- Email: [email protected]
Poisoning from Common Household Products
r Poisoning from Common Household Products ALAN K. DONE, M.D.*
Common household products pose a difficult problem in poisoning: Although involved less commonly than drugs, they are usually accompanied by much less information. Frequently the only information available is the trade name of the product and the purposes for which it was intended. Toxicity data are essential for prompt and intelligent decisions regarding the prognosis and the need for hospitalization, diagnostic tests, and treatment. While the necessary data can often be obtained from the files of Poison Control Centers and such excellent references as that by Gleason, Gosselin, and Hodge,12 the rapid proliferation of new products makes it impossible for such information to be obtained readily in all instances. It is possible in most instances to make at least a rough apprOximation of expected toxicity on the basis of the nature of the product. While there will always be deviations from any such categorical characterization, generalizations can be made which are useful with cognizance of their limitations. The purpose of this report is to consider the toxic potential of those common household products which are most frequently involved in childhood ingestions, not only for purposes of prognostication in cases of ingestion but also to alert physicians to hazards which are frequently ignored. There is no intention of being precise, for that is impossible without considering each individual product specifically. Nor can we attempt to cover all of the almost limitless possibilities for toxic exposure in the home. Table 1 lists those non medicinal household products which are most commonly involved in ingestions by children under the age of 5 years. The importance of some of these lies mainly in the numbers of people involved; with others there is a disproportionate morbidity which is reflected in the hospitalization rate. For instance, cosmetics are numerically very important, even though their ingestion is rarely associated ':'Professor of Pediatrics, Adjunct Professor of Pharmacology, and Director of the Poison Information and Therapy Center, University of Utah Medical Center, Salt Lake City, Utah
Pediatric Clinics of North America- Vol. 17, No.3, August, 1970
569
570
ALAN
K.
DONE
with significant morbidity. On the other hand, lye and corrosives, petroleum products, and polishes and waxes (mainly furniture polish) are less frequently ingested, but have a very high hospitalization rate. Intermediate in terms of severity of poisoning are pesticides, soaps and cleaners, bleaches, and disinfectants and deodorizers. In total, these classes of agents account for 30 per cent of the accidental ingestions by children under the age of 5 yearsY The purpose of this report is to summarize the toxic potential of these types of products.
Table 1. Common Nonmedicinal Household Products Most Frequently Ingested by Children Under 5 Years of Age (1966)''17 PER CENT OF INGESTIONS
Cosmetics Pesticides Petroleum products Soaps and cleaners Bleaches Disinfectants and deodorizers Polishes and waxes Lye and corrosives
HOSPIT ALIZA TION RATE (PER CENT)
5.9
4 16 34 9
5.8 5.0 4.0
3.5
14':'
2.2 2.1 1.5
21':' 36':'
49
':'Estimated from earlier data of National Clearinghouse for Poison Control Centers.
ASSESSING TOXICITY A system of "toxicity ratings" was established by Gleason, Gosselin, and Hodge l2 • 13 based upon the probable lethal dose for human beings,
Table 2. Dose Basis for Approximate Toxicity Ratings, and Factors Tending to Raise or Lower Rating PROBABLE LETHAL DOSE TOXICITY RATING':'
PER KG.
Extreme High Medium Nil or Low
5 mg. 50-500 mg. 0.5-5 gm. 5 gm.
VOL. IN
2
YEAR OLD
A swallowt or less 2-3 swallows t '12-6 oz. More than 6 oz.
Raise
Lower
Liquid Pellets Flavorful Large volume Low viscosity hydrocarbon
Solid or semisolid Powdered (unless caustic) Distasteful Small volume Viscous
Method of dispensing or packaging ':'Modified from Gosselin,13 and Gleason, Gosselin, and HodgeY tBased upon average swallow volume of 4 to 5 m!. in a 2 year old child."
POISONING FROM COMMON HOUSEHOLD PRODUCTS
571
estimated from animal studies and clinical data. This means of assessing toxic potential has proved to be of great value in providing at least an approximate answer to the question, "How toxic is it?" Table 2 presents a similar rating system, but with fewer gradations. The dosage data are translated into practical equivalents of volumes which would be expected to be potentially lethal in the average 2 year old child (number of swallows or ounces). No attempt is made to be any more precise than to indicate whether a material is likely to be lethal in a dose even smaller than one swallow (extreme toxicity), would require more than one but less than about three swallows (high toxicity), 0.5 to 6 ounces (medium toxicity), or more than about 6 ounces (toxicity nil or low). Thus, an error of 100 per cent or even more would not be expected to change the assessment significantly. In assessing the potential toxicity of various types of products, the author borrowed extensively from the published estimates of others lH3 • 16 and combined these with the experiences of this center. An attempt was made to rate products not only on the basis of dose, but also the likelihood that harmful quantities would be ingested or that the available toxicity data do not truly reft.ect the potential for harm in human beings. Since the dose ingested by a child can rarely be estimated except very grossly, it seemed important to take such factors into account insofar as possible. The factors which were considered to be of importance are listed in the bottom half of Table 2. Experience has shown that liquids or pelleted materials are more likely to be ingested in large quantity than powders and solids or semisolids. Flavoring has little to do with determining whether a product is ingested, but does inft.uence the amount taken. Some substances are present in such small volumes that a toxic dose cannot be obtained from a single container. As noted below under Petroleum Products, low-viscosity hydrocarbons pose a threat of chemical pneumonia, and intrapulmonary aspiration of such substances makes the ingested dose irrelevant. A factor which should be taken into account in individual instances, but which could not be anticipated here because of variations from one product to another, is the method of dispensing or packaging. For example, a substance which is available in aerosol form is usually less likely than a liquid in an ordinary bottle to be ingested in large quantities. A bottle having a very small aperture, such as is used with many shaving lotions, perfumes, and toilet waters, is likely to be ingested in smaller quantities than the same product in a wide-mouth bottle. These were weighed one against another to arrive, rather arbitrarily, at a final rating. In some instances, there were solid data upon which to base a rating, while in others it was necessary to use theoretical considerations. In all instances, however, the final arbiter was clinical experience. While the latter admittedly is inaccurate and often subjective, the resulting estimate should be sufficiently accurate for clinical purposes in placing products into one of the four broad toxicity categories.
572
ALAN
Table 3.
K. DONE
Cosmetics
TOXIC INGREDIENT TOXICITY
High
PRODUCT
OR EFFECT
Permanent wave neutralizer
May contain either: Perborate (boric acid poisoning) Bromate (irritation, collapse, hemolysis, kidney damage)
Fingernail polish remover
Toluene; aliphatic acetates (irritation; central nervous system depression)
Medium Fingernail polish
Same as fingernail polish remover Metal salts, pyrogallol (metal poisoning; corrosive) Thioglycolate (irritation; possible hypoglycemia) Perfume; sulfated castor oil Alcohol Alcohol, others (variable) Alcohol, essential oils
Hair dye, metallic Permanent wave lotion Bath oil Shaving lotion Hair tonic Cologne; toilet water Low
Perfume Shampoo Bubble bath Depilatories Hair straightener Hair dye, oxidation
Deodorants
Shaving cream Bath salts Nil
Make-up, liquid Eye make-up Hair dye, vegetable (henna, indigo) Cleansing or conditioning cream Hair dressing (nonalcoholic) Hand lotion or cream Lipstick, tube rouge
TREATMENT
Supportive For boric acid poisoning Sodium thiosulfate by mouth; demulcent; consider dialysis early Supportive
Supportive For metal (if severe);7. 8 demulcents Supportive; demulcent Demulcent (milk) Supportive Supportive; t demulcents Supportive; t demulcents
Alcohol, essential oils (irriSupportive;t demulcents tation; possible hypoglycemia) Anionic detergent (irritaDemulcent (milk) tion) Sodium lauryl sulfate (gas- Demulcent (milk) trointestinal irritation) Thioglycolate (see above) Supportive; demulcent Glycols and alcohols; may Supportive ± as for be caustic caustic Various amines, etc. Demulcent; methylene (gastrointestinal irritablue for severe methemoglobinemia. 7.8 tion; ?methemoglobinemia) Alcohol; aluminum or zinc Supportive; t demulcents salts (gastrointestinal irritation; hypoglycemia possible) Soaps Milk Polymeric phosphate; borax For causticity or boric acid poisoning
None
None
"'In addition to evacuation of stomach or removal from skin, or both, when indicated. tEthyl alcohol, in addition to being a depressant, may produce hypoglycemia in young children.' Related alcohols, with the exception of methanol, have qualitatively similar effects; none of the above contains methanol.
