
  and the beast  (not for children under 3 small
  parts -). SMOBY promissed to improve the
  adhesion of the gems on the crown
• Confectioneries
• Risks of swallowing half a shell of a  
  surprise  KINDER egg   (2 cases, 1 in 1997 and 1
  in 2003, the applicant )notices the ventilation
  holes on the CADBURY eggs)
• Submission by DGCCRF (20 November 2003) of the
  ingestion risks of a  diabolins egg  sweet.
  AFFSA 3 december 2001 opinion on the  very great
  acidity  of a sweet called  fini boom super
  acid  with high-grade citric acid.

12
NON FATAL CASES (continuation)

• Other types of FB
• Inhalation of the cap protecting the rubber on a
   STABILO frost 0,5  criterium (UFC Que Choisir,
  10 décember 1998)
• Soothers  BEBISOL 

13
ACCIDENTOLOGY IN FRANCE

• Incoherent figures
• Sources vary
• figures vary
• Estimation of the annual number of deaths of
  children from 1 to 4 between 20 and 40

14
ACCIDENTOLOGY IN FRANCE (continuation)

• Data of the pediatric emergency unit of  NECKER
  ENFANTS MALADES
• 1 to 3 annual cases for the Paris SAMU
• Since 1 January 1996 9 cases
• 3 cases with currents ITALIA (14 months, 9 months
  and 5 years). Death.
• Chewing-gum (22 months). Death
• Sausage slice (19 month). No after effects
• English fruit drop (12 months). No after effects.
• Spaghetti ball (7 year-old). No after effects.
• Marshmallows (3 year-old). Neurological after
  effects
• Rubber ball of a game belonging to older brother
  (18 months). Death.

15
ACCIDENTOLOGY IN FRANCE (continuation)

• Informations by InVS (Health Watch Institute)
  Weekly epidemiological Bulletin (BEH n 19-20) 11
  May 2004
• Choking was the 2nd cause of everyday life
  accidents (3543 deaths in 1999, 6/10 000 et 18
  of the AcVC)
• ¾ on people over 65
• For children less than 1, choking was the 1st
  cause of death among the 85 deaths by everyday
  life accident of children under 1

16
CHOKING AMONG CHILDREN UNDER 15

• 1243 accidents on 14 0310 between 1996 and 1999
• By age
• 0-4 66,3
• 5-9 25,9
• 10-14 7,8
• By sex
• Male 50,3
• Female 49,6
• Products causing the accidents
• Food (52 ) fish (7,2 ), sweets (2,2 ),
  fruits (1,5 ), bones (1 ), others (3,5 )
• Non food 48 of the involved products (ex
  coins 14 marbles 7,9 )

17
CHOKING AMONG CHILDREN UNDER 5

• 824 cases (between 1996 and 1999)
• By sex
• Male 49
• Female 51
• Products cause of the accident same
  classification as for children under 15, bur
• More important number of injuries resulting from
  the handling of toys (18 )
• Money, coins 12
• Marbles 6
• Games 6
• Toys in general 6
• Fish 5
• Other food 4
• Loose stones 3
• Unknown 14

18
RISK ASSESSMENT (1)

• Objects or products specifically designed for
  children
• sweets
• products games or toys marbles, other games
  or toys, pencils soothers (Cf the CSC
  Recommendation)

19
RISK ASSESSMENT (2)

• Objects or products in the childs environment
  but not specifically intended for him
• Food products (F) fishes, fruits, bones, but
  also peanuts, pistachios, nuts, walnuts Their
  design cannot be modified (See Recommendation of
  3 Juy 1991 that asked for a better information
  of the parents)
• Non food products (non F) reasonably
  foreseeable use without a parental mediation.
  Vulnerable age Children under 3. Limits of a
  prevention policy (no chain of causation between
  the nature of the product and the accident but
  rather a concomitance)
• The authorities have imposed safety tests for
  rattles - the product is blamed for the accident
• No tests for pawns or marbles the person is to
  be blamed for the accident, unless the design of
  the product is obviously accident-proning
  ( push-push  malabar). Bad chewing (malabar) or
  lack of supervision (marble)

