- Email: [email protected]
Ingestion of Concentrated Laundry Detergent Pods
The Journal of Emergency Medicine, Vol. 49, No. 1, pp. e37–e38, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
Letter to the Editor , INGESTION OF CONCENTRATED LAUNDRY DETERGENT PODS
had normal tone and when stimulated would move all extremities symmetrically. Both of the children had a significantly increased anion gap acidosis (highest of 25), elevated serum lactate level (maximal of 13.3 mmol/L), and a metabolic acidemia (lowest pH 7.22) on arterial blood gas assays, but negative urine drugs-of-abuse screens. Chest radiographs and computed tomography of their heads were found to be normal. They were treated with supplemental oxygen and intravenous isotonic fluids and had rapid improvement in their symptoms over several hours, becoming alert and appropriately interactive. Repeat laboratory studies confirmed improvement and ultimately, resolution of the lactic acidosis and metabolic abnormalities over 6 h. One patient was admitted for ongoing supportive care and observation, and the other was observed in the ED for 8 h prior to being discharged home. Laundry pods contain concentrated liquid detergent within a water-soluble membrane; they were introduced into the U.S. market in 2010 (3). The first fatality attributed to ingestion of a detergent pod, in a 7-month-old boy in Florida, was recently reported (4). Prior to pods, ingestion of household detergent (laundry or dishwashing) was considered to be only slightly toxic and caused minor clinical poisoning, with the typical symptoms being mild oral and gastrointestinal irritation (5,6). In the United States in 2012, 94% of the laundry detergent exposures occurred in children <5 years of age (3). When comparing ingestions of standard laundry detergent to detergent pods, pod-exposed children were significantly younger and had significantly more adverse health effects, including a much higher rate of potentially serious outcomes, such as coma or need for intubation and mechanical ventilation (2.4% in standard vs. 12.3% in pod-exposed children) (3,7). The most frequently reported symptoms of pod ingestion include vomiting, coughing, and drowsiness or lethargy that may progress to coma with the need for intubation and mechanical ventilation (3,7). The type of pods that these children ingested contain anionic and nonionic surfactants, polymer, and fragrance; the
, To the Editor: I would like to report on the dangers to young children from the ingestion of highly concentrated laundry detergent packets, also known as pods. In the last 4 months, I have had two cases of young children (a 3-year-old boy and a 2-year-old boy) who had exploratory ingestion of portions of these pods witnessed by family members. Exploratory ingestion is the preferred term in Pediatric Toxicology literature when young, curious children ingest substances (or exploratory exposure if the contact with the substance is dermal, ocular, or inhalational) as they are exploring their environments. It is a more accurate description than accidental or unintentional because they indeed did intend on ingesting the substance but were not aware of the danger, whereas the term intentional ingestion typically indicates a selfharmful or suicidal behavior (1,2). Both patients had very similar presentations after they had bit into one of these brightly colored pods, which closely resemble candy (Figure 1), initially developing nausea and repeated vomiting followed by profound somnolence. On arrival to the Emergency Department (ED), they had tachycardia and tachypnea, but were normothermic and normotensive. One child had mild pharyngeal and lingual erythema, but neither child had significant oral burns, edema, or swelling. The children both had what is often described with metabolic acidosis as “quiet tachypnea” without signs of respiratory distress such as nasal flaring, thoracic retractions, or grunting, and their lung fields were normal to auscultation. Their skin was well perfused without cyanosis or diaphoresis. Although both patients were somnolent, one of the children became unresponsive for a brief period (1–2 min) but still maintained his airway; he then would react to tactile stimulation, and cried when an intravenous line was placed, but then would fall back to sleep. They both
e37
e38
Letter to the Editor
exploratory exposures to pods, and manufacturers should consider child-resistant packaging. Emily Fontane, MD, FAAEM, FACEP, FAAP Department of Emergency Medicine and Pediatrics University of Florida – College of Medicine Jacksonville, Florida http://dx.doi.org/10.1016/j.jemermed.2015.01.007 REFERENCES
Figure 1. Laundry pod appears similar to candy.
material safety data sheet provided by the company producing it states that the LD50 for ingestion is >2 g/kg (8). These chemical components are common in many detergents and soaps, so the reason for the apparent increased toxicity of laundry detergent pods is not clear at this point; their more concentrated formulation alone would not be sufficient (5,6). As further investigation is conducted, it would be prudent to advise parents to take precautions to avoid
1. Hays HL, Joliff HA, Casavant MJ. Thyrotoxicosis after massive levothyroxine ingestion in a 3-year-old patient. Pediatr Emerg Care 2013;29:1217–9. 2. Osterhoudt KC. Toxic topic: this treat is not so sweet: exploratory sulfonylurea ingestion by a toddler. Pediatr Case Rev 2003;4:215–7. 3. Centers for Disease Control and Prevention (CDC). Health hazards associated with laundry detergent pods – United States, May–June 2012. MMWR Morb Mortal Wkly Rep 2012;61:825–9. 4. Herna´ndez AR. Infant dies after ingesting detergent pod. Orlando Sentinel 2013. 5. Bajpai D, Tyagi VK. Laundry detergents: an overview. J Oleo Sci 2007;56:327–40. 6. Kosswig K. Surfactants. In: Elvers B, ed. Ulmann’s encyclopedia of industrial chemistry. Weinheim, Germany: Wiley-VCH; 2005:747– 815. 7. Forrester MB. Comparison of pediatric exposures to concentrated “pack” and traditional laundry detergents. Pediatr Emerg Care 2013;29:482–6. 8. Proctor & Gamble Company. Material data safety sheet # RQ1003262. Cincinnati, OH: Proctor & Gamble; 2011. Accessed August 21, 2013.