POISONING FROM COMMON HOUSEHOLD PRODUCTS
573
COSMETICS Table 3 indicates that the majority of cosmetics can be given a fairly low toxicity rating on the basis of the system used here. Exceptions are permanent wave neutralizers and fingernail polish removers. (Fingernail polish remover is no more toxic than the polish on a weight basis, but the volume of the latter is generally less.) There has been a tendency in recent years to replace bromate with the less toxic perborate in permanent wave neutralizers; the toxic potential remains relatively high, however. The solvents in fingernail polish remover or the polish itself produce principally narcotic effects on the central nervous system and some gastrointestinal irritation. Most of the remaining products listed owe what toxicities they have to gastrointestinal irritation or to the presence of alcohol. Alcohol, in addition to its central nervous depressant effects, may produce hypoglycemia, especially in young children. 5 Among the exceptions, metallic hair dyes may rarely produce various types of metal pOisoning and may be somewhat corrosive upon ingestion. Permanent wave lotions frequently contain thioglycolate which, like alcohol, may produce hypoglycemia. A few additional materials deserve comment. Perfume is more toxic, milligram-per-milligram, than most colognes, but the volume of the former is usually quite small. Depilatories formerly contained thallium, but the latter has been replace by relatively nontoxic thioglycolate salts similar to those described above for wave lotions. Some oxidation types of hair dyes, in addition to causing gastrointestinal irritation when ingested, would be expected to cause methemoglobinemia, but this has not been seen with any degree of frequency. The aluminum or zinc compounds in deodorants have theoretical toxicity, but the nature of the formulations and the types of packaging make the ingestion of hazardous quantities highly unlikely. Bath salts occasionally contain borax, which is potentially capable of causing boric acid poisoning, but because they are powders the amounts ingested are usually small and serious difficulty rarely arises. Numerous other cosmetics contain materials which themselves have significant toxicities, but factors mentioned previously tend to mitigate the toxic hazard. Prime examples here are eye make-up, lipstick, or tube rouge. These and other products shown at the bottom of Table 3 are practically devoid of toxic reactions.
PESTICIDES It can be seen in Table 4 that for most classes of pesticides the range of toxicity is great and relatively high. The reader is referred to other sources for more details about toxic manifestations and treatment.6-B, 19,20 The inorganic compounds listed all have extreme toxicity. Fortunately, they also have fairly effective antidotes as noted. In some instances these products represent an unnecessary risk, and it is often possible to reduce the hazard to children by substituting products having
Table 4.
Pesticides Ul
..:r
TOXICITY RATING CHEMICAL CLASS
Medium (or low)
High
Inorganics
Chlorinated hydrocarbons
Chlorobenzilate Kelthane Methoxychlor DDD Perthane 2,4-D 2,4,5-T
Dieldrin Toxaphene Lindane Chlordane Heptachlor Thiodan DDT
Organophosphate anticholinesterases
Chlorthion NPD Butonate Phostex
Mipafox Pirazinon Dibrom Dipterex Diazinon Ethion Navadel DDVP Co-ral
Carbamates
Zineb Captan
Botanicals Miscellaneous
Malathion
Ferbam
pyrethrins Allethrin
~
Extreme
TREATMENT':'
Cyanide Phosphorus Arsenic (soluble)! Thallium Fluoride
Nitrite - Thiosulfate t CuSO" 0.2% lavage;t supportive Dimercaprol (BAL)t Diethyldithiocarbamatet Calciumt
Endrin Aldrin
Supportive; combat CNS excitation.
1 Trithion Dimefox Demeton Guthion Phosphamidon OMPA Pyrazothion Isolan EPN
Atropine, Cholinesterase regenerators (e.g.,2-PAM)t
Atropinet (cholinesterase regenerators not useful)
Sevin Rotenone
(more toxic) TEPP Paraoxon Parathion Di-syston Pyrazoxon Phosdrin Thimet
Nicotine Strychnine
Warfarin Fluoroacetate
Supportive
>
t" ;..
Vitamin Kt Glycerol monoacetatet
Z
p::: tj
':'In addition to evacuation of stomach or removal from skin, when indicated, as well as supportive measures. tDetails of specific antidotal treatment can be found elsewhere."" 19. 20 !Arsenic acid or sodium arsenite. Relatively insoluble salts such as lead arsenate or arsenic trioxide, and organic arsenicals such as the methanearsonates (all of which are common constituents of herbicides) have a much lower ("medium") toxicity.'
o Z
"'
575
POISONING FROM COMMON HOUSEHOLD PRODUCTS
lesser toxicity and comparable effectiveness. For instance, there is little reason for employing thallium or phosphorus as a rodenticide when warfarin, which has little or no acute toxicity in humans, can be used effectively. The chlorinated hydrocarbons tend to have a lesser degree of toxicity and a wider range than the inorganics. Here, again, it is often possible to select for home use a product which is comparatively less toxic than some others without necessarily sacrificing efficiency. Among organophosphate insecticides the preparations are legion and the toxicity range again is quite wide. Individually, the organophosphates in the "extreme" toxicity class are not included frequently in pesticides intended for lay use; as a group, however, they may be encountered with some degree of frequency as causes of poisoning due to household products. An additional example of the ability frequently to substitute a substance of lesser toxicity without prohibitive loss of effectiveness is provided by malathion. It is rapidly detoxified by mammals and so has a very low order of toxicity, but is an effective cholinesterase inhibitor in insects. 19 The carbamates have a relatively low degree of toxicity in vertebrates. Zineb and Captan are fungicides; ferbam and sevin are mild cholinesterase inhibitors and are insecticidal. Unlike the organophosphate anticholinesterases, the cholinesterase inhibition of carbamates is not relieved by the cholinesterase regenerators, which may actually increase the severity of poisoning. Among the botanicals, nicotine and strychnine are unnecessarily toxic; on the other hand, the pyrethrins and the synthetic relative, allethrin, have a very low degree of toxicity. Warfarin is probably the most widely used rodenticide at the present time. Its action is to inhibit prothrombin formation and its effects are counteracted by vitamin K. Like the closely related medicinal, Dicumarol, warfarin produces hypoprothrombinemia only after repeated adminis-
Table 5.