20
ACCIDENTOLOGY ABROAD (1)

• Report 28 February 2003 financed by the European
  Commission  Development of a method in order to
  define safety rules for specific classes of
  products. They must be met by technical standards
  issued by European bodies under a mandate of the
  European Commission (Pr Paul DEHEUVELS) very
  different situations in the world
• USA the blockage of the airways is the main
  cause of mortality among children under 1, the
  4th among children between 1 and 9. Other
  products are incriminated. Dropping.
• EUROPE (ANEC) over a period of 5 years, on
  15339 accidents recorded, 1418 involving coins,
  518 nails and screws, 5 food products associated
  with domestic products

21
ACCIDENTOLOGY ABROAD (2)

• English situation exemplary HADD exhaustive
  figures and analysis given by the DTI (Department
  of Traide and Industry). Study from 1986 to 1997.
• 290 fatal accidents among which
• 130 children under 1
• 63 1 year-old children
• 30 2 year-old children
• 16 3 year-old children
• 85 children under 3, 90 children under 4.
• Average of 20 accidents a year (52 food
  products, less than 6 toys)
• 14 food
• 4 non alimentary products not toys
• 1 vomit
• 1 unidentified toy

22
ACCIDENTOLOGY ABROAD (3)

• Study by CEREPRI (University of Athens) food
  containing not comestible products in Europe
• In Europe Cost 1 M 1996 écus. 7 deaths
  clearly identified
• 1977 5 ½ girl in Greece. The Hat of a doll in a
  crisps bag
• 1985 3 year old boy in Northern Irleand.
  Plastic wheels and axle of a truck contained in a
  chocolate egg
• 1989 3 year-old girl in Birmingham (GB).
  Detachable foot of a pink panther contained in a
  chocolate egg
• 1991 4 year-old girl in Brighton. Plastic toy
  (2 ,5 cm long and 3 cm diameter in a Bart Simpson
  egg)
• 1996 68 year-old woman in Belgium. Cardboard
  disc in a  flippo  Croky crisps bag
• 1997 5 months old girl in France. Plastic
  particule contained in a  Thumb pop  sweet
• 1994 3 year-old child in Portugal. Surprise
  doll contained in NESTUM honey cereal bags

23
HEARINGS

• Quality Manager  Grocery-Liquids-Hardware-Perfume
  s-Hygiene  AUCHAN
• Les Entreprises du médicament (LEEM)
• The Union Alliance 7 (professionals of food
  industry)
• Association SAFETY CHANNEL
• Technical Manager of Responsable FJP
• Director  scientific affairs, regulatory 
  CADBURY
• RAVENSBURGER
• National Délégation to emergency and First aid
  (RED CROSS)
• FERRERO
• review PRESCRIRE
• Toy specialists at the LNE

24
PRODUCTS FOR WHICH REGULATION OR STANDARD IMPOSE
DESIGN REQUIREMENTS IN ORDER TO PREVENT RISKS OF
INGESTION OR INHALATION OF SMALL FOREIGN BODIES
(FB)

• The regulation on toy safety
• The prevention of ingestion and inhalation of
  small parts with the  truncated cylinder  test
• Prevention of chokings by the  gauge E 
• The prevention of suffocations due to the
  obstruction of the nose and of the mouth by
  hemispheric toys
• Other areas of application
• The regulation on pacifiers
• The standard on caps for writing and marking
  instruments (ISO and BSI)

25
THE REGULATION ON TOY SAFETY

• Decree n 89-662 of 12 september 1989 modified
  transposing the 88/378/CEE Directive on toy
  safety. The toys must meet the essential safety
  requirements defined in Annex II
• General principles users and third persons
  protected against risks for health and injury
  (toy used as it is designed for and forseeable
  use considering childrens behaviour)
• Specific risks detachable parts of the toys
   obviously  designed for children under 36
  months must be of dimensions large enough for
  them not to be swallowed or inhaled. No risks of
  strangulation or suffocation
• CE Marking compulsary conformity to standards
  or CE  type  attestation
• Notice OJ 28 February 2003 mentions standard EN
  71