Letter to the Editor , INGESTION OF CONCENTRATED LAUNDRY DETERGENT PODS
had normal tone and when stimulated would move all extremities symmetrically. Both of the children had a significantly increased anion gap acidosis (highest of 25), elevated serum lactate level (maximal of 13.3 mmol/L), and a metabolic acidemia (lowest pH 7.22) on arterial blood gas assays, but negative urine drugs-of-abuse screens. Chest radiographs and computed tomography of their heads were found to be normal. They were treated with supplemental oxygen and intravenous isotonic fluids and had rapid improvement in their symptoms over several hours, becoming alert and appropriately interactive. Repeat laboratory studies confirmed improvement and ultimately, resolution of the lactic acidosis and metabolic abnormalities over 6 h. One patient was admitted for ongoing supportive care and observation, and the other was observed in the ED for 8 h prior to being discharged home. Laundry pods contain concentrated liquid detergent within a water-soluble membrane; they were introduced into the U.S. market in 2010 (3). The first fatality attributed to ingestion of a detergent pod, in a 7-month-old boy in Florida, was recently reported (4). Prior to pods, ingestion of household detergent (laundry or dishwashing) was considered to be only slightly toxic and caused minor clinical poisoning, with the typical symptoms being mild oral and gastrointestinal irritation (5,6). In the United States in 2012, 94% of the laundry detergent exposures occurred in children <5 years of age (3). When comparing ingestions of standard laundry detergent to detergent pods, pod-exposed children were significantly younger and had significantly more adverse health effects, including a much higher rate of potentially serious outcomes, such as coma or need for intubation and mechanical ventilation (2.4% in standard vs. 12.3% in pod-exposed children) (3,7). The most frequently reported symptoms of pod ingestion include vomiting, coughing, and drowsiness or lethargy that may progress to coma with the need for intubation and mechanical ventilation (3,7). The type of pods that these children ingested contain anionic and nonionic surfactants, polymer, and fragrance; the
, To the Editor: I would like to report on the dangers to young children from the ingestion of highly concentrated laundry detergent packets, also known as pods. In the last 4 months, I have had two cases of young children (a 3-year-old boy and a 2-year-old boy) who had exploratory ingestion of portions of these pods witnessed by family members. Exploratory ingestion is the preferred term in Pediatric Toxicology literature when young, curious children ingest substances (or exploratory exposure if the contact with the substance is dermal, ocular, or inhalational) as they are exploring their environments. It is a more accurate description than accidental or unintentional because they indeed did intend on ingesting the substance but were not aware of the danger, whereas the term intentional ingestion typically indicates a selfharmful or suicidal behavior (1,2). Both patients had very similar presentations after they had bit into one of these brightly colored pods, which closely resemble candy (Figure 1), initially developing nausea and repeated vomiting followed by profound somnolence. On arrival to the Emergency Department (ED), they had tachycardia and tachypnea, but were normothermic and normotensive. One child had mild pharyngeal and lingual erythema, but neither child had significant oral burns, edema, or swelling. The children both had what is often described with metabolic acidosis as “quiet tachypnea” without signs of respiratory distress such as nasal flaring, thoracic retractions, or grunting, and their lung fields were normal to auscultation. Their skin was well perfused without cyanosis or diaphoresis. Although both patients were somnolent, one of the children became unresponsive for a brief period (1–2 min) but still maintained his airway; he then would react to tactile stimulation, and cried when an intravenous line was placed, but then would fall back to sleep. They both
e37
e38
Letter to the Editor
exploratory exposures to pods, and manufacturers should consider child-resistant packaging. Emily Fontane, MD, FAAEM, FACEP, FAAP Department of Emergency Medicine and Pediatrics University of Florida – College of Medicine Jacksonville, Florida http://dx.doi.org/10.1016/j.jemermed.2015.01.007 REFERENCES
Figure 1. Laundry pod appears similar to candy.
material safety data sheet provided by the company producing it states that the LD50 for ingestion is >2 g/kg (8). These chemical components are common in many detergents and soaps, so the reason for the apparent increased toxicity of laundry detergent pods is not clear at this point; their more concentrated formulation alone would not be sufficient (5,6). As further investigation is conducted, it would be prudent to advise parents to take precautions to avoid
1. Hays HL, Joliff HA, Casavant MJ. Thyrotoxicosis after massive levothyroxine ingestion in a 3-year-old patient. Pediatr Emerg Care 2013;29:1217–9. 2. Osterhoudt KC. Toxic topic: this treat is not so sweet: exploratory sulfonylurea ingestion by a toddler. Pediatr Case Rev 2003;4:215–7. 3. Centers for Disease Control and Prevention (CDC). Health hazards associated with laundry detergent pods – United States, May–June 2012. MMWR Morb Mortal Wkly Rep 2012;61:825–9. 4. Herna´ndez AR. Infant dies after ingesting detergent pod. Orlando Sentinel 2013. 5. Bajpai D, Tyagi VK. Laundry detergents: an overview. J Oleo Sci 2007;56:327–40. 6. Kosswig K. Surfactants. In: Elvers B, ed. Ulmann’s encyclopedia of industrial chemistry. Weinheim, Germany: Wiley-VCH; 2005:747– 815. 7. Forrester MB. Comparison of pediatric exposures to concentrated “pack” and traditional laundry detergents. Pediatr Emerg Care 2013;29:482–6. 8. Proctor & Gamble Company. Material data safety sheet # RQ1003262. Cincinnati, OH: Proctor & Gamble; 2011. Accessed August 21, 2013.