Petroleum Products: Estimation of Aspiration Hazard and Systemic Toxicity
PRODUCT
Petroleum ether or benzine Gasoline Naphtha Kerosene Mineral seal oil Fuel or diesel oil Mineral oil Lubricating oil
SOURCE(S)
Industrial or rubber solvents Fuel Solvent, lighter fluid, dry cleaner, thinner Fuel, charcoal lighter fluid, thinner, pesticide solvent Furniture polish Fuel; heating oil
SYSTEMIC TOXICITY
ASPIRATION HAZARD':'
4+ 3+ 3+
2+ 3+
2+
2+
3+ 1+
4+ 1+
Motor oil, cutting oil, transmission fluid
':'Formulations with increased viscosity have decreased aspiration hazardY : Low-grade lipoid pneumonia possible with aspiration.
-
576
ALAN
K.
DONE
tration and not with a single dose even if large. Consequently, although animal studies suggest a higher toxicity, warfarin is ranked medium to low in terms of acute poisoning in humans. Fluoroacetate is extremely toxic, but is not generally available except to professional exterminators; there is experimental evidence that its toxic effects are inhibited by glycerol monoacetate.6-8 It is important to recognize that the solvents employed in pesticide formulations are sometimes at least as toxic as the pesticide itself. This fact could not be taken into account in the construction of Table 4 because the solvents differ widely among various preparations of the same pesticide. However, the solvents usually used are petroleum products such as those listed in Table 5. Xylene is also sometimes used. The nature of the solvent will usually be specified on the label, which should always be consulted in cases of potential pesticide poisoning.
PETROLEUM PRODUCTS A departure from the approach used thus far is necessary in the discussion of petroleum products (Table 5). Here it is difficult to be categorical about toxic potential because there are two possible effects which are unrelated: systemic toxicity and aspiration hazard. The latter is related principally to the viscosity or surface tension of the compound,!1 while systemic effects are related to other chemical properties. Thus, a material which has only mild or moderate systemic toxicity may be extremely dangerous if aspirated into the lungs even in very small quantity. Conversely, a preparation such as petroleum ether or benzine may have striking systemic toxicity and no appreciable aspiration hazard. The matter is complicated further by the fact that in many formulations a material which otherwise would be a striking aspiration hazard may not be such if the viscosity has been increased by various means. Among materials which pose an aspiration hazard, intrapulmonary aspiration of at least small quantities is nearly assured by the low surface tension of the material. As a result, ingestion of such products as kerosene and mineral seal oil is nearly always followed by at least some chemical pneumonia. Gasoline, naphtha, kerosene, and mineral seal oil produce both systemic and pulmonary effects. The latter effect is especially pronounced with mineral seal oil, which is a constituent of many furniture polishes. Fuel or diesel oil produce little systemic or pulmonary effect. Mineral oil and lubricating oil are too viscid to produce the typically severe "hydrocarbon" or "chemical" pneumonia, but they are capable of producing a low-grade lipoid pneumonia if aspirated in large quantities. The pneumonia produced by some of these agents can be fulminating and pose a difficult therapeutic problem. The management is well discussed elsewhere. IS Systemic toxicity of these materials usually is manifest by a state resembling alcoholic intoxication, together with restlessness, incoordination, confusion, coma (sometimes with convulsions), cardiovascular collapse, and death due to respiratory failure or ventricular fibrillation.
577
POISONING FROM COMMON HOUSEHOLD PRODUCTS
Many petroleum products contain additives which have significant toxicities of their own, but their concentrations are usually so low as to not contribute appreciably to the acute effects of the parent compound. 10
SOAPS, DETERGENTS, CLEANERS, AND BLEACHES As can be seen in Table 6, what toxicity is exhibited by soaps, detergents, and cleaners is most often related to irritant or caustic properties. Materials which are frankly caustic will usually have a warning to that effect on the label. Table 6. TOXICITY
High
Soaps, Detergents, Cleaners, and Bleaches
PRODUCT
Electric dishwasher granulest Ammoniat Bleach, commercial Bleach, oxygen
TOXIC INGREDIENT OR EFFECT
TREATMENT*
Caustic (may be severe)
Treat as caustic burnt
Caustic; coma and convulsions Boric acid or oxalate poisoning Boric acid poisoning
As caustict; supportive Milk; calcium; supportive Supportive
Disinfectant cleaners: See Disinfectants and Deodorizers (Table 7) Medium Bleach, chlorine
Gastrointestinal irritation, some causticity Boric acid poisoning Some caustic; hypocalcemia and acidosis possible
Borax Water softenerst (soluble) Liquid general cleaners: Pneumonia, systemic Kerosene toxicity Pine oil Gastrointestinal and genitourinary irritation; depression and weakness Detergent granulest Gastrointestinal irritation for laundry, dishes to causticity (some and general use frankly caustic and have higher toxicity) Low
Detergent powderst Liquid detergents Toilet soap Fabric softeners Window cleaners (liquid)
Gastrointestinal irritation (causticity possible, but unlikely) Gastrointestinal irritation Gastrointestinal irritation None Alcohol
Inhala- Chlorine bleach mixed with: Strong acid (bowl Chlorine gas (intense respition cleaner) ratory irritation) hazard Ammonia Chloramine fumes (respiratory irritation, nausea)
Demulcents ± treat as caustic burn Supportive Milk; as for caustict; supportive As for petroleum distillatest Supportive; demulcents Demulcents; treat as caustic burnt
Demulcents, soap; ± treat as caustic burnt Demulcents, soap Demulcents None See footnote to Table 3
Bicarbonate aerosol;'" oxygen Terminate exposure; supportive
"In addition to evacuation of stomach (except with caustic burn) or removal from skin, when indicated. tProducts threatening caustic effects will be identified with a caution label. Details of treatment can be found elsewhere.2 tDetails of treatment can be found elsewhere."
578
ALAN
K.
DONE
Electric dishwasher granules may be severely caustic and have, on occasion, caused complete destruction of the stomach. Most of the hospitalizations following ingestions of cleaning preparations are attributable to ammonia, which is highly caustic in its concentrated form. It is important, however, to appreciate that products which simply contain ammonia, but in highly diluted form, have only the toxic potential of the basic cleaning compound. In other words, one must distinguish between ammonia per se and materials which are simply ammoniated. The treatment of such caustic burns is well described elsewhere. 2 Most other types of detergent preparations have medium or low toxicity ratings, but it is important to realize that there are rare exceptions; occasional products will be disproportionately caustic. The toxic potential of bleaches varies according to the type. Generally speaking, the oxygen-type household bleaches and the commercial ones have the highest toxicities, both being capable of producing boric acid poisoning or (in the case of the commercial products) sometimes oxalic acid poisoning. Chlorine bleaches, which are usually dilute solutions of sodium hypochlorite, are generally overrated so far as toxicity is concerned. Systemic toxicity is low and, while there is some caustic effect, it is rarely sufficiently severe to cause fatality or stricture. Borax may cause boric acid poisoning, but the likelihood is diminished when the product is in powder form. Soluble water softeners which contain polymeric phosphates are not only potentially caustic, but may also produce hypocalcemia and acidosis. (Insoluble water softener resins have low or nil toxicity). Liquid cleaners intended for general purposes usually owe their moderate toxicities principally to such additives as pine oil or kerosene, as noted in Table 6. It is important, however, not to overestimate the toxicity of the many preparations which simply have a pine oil scent; the effects produced would be those of the basic detergent or other cleaning agent. An unusual hazard exists when chlorine bleaches are mixed with strong acids (such as those contained in some toilet bowl cleaners) or strong ammonia solutions. As noted in Table 6, strong acid causes the release of chlorine gas, and ammonia combines with hypochlorite to produce chloramine. The fumes of eiti'er are intensely irritating to eyes and respiratory trace, and occasional individuals have been "overcome." A new and very serious hazard is the liquid preparations of caustic alkalis which have recently been marketed and unfortunately widely advertised and cause serious esophageal burns.