26
THE PREVENTION OF INGESTION AND INHALATION OF
SMALL PARTS WITH THE TRUNCATED CYLINDER

• Created in the US in 1971, imported in Europe in
  1982 and described in EN 71, par. 8.2.
• Truncated diagonally (57,1 mm/25,4 mm), 31,7 mm
  diameter.
• Principle Any toy and detachable element that
  completely fits in the cylinder without
  compression and in all the directions possible is
  said to be inappropriate for a child under 36
  months. Mention  Not for children under 36
  months  (this is the case for the RAVENSBURGER E
  M6 game).
• Anthropométric basis unknown (CF FJP or AFNOR).
  It is not the trachea of a new born baby (7 mm)
  or of an adult (25 mm). Maximum size for a child
  under 47 mm for a boy, 41 mm for a girl
  distance between 2 incisors (Cf CHILDATA
  published in 1995 by the DTI).The standard
  developpers took this bases to create a new
   gauge E .
• The truncated cylinder addresses the risks of
   false passage  but not those of suffocation
  due to the obstruction of the airways.

27
THE PREVENTION OF SUFFOCATIONS BY THE  GAUGE E 

• Amendment A8 to EN 71 standard July 2003 to meet
  the risks of suffocation provoqued by  a
  spheric, ovoid or ellipsoidal intended to be
  thrown, hitted, rolled, kicked or designed to
  bounce  
• Origin of this amendment accidents in 1998 due
  to the use of a LEGO  ladybird , hemispheric.
  Its concave part clinged
• Called  small balls  because it concerns the
  balls that can get into the airways behind the
  mouth and in the upper part of the throat and
  block them. If they get in this cylinder, the toy
  is not fit for children under 36 months.
• Spheric shape of the toys gt ventilation is not
  considered as an appropriate means to avoid the
  dangers presented by small balls. On what
  scientific basis ?
• Products with similar shapes for which holes have
  been considered as necessary

28
THE PREVENTION OF SUFFOCATION BY OBSTRUCTION OF
THE NOSE AND OF THE MOUTH CAUSED BY HEMISPHERIC
TOYS

• Amendment A 10 to EN 71 standard.
• Origin accidents in the US revealed by CPSC.
  Children between 4 to 24 months suffocated
  because they put on their nose or their mouth
  kitchen utensils toys (bowls, cups) of a
  diameter between 69 mm and 97 mm.
• Ventilation holes considered necessary to allow
  the child to breathe. 2 openings at least 13 mm
  away from one another are provided.

29
OTHER AREAS OF APPLICATION

• Liability of the gauges. The authorities wished
  to apply them to other fields
• Inadequate warning mentions
• Some products are considered by a professionnal
  as obviously meant for children under 36 months
  whereas they are not if you consider the
  critirion of the reasonably foreseeable use of a
  product
• Products imitating foodstuffs
• Decree n 92-985 of 9 september 1992 the
  products that are not food but that can be
  mistaken for food must not present risks of
  choking and     must be big enough not to be
  ingested by children under 36 months  (that is
  to say not fit in the 37,1 mm truncated cylinder)
• Other examples children clothes, ventouses
  pare-soleil, confectioneries associated with an
  energy source, swimming pool fences
• Cf decrees 26 February 2004 and 24 February 2005
  suspending the marketing of a luminous sweet
  shaped as a soother (a child ingested the button
  cell that lighted its edible part).

30
THE REGULATIONS ON PACIFIERS (1)

• Decree n 92-631 du 8 July 1992 on materials and
  objects designed to be in contact with food,
  products and drinks for man or animals.
• Major risk suffocation.
• The shield remains blocked in the childs throat
• The broken soother is inhaled by the child

31
THE REGULATION ON PACIFIERS (2)

• Standard NF EN 1400  child care articles
  soothers for infants and young children   May
  2003
• The test gauge
• Precut sheet with dimensions (43 mm) near those
  of  gauge E 
• The shield must be introduced by the wrong size
  and the right size. CSC Recommendation 2 April
  2003 asks for a modification of this standard
  providing a sideways introduction
• The ventilation holes
• Reduce the risk of inhalation of the soother
  through the pharynx
• Dimension (20 mm2 and distance 15 mm) big enough
  not to be obstructed by saliva and secretions.
  But holes too big can make the expulsion reflex
  less efficient
• The ingestion of the soother Cf Recommendation
  du 2 April 2003 for the standard to provide that
  the cutting tip should not only pierce the center
  but the sides of the silicone soother
• Standard ISO 11540 May 1993 on caps for writing
  and marking instruments continuous air passage
  on at least 6,8 mm2 on all the length of the cap.
  Minimum air flow 8.1/min. Test methods.