DISINFECTANTS AND DEODORIZERS Referring to Table 7, those deodorizers in cake form (usually intended for bathrooms, toilets, or garbage cans) which contain naphthalene have high degrees of toxicity, while those which contain p-dichlorobenzene or sodium bisulfate are much less toxic, yet the latter are equally effective for their intended purposes. Among disinfectants, the acidic or phenolic ones have the highest toxicities. Acid disinfectants may not only be somewhat corrosive, but the anion (borate, formate, etc.)
579
POISONING FROM COMMON HOUSEHOLD PRODUCTS
may have additional toxicity. The phenolic disinfectants may cause irritation or corrosion, shock, coma, and renal damage which may progress to failure.
Table 7. Disinfectants and Deodorizers TOXICITY
High
PRODUCT
Naphthalene deodorizer (bathroom, toilet, garbage can) Acid disinfectant (boric, chloroacetic, formic, salicylic, etc.) Phenolic disinfectant
Medium Alkali disinfectant (sodium or ammoto nium hydroxides) hight Benzalkonium and other QACt disinfectants Pine oil disinfectant Halogen disinfectants
Medium Wick deodorizers
Deodorizing cleansers p-Dichlorobenzene or sodium bisulfate deodorizer (bathroom, toilet, garbage can) Low
Iodophor disinfectant
Nil
Spray deodorizers Refrigerator deodorizer
TOXIC INGREDIENT OR EFFECT
TREATMENT'"
Irritation, coma, convulsions, hemolysis, kidney damage Corrosive, plus systemic effects of anion
Supportive; alkalinize urine; transfuse as needed Supportive and as caustic burnfl
Phenols; hexachlorophene (gastrointestinal irritation, shock, coma; corrosion or kidney damage possible)
Treat as caustic burnfl or anticipate renal failure
Potentially caustic
Demulcents ± treat as caustic burnfl
Gastrointestinal irritation, convulsions, coma, respiratory distress, collapse Gastrointestinal and genitourinary irritation; depression and weakness Hypochlorites or chlorinated hydrocarbons (irritation; excitation)
Supportive; demulcents; mild soap solution or milk Supportive; demulcents Demulcents ± treat as caustic burn:f1 sedation as needed
Formaldehyde and hydroSupportive; demulcents carbons (gastrointestinal irritation, abdominal pain, shock, hematuria, coma, convulsions) Pine oil or QACt (See above) Irritation, abdominal pain, Supportive; demulcents; narcosis; liver, kidney sodium bicarbonate damage possible
Detergent-iodine complex (gastrointestinal irritation) (Variable) Charcoal (inert)
Demulcents Symptomatic None
"In addition to evacuation of stomach (except with caustic burn) or removal from skin, when indicated. tQuaternary ammonium compounds. tDepending upon constitution and concentration. f1Details of treatment can be found elsewhere.'
The toxicities of alkali, quaternary ammonium, pine oil, and halogen disinfectants vary on the basis of concentration of the active ingredients (see Table 7). Wick deodorizers and deodorizing cleansers have variable composition and are generally rated in the "medium" group. The iodo-
580
ALAN
K.
DONE
phor disinfectants are among the safest. Spray deodorizers cause little difficulty because the obtaining of a large dose is improbable.
OTHERS Two additional classes of compounds, polishes and waxes and lye and other corrosives, are important not only numerically but also because they produce disproportionate morbidity. Generally speaking, polishes and waxes create little problem except for furniture polishes containing petroleum hydrocarbons, which have already been discussed. Corrosive materials in addition to those previously discussed are usually strong alkalis most commonly used in drain pipe cleaners, paint removers, and some cleaning agents. Reagent tablets for detecting sugar in urine have also represented a caustic hazard. The toxicologic problem of principal concern with respect to caustic alkalis is the local tissue injury involving esophagus and sometimes stomach which can result in shock, asphyxia, perforation, or late formation of esophageal strictures. These problems and their treatment are discussed in more detail elsewhere. 2
SUMMARY A review of hazardous household products is not only potentially helpful in the management of cases of acute poisoning, but also provides opportunities for practicing preventive medicine. Much more effective than generalizing about the importance of keeping things out of the reach of small children are specific recommendations concerning particular materials. These can be in the form of suggestions either to avoid certain highly toxic materials or to surround their use with effective safeguards. An attempt was made here to characterize the potential hazards of the household products which are most frequently ingested by children.
REFERENCES 1. Arena, J. M.: Poisonings and other health hazards associated with the use of detergents. J.A.M.A., 190:56-58, 1964. 2. Arena, J. M.: Treatment of caustic alkali poisoning. Modern Treatment, 4:729-733,1967. 3. Calandra, J. C., and Fancher, O. E.: Cleaning products and their accidental ingestion. Soap and Detergent Association, Scientific and Technical Report No.5, April 1967. 4. Cann, H. M., and Verhulst, H. L.: Toxicity of household soap and detergent products and treatment of their ingestion. Amer. J. Dis. Child., 100:287-290, 1960. 5. Cummins, L. H.: Hypoglycemia and convulsions in children following alcohol ingestion. J. Pediat., 58:23-26, 1961. 6. Done, A. K.: Clinical pharmacology of systemic antidotes. Clin. Pharmacol. Therap., 2:750-793,1961. 7. Done, A. K: Specific antidotes. In Shirkey, H. C., ed.: Pediatric Therapy. 3rd ed. St. Louis, C. v. Mosby Co., 1968, pp. 133-147. 8. Done, A. K: Pharmacologic principles in the treatment of poisoning. Pharmacology for Physicians, 3:1-10,1969. 9. Done, A. K: Comparative acute toxicities of arsenical herbicides. (Manuscript in preparation.)
POISONING FROM COMMON HOUSEHOLD PRODUCTS
581
10. Dooley, A. E.: Toxicity of petroleum product additives. Arch. Environ. Health, 6:324328,1963. 11. Gerarde, H. W.: Toxicological studies on hydrocarbons. IX. The aspiration hazard and toxicity of hydrocarbons and hydrocarbon mixtures. Arch. Environ. Health, 6:329-341, 1963. 12. Gleason, M. N., Gosselin, R E., Hodge, H. C., and Smith, R P.: Clinical TOxicology of Commercial Products. Baltimore, Williams & Wilkins Co., 1969. 13. Gosselin, R E.: How toxic is it? J.A.M.A., 163:1333-1337, 1957. 14. Hodge, H. C., and Downs, W. L.: The approximate oral toxicity in rats of selected household products. Toxicol. Appl. Pharmacol., 3:689-695, 1961. 15. Jones, D. V., and Work, C. E.: Volume of a swallow. Amer. J. Dis. Child., 102:427, 1961. 16. Lawrence, R A., and Haggerty, R J.: Household agents and their potential toxicity. Modern Treatment, 4:633-647,1967. 17. National Clearinghouse for Poison Control Centers: Survey of products most frequently named in ingestion aCCidents, 1966. Bulletin, September-October 1967. 18. Shirkey, H. C.: Treatment of petroleum distillate ingestion. Modern Treatment, 4:697709,1967. 19. Upholt, W. M., and Kearney, P. C.: Pesticides. New Eng. J. Med., 275:1419-1426,1966. 20. Zavon, M. R: Diagnosis and treatment of pesticide poisoning. Arch. Environ. Health, 9:615-620, 1964. University of Utah Medical Center Salt Lake City, Utah 84112
Common household products pose a difficult problem in poisoning: Although involved less commonly than drugs, they are usually accompanied by much less information. Frequently the only information available is the trade name of the product and the purposes for which it was intended. Toxicity data are essential for prompt and intelligent decisions regarding the prognosis and the need for hospitalization, diagnostic tests, and treatment. While the necessary data can often be obtained from the files of Poison Control Centers and such excellent references as that by Gleason, Gosselin, and Hodge,12 the rapid proliferation of new products makes it impossible for such information to be obtained readily in all instances. It is possible in most instances to make at least a rough apprOximation of expected toxicity on the basis of the nature of the product. While there will always be deviations from any such categorical characterization, generalizations can be made which are useful with cognizance of their limitations. The purpose of this report is to consider the toxic potential of those common household products which are most frequently involved in childhood ingestions, not only for purposes of prognostication in cases of ingestion but also to alert physicians to hazards which are frequently ignored. There is no intention of being precise, for that is impossible without considering each individual product specifically. Nor can we attempt to cover all of the almost limitless possibilities for toxic exposure in the home. Table 1 lists those non medicinal household products which are most commonly involved in ingestions by children under the age of 5 years. The importance of some of these lies mainly in the numbers of people involved; with others there is a disproportionate morbidity which is reflected in the hospitalization rate. For instance, cosmetics are numerically very important, even though their ingestion is rarely associated ':'Professor of Pediatrics, Adjunct Professor of Pharmacology, and Director of the Poison Information and Therapy Center, University of Utah Medical Center, Salt Lake City, Utah
Pediatric Clinics of North America- Vol. 17, No.3, August, 1970
569
570
ALAN
K.
DONE
with significant morbidity. On the other hand, lye and corrosives, petroleum products, and polishes and waxes (mainly furniture polish) are less frequently ingested, but have a very high hospitalization rate. Intermediate in terms of severity of poisoning are pesticides, soaps and cleaners, bleaches, and disinfectants and deodorizers. In total, these classes of agents account for 30 per cent of the accidental ingestions by children under the age of 5 yearsY The purpose of this report is to summarize the toxic potential of these types of products.
Table 1. Common Nonmedicinal Household Products Most Frequently Ingested by Children Under 5 Years of Age (1966)''17 PER CENT OF INGESTIONS
Cosmetics Pesticides Petroleum products Soaps and cleaners Bleaches Disinfectants and deodorizers Polishes and waxes Lye and corrosives
HOSPIT ALIZA TION RATE (PER CENT)
5.9
4 16 34 9
5.8 5.0 4.0
3.5
14':'
2.2 2.1 1.5
21':' 36':'
49
':'Estimated from earlier data of National Clearinghouse for Poison Control Centers.
ASSESSING TOXICITY A system of "toxicity ratings" was established by Gleason, Gosselin, and Hodge l2 • 13 based upon the probable lethal dose for human beings,
Table 2. Dose Basis for Approximate Toxicity Ratings, and Factors Tending to Raise or Lower Rating PROBABLE LETHAL DOSE TOXICITY RATING':'
PER KG.
Extreme High Medium Nil or Low
5 mg. 50-500 mg. 0.5-5 gm. 5 gm.
VOL. IN
2
YEAR OLD
A swallowt or less 2-3 swallows t '12-6 oz. More than 6 oz.
Raise
Lower
Liquid Pellets Flavorful Large volume Low viscosity hydrocarbon
Solid or semisolid Powdered (unless caustic) Distasteful Small volume Viscous
Method of dispensing or packaging ':'Modified from Gosselin,13 and Gleason, Gosselin, and HodgeY tBased upon average swallow volume of 4 to 5 m!. in a 2 year old child."
POISONING FROM COMMON HOUSEHOLD PRODUCTS
571
estimated from animal studies and clinical data. This means of assessing toxic potential has proved to be of great value in providing at least an approximate answer to the question, "How toxic is it?" Table 2 presents a similar rating system, but with fewer gradations. The dosage data are translated into practical equivalents of volumes which would be expected to be potentially lethal in the average 2 year old child (number of swallows or ounces). No attempt is made to be any more precise than to indicate whether a material is likely to be lethal in a dose even smaller than one swallow (extreme toxicity), would require more than one but less than about three swallows (high toxicity), 0.5 to 6 ounces (medium toxicity), or more than about 6 ounces (toxicity nil or low). Thus, an error of 100 per cent or even more would not be expected to change the assessment significantly. In assessing the potential toxicity of various types of products, the author borrowed extensively from the published estimates of others lH3 • 16 and combined these with the experiences of this center. An attempt was made to rate products not only on the basis of dose, but also the likelihood that harmful quantities would be ingested or that the available toxicity data do not truly reft.ect the potential for harm in human beings. Since the dose ingested by a child can rarely be estimated except very grossly, it seemed important to take such factors into account insofar as possible. The factors which were considered to be of importance are listed in the bottom half of Table 2. Experience has shown that liquids or pelleted materials are more likely to be ingested in large quantity than powders and solids or semisolids. Flavoring has little to do with determining whether a product is ingested, but does inft.uence the amount taken. Some substances are present in such small volumes that a toxic dose cannot be obtained from a single container. As noted below under Petroleum Products, low-viscosity hydrocarbons pose a threat of chemical pneumonia, and intrapulmonary aspiration of such substances makes the ingested dose irrelevant. A factor which should be taken into account in individual instances, but which could not be anticipated here because of variations from one product to another, is the method of dispensing or packaging. For example, a substance which is available in aerosol form is usually less likely than a liquid in an ordinary bottle to be ingested in large quantities. A bottle having a very small aperture, such as is used with many shaving lotions, perfumes, and toilet waters, is likely to be ingested in smaller quantities than the same product in a wide-mouth bottle. These were weighed one against another to arrive, rather arbitrarily, at a final rating. In some instances, there were solid data upon which to base a rating, while in others it was necessary to use theoretical considerations. In all instances, however, the final arbiter was clinical experience. While the latter admittedly is inaccurate and often subjective, the resulting estimate should be sufficiently accurate for clinical purposes in placing products into one of the four broad toxicity categories.
572
ALAN
Table 3.