32
EXAMPLES FOR WICH THERE IS NO SPECIFIC REGULATION
NOR STANDARD (1)

• Confectioneries French market 620 M euros,
  250 millions items
• Traditional confectioneries importance of the
  size, the shape, but also of the consistancy
  (strong acidity, for exemple, cf AFSSA notice).
  Suspension of marketing measures taken by the
  administration on an individual basis following
  experts advice (CSC, AFSSA) .
• Example of deree n 2004-572 of 17 June 2004 on
  jellied confectioneries (containing konjak).
• The fatal ingestion of the  push-push malabar 
  ice-cream The DGCCRF asked for it to be
  withdrawn from the market but did not forbid it.
  Could be put again on the market
•  diabolins egg marketting limited in time
  (Until 27 May 2003). Shape and size (45 mm/30
  mmm) would justify the use of  gauge E  because
  it fits in this gauge. Risk of blockage in the
  respiratory track of a child under 36 months.

33
EXAMPLES FOR WHICH THERE IS NO SPECIFIC
REGULATION NOR STANDARD (2)

• Confectioneries sold with inedible objects risk
  of ingestion or inhalation of the inedible
  objects
• The most usual ones combine sweets and toys, easy
  to distinguish because the inedible object is not
  directly in contact with the foodstuff.
• New products  bolder  design, the
  confectionery is jointed with the inedible part.
  Ex. the luminous confectioneries. (lollipop).
  Danger that the child might swallow all or part
  of the inedible part. Suspended by a 26 February
  2004 decree for 1 year. 25 March 2004 CSC
  Recommendation asked for the cylinder test.
• Guide of the ALLIANCE 7 Union of the
  professionals of food industry the basic
  reference is the NF EN 71 stadard. Provides the
  truncated cylinder test. Refers to Amendement 8
  ( small balls ) for spheric, round or
  ellipsoidal objects, but does not specify what
  tests must be carried out. Now, it is a new
  gauge. The guide will be updated.

34
THE SURPRISE  EGGS CASE (1)

• Market in 2003 34 M items, 62,5 M (10,2 of
  the confectioneries market).
• For chocolate products surprise eggs represent
  1400 t, soit 33 M (2,5 of the market of
  chocolate products, evaluated 55 000 t)
• Kinder egg on the market for the first time in
  1976. FERRERO (an italian company) holds a near
  monopoly of the market.
• AUCHAN sells 3,5 M surpise eggs a year, that is
  to say 10 of the surpsie eggs market.
• Cases known by the European commission of
  accidents involving  Kinder surprise  eggs
• 1989 3 year-old little girl in GB (foot of a
  pink panther). CSC 6 March 1991 Recommendation
  asked to put up to 5 the minimum age for a child
  to handle the product. FERRERO agreed, then
  stopped because of the reluctance of the DGCCRF
• 3 other cases non fatal
• 1997 2 year-old. Swallowed a piece of plastic
   fragment of a kinder surprise  type.
• 1998 1 year-old. Kinder toy in the nostril
• 1999 3 year-old. Swallowed a plastic flag in a
  kinder egg

35
THE  SURPRISE  EGG CASE (2)

• Another inedible element the two-parts shell.
  The opening strength high, deterrent  for child
  under 3. Packing, not a toy, for CADBURY and
  FERRERO. Petition 04-012 a child under 3
  swallowed half a shell, the mother could talke it
  off. Risk that the  small balls  is meant to
  stop. FERREO and CADBURY make no particular
  warning on the risk of blockage of the
  respiratory track for children under 3.
• CADBURY shells not tested with  small balls 
  but with the 31,7 cm truncated cylinder. 32 mm or
  33 mm shells cannot completely fit in it. Risks
  of suffocation are known HASBRO (for the Action
  Man range) asked in 1999 for 6 ovoid ventilation
  holes about 7 mm onr 4 mm . This was applied to
  the BARBIE shells for girls, smaller holes
  (CADBURY could make them wider if their
  efficiency was proved). The effeiciency of the
  holes is not tested.
• FERRERO the  Kinder surprise . Shells not
  tested with  small balls  but truncated
  cylinder for small parts. Different from CADBURY
  ventilation holes on the shells non efficient,
  even dangerous. No accident data
• Hygiene introduction of foreign bodies during
  the phase following the packaging of the toys,
  before and during the production of the chocolate
  egg
• Experts definite opinion General Secretary of
  the French ORL Society.
• Reporters comments the shell or the half-shell
  has a secondary value of game and justifies a
  warning. Reservations on the fact that the holes
  have been excluded from the  small balls 
  standard