K. DONE
Cosmetics
TOXIC INGREDIENT TOXICITY
High
PRODUCT
OR EFFECT
Permanent wave neutralizer
May contain either: Perborate (boric acid poisoning) Bromate (irritation, collapse, hemolysis, kidney damage)
Fingernail polish remover
Toluene; aliphatic acetates (irritation; central nervous system depression)
Medium Fingernail polish
Same as fingernail polish remover Metal salts, pyrogallol (metal poisoning; corrosive) Thioglycolate (irritation; possible hypoglycemia) Perfume; sulfated castor oil Alcohol Alcohol, others (variable) Alcohol, essential oils
Hair dye, metallic Permanent wave lotion Bath oil Shaving lotion Hair tonic Cologne; toilet water Low
Perfume Shampoo Bubble bath Depilatories Hair straightener Hair dye, oxidation
Deodorants
Shaving cream Bath salts Nil
Make-up, liquid Eye make-up Hair dye, vegetable (henna, indigo) Cleansing or conditioning cream Hair dressing (nonalcoholic) Hand lotion or cream Lipstick, tube rouge
TREATMENT
Supportive For boric acid poisoning Sodium thiosulfate by mouth; demulcent; consider dialysis early Supportive
Supportive For metal (if severe);7. 8 demulcents Supportive; demulcent Demulcent (milk) Supportive Supportive; t demulcents Supportive; t demulcents
Alcohol, essential oils (irriSupportive;t demulcents tation; possible hypoglycemia) Anionic detergent (irritaDemulcent (milk) tion) Sodium lauryl sulfate (gas- Demulcent (milk) trointestinal irritation) Thioglycolate (see above) Supportive; demulcent Glycols and alcohols; may Supportive ± as for be caustic caustic Various amines, etc. Demulcent; methylene (gastrointestinal irritablue for severe methemoglobinemia. 7.8 tion; ?methemoglobinemia) Alcohol; aluminum or zinc Supportive; t demulcents salts (gastrointestinal irritation; hypoglycemia possible) Soaps Milk Polymeric phosphate; borax For causticity or boric acid poisoning
None
None
"'In addition to evacuation of stomach or removal from skin, or both, when indicated. tEthyl alcohol, in addition to being a depressant, may produce hypoglycemia in young children.' Related alcohols, with the exception of methanol, have qualitatively similar effects; none of the above contains methanol.
POISONING FROM COMMON HOUSEHOLD PRODUCTS
573
COSMETICS Table 3 indicates that the majority of cosmetics can be given a fairly low toxicity rating on the basis of the system used here. Exceptions are permanent wave neutralizers and fingernail polish removers. (Fingernail polish remover is no more toxic than the polish on a weight basis, but the volume of the latter is generally less.) There has been a tendency in recent years to replace bromate with the less toxic perborate in permanent wave neutralizers; the toxic potential remains relatively high, however. The solvents in fingernail polish remover or the polish itself produce principally narcotic effects on the central nervous system and some gastrointestinal irritation. Most of the remaining products listed owe what toxicities they have to gastrointestinal irritation or to the presence of alcohol. Alcohol, in addition to its central nervous depressant effects, may produce hypoglycemia, especially in young children. 5 Among the exceptions, metallic hair dyes may rarely produce various types of metal pOisoning and may be somewhat corrosive upon ingestion. Permanent wave lotions frequently contain thioglycolate which, like alcohol, may produce hypoglycemia. A few additional materials deserve comment. Perfume is more toxic, milligram-per-milligram, than most colognes, but the volume of the former is usually quite small. Depilatories formerly contained thallium, but the latter has been replace by relatively nontoxic thioglycolate salts similar to those described above for wave lotions. Some oxidation types of hair dyes, in addition to causing gastrointestinal irritation when ingested, would be expected to cause methemoglobinemia, but this has not been seen with any degree of frequency. The aluminum or zinc compounds in deodorants have theoretical toxicity, but the nature of the formulations and the types of packaging make the ingestion of hazardous quantities highly unlikely. Bath salts occasionally contain borax, which is potentially capable of causing boric acid poisoning, but because they are powders the amounts ingested are usually small and serious difficulty rarely arises. Numerous other cosmetics contain materials which themselves have significant toxicities, but factors mentioned previously tend to mitigate the toxic hazard. Prime examples here are eye make-up, lipstick, or tube rouge. These and other products shown at the bottom of Table 3 are practically devoid of toxic reactions.
PESTICIDES It can be seen in Table 4 that for most classes of pesticides the range of toxicity is great and relatively high. The reader is referred to other sources for more details about toxic manifestations and treatment.6-B, 19,20 The inorganic compounds listed all have extreme toxicity. Fortunately, they also have fairly effective antidotes as noted. In some instances these products represent an unnecessary risk, and it is often possible to reduce the hazard to children by substituting products having
Table 4.
Pesticides Ul
..:r
TOXICITY RATING CHEMICAL CLASS
Medium (or low)
High
Inorganics
Chlorinated hydrocarbons
Chlorobenzilate Kelthane Methoxychlor DDD Perthane 2,4-D 2,4,5-T
Dieldrin Toxaphene Lindane Chlordane Heptachlor Thiodan DDT
Organophosphate anticholinesterases
Chlorthion NPD Butonate Phostex
Mipafox Pirazinon Dibrom Dipterex Diazinon Ethion Navadel DDVP Co-ral
Carbamates
Zineb Captan
Botanicals Miscellaneous
Malathion
Ferbam
pyrethrins Allethrin
~
Extreme
TREATMENT':'
Cyanide Phosphorus Arsenic (soluble)! Thallium Fluoride
Nitrite - Thiosulfate t CuSO" 0.2% lavage;t supportive Dimercaprol (BAL)t Diethyldithiocarbamatet Calciumt
Endrin Aldrin
Supportive; combat CNS excitation.
1 Trithion Dimefox Demeton Guthion Phosphamidon OMPA Pyrazothion Isolan EPN
Atropine, Cholinesterase regenerators (e.g.,2-PAM)t
Atropinet (cholinesterase regenerators not useful)
Sevin Rotenone
(more toxic) TEPP Paraoxon Parathion Di-syston Pyrazoxon Phosdrin Thimet
Nicotine Strychnine
Warfarin Fluoroacetate
Supportive
>
t" ;..
Vitamin Kt Glycerol monoacetatet
Z
p::: tj
':'In addition to evacuation of stomach or removal from skin, when indicated, as well as supportive measures. tDetails of specific antidotal treatment can be found elsewhere."" 19. 20 !Arsenic acid or sodium arsenite. Relatively insoluble salts such as lead arsenate or arsenic trioxide, and organic arsenicals such as the methanearsonates (all of which are common constituents of herbicides) have a much lower ("medium") toxicity.'
o Z
"'
575
POISONING FROM COMMON HOUSEHOLD PRODUCTS
lesser toxicity and comparable effectiveness. For instance, there is little reason for employing thallium or phosphorus as a rodenticide when warfarin, which has little or no acute toxicity in humans, can be used effectively. The chlorinated hydrocarbons tend to have a lesser degree of toxicity and a wider range than the inorganics. Here, again, it is often possible to select for home use a product which is comparatively less toxic than some others without necessarily sacrificing efficiency. Among organophosphate insecticides the preparations are legion and the toxicity range again is quite wide. Individually, the organophosphates in the "extreme" toxicity class are not included frequently in pesticides intended for lay use; as a group, however, they may be encountered with some degree of frequency as causes of poisoning due to household products. An additional example of the ability frequently to substitute a substance of lesser toxicity without prohibitive loss of effectiveness is provided by malathion. It is rapidly detoxified by mammals and so has a very low order of toxicity, but is an effective cholinesterase inhibitor in insects. 19 The carbamates have a relatively low degree of toxicity in vertebrates. Zineb and Captan are fungicides; ferbam and sevin are mild cholinesterase inhibitors and are insecticidal. Unlike the organophosphate anticholinesterases, the cholinesterase inhibition of carbamates is not relieved by the cholinesterase regenerators, which may actually increase the severity of poisoning. Among the botanicals, nicotine and strychnine are unnecessarily toxic; on the other hand, the pyrethrins and the synthetic relative, allethrin, have a very low degree of toxicity. Warfarin is probably the most widely used rodenticide at the present time. Its action is to inhibit prothrombin formation and its effects are counteracted by vitamin K. Like the closely related medicinal, Dicumarol, warfarin produces hypoprothrombinemia only after repeated adminis-
Table 5.
Petroleum Products: Estimation of Aspiration Hazard and Systemic Toxicity
PRODUCT
Petroleum ether or benzine Gasoline Naphtha Kerosene Mineral seal oil Fuel or diesel oil Mineral oil Lubricating oil
SOURCE(S)
Industrial or rubber solvents Fuel Solvent, lighter fluid, dry cleaner, thinner Fuel, charcoal lighter fluid, thinner, pesticide solvent Furniture polish Fuel; heating oil
SYSTEMIC TOXICITY
ASPIRATION HAZARD':'
4+ 3+ 3+
2+ 3+
2+
2+
3+ 1+
4+ 1+
Motor oil, cutting oil, transmission fluid
':'Formulations with increased viscosity have decreased aspiration hazardY : Low-grade lipoid pneumonia possible with aspiration.
-
576
ALAN
K.
DONE
tration and not with a single dose even if large. Consequently, although animal studies suggest a higher toxicity, warfarin is ranked medium to low in terms of acute poisoning in humans. Fluoroacetate is extremely toxic, but is not generally available except to professional exterminators; there is experimental evidence that its toxic effects are inhibited by glycerol monoacetate.6-8 It is important to recognize that the solvents employed in pesticide formulations are sometimes at least as toxic as the pesticide itself. This fact could not be taken into account in the construction of Table 4 because the solvents differ widely among various preparations of the same pesticide. However, the solvents usually used are petroleum products such as those listed in Table 5. Xylene is also sometimes used. The nature of the solvent will usually be specified on the label, which should always be consulted in cases of potential pesticide poisoning.
PETROLEUM PRODUCTS A departure from the approach used thus far is necessary in the discussion of petroleum products (Table 5). Here it is difficult to be categorical about toxic potential because there are two possible effects which are unrelated: systemic toxicity and aspiration hazard. The latter is related principally to the viscosity or surface tension of the compound,!1 while systemic effects are related to other chemical properties. Thus, a material which has only mild or moderate systemic toxicity may be extremely dangerous if aspirated into the lungs even in very small quantity. Conversely, a preparation such as petroleum ether or benzine may have striking systemic toxicity and no appreciable aspiration hazard. The matter is complicated further by the fact that in many formulations a material which otherwise would be a striking aspiration hazard may not be such if the viscosity has been increased by various means. Among materials which pose an aspiration hazard, intrapulmonary aspiration of at least small quantities is nearly assured by the low surface tension of the material. As a result, ingestion of such products as kerosene and mineral seal oil is nearly always followed by at least some chemical pneumonia. Gasoline, naphtha, kerosene, and mineral seal oil produce both systemic and pulmonary effects. The latter effect is especially pronounced with mineral seal oil, which is a constituent of many furniture polishes. Fuel or diesel oil produce little systemic or pulmonary effect. Mineral oil and lubricating oil are too viscid to produce the typically severe "hydrocarbon" or "chemical" pneumonia, but they are capable of producing a low-grade lipoid pneumonia if aspirated in large quantities. The pneumonia produced by some of these agents can be fulminating and pose a difficult therapeutic problem. The management is well discussed elsewhere. IS Systemic toxicity of these materials usually is manifest by a state resembling alcoholic intoxication, together with restlessness, incoordination, confusion, coma (sometimes with convulsions), cardiovascular collapse, and death due to respiratory failure or ventricular fibrillation.
577
POISONING FROM COMMON HOUSEHOLD PRODUCTS
Many petroleum products contain additives which have significant toxicities of their own, but their concentrations are usually so low as to not contribute appreciably to the acute effects of the parent compound. 10
SOAPS, DETERGENTS, CLEANERS, AND BLEACHES As can be seen in Table 6, what toxicity is exhibited by soaps, detergents, and cleaners is most often related to irritant or caustic properties. Materials which are frankly caustic will usually have a warning to that effect on the label. Table 6. TOXICITY
High
Soaps, Detergents, Cleaners, and Bleaches
PRODUCT
Electric dishwasher granulest Ammoniat Bleach, commercial Bleach, oxygen
TOXIC INGREDIENT OR EFFECT
TREATMENT*
Caustic (may be severe)
Treat as caustic burnt
Caustic; coma and convulsions Boric acid or oxalate poisoning Boric acid poisoning
As caustict; supportive Milk; calcium; supportive Supportive
Disinfectant cleaners: See Disinfectants and Deodorizers (Table 7) Medium Bleach, chlorine
Gastrointestinal irritation, some causticity Boric acid poisoning Some caustic; hypocalcemia and acidosis possible
Borax Water softenerst (soluble) Liquid general cleaners: Pneumonia, systemic Kerosene toxicity Pine oil Gastrointestinal and genitourinary irritation; depression and weakness Detergent granulest Gastrointestinal irritation for laundry, dishes to causticity (some and general use frankly caustic and have higher toxicity) Low
Detergent powderst Liquid detergents Toilet soap Fabric softeners Window cleaners (liquid)
Gastrointestinal irritation (causticity possible, but unlikely) Gastrointestinal irritation Gastrointestinal irritation None Alcohol
Inhala- Chlorine bleach mixed with: Strong acid (bowl Chlorine gas (intense respition cleaner) ratory irritation) hazard Ammonia Chloramine fumes (respiratory irritation, nausea)
Demulcents ± treat as caustic burn Supportive Milk; as for caustict; supportive As for petroleum distillatest Supportive; demulcents Demulcents; treat as caustic burnt
Demulcents, soap; ± treat as caustic burnt Demulcents, soap Demulcents None See footnote to Table 3
Bicarbonate aerosol;'" oxygen Terminate exposure; supportive
"In addition to evacuation of stomach (except with caustic burn) or removal from skin, when indicated. tProducts threatening caustic effects will be identified with a caution label. Details of treatment can be found elsewhere.2 tDetails of treatment can be found elsewhere."
578
ALAN
K.
DONE
Electric dishwasher granules may be severely caustic and have, on occasion, caused complete destruction of the stomach. Most of the hospitalizations following ingestions of cleaning preparations are attributable to ammonia, which is highly caustic in its concentrated form. It is important, however, to appreciate that products which simply contain ammonia, but in highly diluted form, have only the toxic potential of the basic cleaning compound. In other words, one must distinguish between ammonia per se and materials which are simply ammoniated. The treatment of such caustic burns is well described elsewhere. 2 Most other types of detergent preparations have medium or low toxicity ratings, but it is important to realize that there are rare exceptions; occasional products will be disproportionately caustic. The toxic potential of bleaches varies according to the type. Generally speaking, the oxygen-type household bleaches and the commercial ones have the highest toxicities, both being capable of producing boric acid poisoning or (in the case of the commercial products) sometimes oxalic acid poisoning. Chlorine bleaches, which are usually dilute solutions of sodium hypochlorite, are generally overrated so far as toxicity is concerned. Systemic toxicity is low and, while there is some caustic effect, it is rarely sufficiently severe to cause fatality or stricture. Borax may cause boric acid poisoning, but the likelihood is diminished when the product is in powder form. Soluble water softeners which contain polymeric phosphates are not only potentially caustic, but may also produce hypocalcemia and acidosis. (Insoluble water softener resins have low or nil toxicity). Liquid cleaners intended for general purposes usually owe their moderate toxicities principally to such additives as pine oil or kerosene, as noted in Table 6. It is important, however, not to overestimate the toxicity of the many preparations which simply have a pine oil scent; the effects produced would be those of the basic detergent or other cleaning agent. An unusual hazard exists when chlorine bleaches are mixed with strong acids (such as those contained in some toilet bowl cleaners) or strong ammonia solutions. As noted in Table 6, strong acid causes the release of chlorine gas, and ammonia combines with hypochlorite to produce chloramine. The fumes of eiti'er are intensely irritating to eyes and respiratory trace, and occasional individuals have been "overcome." A new and very serious hazard is the liquid preparations of caustic alkalis which have recently been marketed and unfortunately widely advertised and cause serious esophageal burns.