36
MEDICINES

• AFSSAPS sphere of competence. Nevertheless,
• According to the association for the prevention
  of suffocation SAFETY CHANNEL
• Medicines with a local anestheci can reveal
  themselves dangerous risk of  false passage 
  because of the anesthesia of the oropharyngial
  area (bout 30 medicines according to the
  automatic data bank on medicines)
• Children particularly vulnerable (2600 cases a
  year). The Academy of pharmacy raised the arm in
  2004 most medicines on the market not
  appropriate for children under 6.
• The warnings are insufficient and difficult to
  read
• Solution a 3,2 mm ventilation canal for the
  medicines but also for food (sweets,
  delicatessens, chesse)
• According to the Medicines Firms (LEEM)
• Attends official commissions at a national level
  (AFSSAPS) and at an international level (EPIA
  European Pharmaceutical Industries and
  Associations - and FIIM Fédération
  internationale des industries du médicament)
• No precise informations on false passages But
  obvious risks for older people they do not
  drink enough while they take their tablets
  (advice that figures on the instructions.)
  Advertisings putting the glass of water in front.
• The ergonomy of the medicine to prevent  false
  passage  not taken into account
• Holes would make the tablets biggers, risk of
  diminishing the stability of the tablets,
  impossible for the divisible tablets.

37
RECOMMENDATIONS
38
TO THE PUBLIC AUTHORITIES (1)

• A About the inventory of the accidents
• A more liable system of collection of the
  accidents data, in particular in the area of
  respiratory obstructions..
• B About formation and information
• Initiatives should be taken to impose on the
  professionals in permanent contact with the
  public and children to teach them the first aid
  movements (in particular the Heimlich maneuver).
  This could be done in schools, in firms, in homes
  for older people, day cares, restaurants Posters
  in those places.
• C. About the safety of toys
• Amendement to EN 71.1 standard taking into
  account the risks presented by the shells
  containing toys in suprise eggs (Cf soothers,
  regulation on similar products and provinding
  holes has proved efficient for suffocation
  accidents).
• D. On confectioneries associated with inedible
  products
• accidents with very acid or very bulky sweets
  removed from the market as they are banned. They
  reappear later with other forms but with the same
  design. For prevention purpose, a decree with the
  essential safety requirements for the shape, the
  consistency, the marking of sweets and their
  packaging intended for children under 4. Cf the
  ALLIANCE 7 guide.

39
TO THE PUBLIC AUTHORITIES (2)

• E. On the vegetable bodies (peanuts, piscachios,
  nuts, walnuts, almonts or nother products like
  starter sausages that should be kept out of young
  childrens reach..
• The CSC reiterates her recommendations of 3 July
  1991 the packaging of those products should
  have visible and easy to read mentions (perhaps
  with pictograms) indicating that they do not fit
  for children under 4 (they swallow them without
  chewing them). 
• F. On the risks of ingestion presented by
  medicines
• The High Health Authority and AFSSAPS should see
  to it that the risks while absorbing medicines,
  for children or older people, are taken into
  account by the pharpaceutical companies.
• G. On the introduction of the shield of the
  pacifiers in the test gauge .
• The authorities should intervene with the CEN for
  a modification of the test method in NF EN 1400
  (diagonal passage of the shield in the gauge, and
  not only right side and wrong side).

40
   TO MANUFACTURERS, DISTRIBUTORS OR IMPORTATORS
OF SURPRISE EGGS

• Instructions for food containing inedible
  products should mention that they are not
  recommended for children under 3 (ingestion
  risks, but also suffocation risks because of the
  blockage of the airways by the shells).
• The shells should be tested (in particular for
  the holes number, size).

41
  TO THE CONSUMERS

• Never let children under 6 come to food products
  known for their risks of suffocation (peanuts)
  generally served as a starter.
• Follow first aid training and refer to the
  existing guides n the maneuvers
• Information of the consumers by associations and
  by the National Consuming Institute (television
  programs).