DISINFECTANTS AND DEODORIZERS Referring to Table 7, those deodorizers in cake form (usually intended for bathrooms, toilets, or garbage cans) which contain naphthalene have high degrees of toxicity, while those which contain p-dichlorobenzene or sodium bisulfate are much less toxic, yet the latter are equally effective for their intended purposes. Among disinfectants, the acidic or phenolic ones have the highest toxicities. Acid disinfectants may not only be somewhat corrosive, but the anion (borate, formate, etc.)
579
POISONING FROM COMMON HOUSEHOLD PRODUCTS
may have additional toxicity. The phenolic disinfectants may cause irritation or corrosion, shock, coma, and renal damage which may progress to failure.
Table 7. Disinfectants and Deodorizers TOXICITY
High
PRODUCT
Naphthalene deodorizer (bathroom, toilet, garbage can) Acid disinfectant (boric, chloroacetic, formic, salicylic, etc.) Phenolic disinfectant
Medium Alkali disinfectant (sodium or ammoto nium hydroxides) hight Benzalkonium and other QACt disinfectants Pine oil disinfectant Halogen disinfectants
Medium Wick deodorizers
Deodorizing cleansers p-Dichlorobenzene or sodium bisulfate deodorizer (bathroom, toilet, garbage can) Low
Iodophor disinfectant
Nil
Spray deodorizers Refrigerator deodorizer
TOXIC INGREDIENT OR EFFECT
TREATMENT'"
Irritation, coma, convulsions, hemolysis, kidney damage Corrosive, plus systemic effects of anion
Supportive; alkalinize urine; transfuse as needed Supportive and as caustic burnfl
Phenols; hexachlorophene (gastrointestinal irritation, shock, coma; corrosion or kidney damage possible)
Treat as caustic burnfl or anticipate renal failure
Potentially caustic
Demulcents ± treat as caustic burnfl
Gastrointestinal irritation, convulsions, coma, respiratory distress, collapse Gastrointestinal and genitourinary irritation; depression and weakness Hypochlorites or chlorinated hydrocarbons (irritation; excitation)
Supportive; demulcents; mild soap solution or milk Supportive; demulcents Demulcents ± treat as caustic burn:f1 sedation as needed
Formaldehyde and hydroSupportive; demulcents carbons (gastrointestinal irritation, abdominal pain, shock, hematuria, coma, convulsions) Pine oil or QACt (See above) Irritation, abdominal pain, Supportive; demulcents; narcosis; liver, kidney sodium bicarbonate damage possible
Detergent-iodine complex (gastrointestinal irritation) (Variable) Charcoal (inert)
Demulcents Symptomatic None
"In addition to evacuation of stomach (except with caustic burn) or removal from skin, when indicated. tQuaternary ammonium compounds. tDepending upon constitution and concentration. f1Details of treatment can be found elsewhere.'
The toxicities of alkali, quaternary ammonium, pine oil, and halogen disinfectants vary on the basis of concentration of the active ingredients (see Table 7). Wick deodorizers and deodorizing cleansers have variable composition and are generally rated in the "medium" group. The iodo-
580
ALAN
K.
DONE
phor disinfectants are among the safest. Spray deodorizers cause little difficulty because the obtaining of a large dose is improbable.
OTHERS Two additional classes of compounds, polishes and waxes and lye and other corrosives, are important not only numerically but also because they produce disproportionate morbidity. Generally speaking, polishes and waxes create little problem except for furniture polishes containing petroleum hydrocarbons, which have already been discussed. Corrosive materials in addition to those previously discussed are usually strong alkalis most commonly used in drain pipe cleaners, paint removers, and some cleaning agents. Reagent tablets for detecting sugar in urine have also represented a caustic hazard. The toxicologic problem of principal concern with respect to caustic alkalis is the local tissue injury involving esophagus and sometimes stomach which can result in shock, asphyxia, perforation, or late formation of esophageal strictures. These problems and their treatment are discussed in more detail elsewhere. 2
SUMMARY A review of hazardous household products is not only potentially helpful in the management of cases of acute poisoning, but also provides opportunities for practicing preventive medicine. Much more effective than generalizing about the importance of keeping things out of the reach of small children are specific recommendations concerning particular materials. These can be in the form of suggestions either to avoid certain highly toxic materials or to surround their use with effective safeguards. An attempt was made here to characterize the potential hazards of the household products which are most frequently ingested by children.
REFERENCES 1. Arena, J. M.: Poisonings and other health hazards associated with the use of detergents. J.A.M.A., 190:56-58, 1964. 2. Arena, J. M.: Treatment of caustic alkali poisoning. Modern Treatment, 4:729-733,1967. 3. Calandra, J. C., and Fancher, O. E.: Cleaning products and their accidental ingestion. Soap and Detergent Association, Scientific and Technical Report No.5, April 1967. 4. Cann, H. M., and Verhulst, H. L.: Toxicity of household soap and detergent products and treatment of their ingestion. Amer. J. Dis. Child., 100:287-290, 1960. 5. Cummins, L. H.: Hypoglycemia and convulsions in children following alcohol ingestion. J. Pediat., 58:23-26, 1961. 6. Done, A. K.: Clinical pharmacology of systemic antidotes. Clin. Pharmacol. Therap., 2:750-793,1961. 7. Done, A. K: Specific antidotes. In Shirkey, H. C., ed.: Pediatric Therapy. 3rd ed. St. Louis, C. v. Mosby Co., 1968, pp. 133-147. 8. Done, A. K: Pharmacologic principles in the treatment of poisoning. Pharmacology for Physicians, 3:1-10,1969. 9. Done, A. K: Comparative acute toxicities of arsenical herbicides. (Manuscript in preparation.)
POISONING FROM COMMON HOUSEHOLD PRODUCTS
581
10. Dooley, A. E.: Toxicity of petroleum product additives. Arch. Environ. Health, 6:324328,1963. 11. Gerarde, H. W.: Toxicological studies on hydrocarbons. IX. The aspiration hazard and toxicity of hydrocarbons and hydrocarbon mixtures. Arch. Environ. Health, 6:329-341, 1963. 12. Gleason, M. N., Gosselin, R E., Hodge, H. C., and Smith, R P.: Clinical TOxicology of Commercial Products. Baltimore, Williams & Wilkins Co., 1969. 13. Gosselin, R E.: How toxic is it? J.A.M.A., 163:1333-1337, 1957. 14. Hodge, H. C., and Downs, W. L.: The approximate oral toxicity in rats of selected household products. Toxicol. Appl. Pharmacol., 3:689-695, 1961. 15. Jones, D. V., and Work, C. E.: Volume of a swallow. Amer. J. Dis. Child., 102:427, 1961. 16. Lawrence, R A., and Haggerty, R J.: Household agents and their potential toxicity. Modern Treatment, 4:633-647,1967. 17. National Clearinghouse for Poison Control Centers: Survey of products most frequently named in ingestion aCCidents, 1966. Bulletin, September-October 1967. 18. Shirkey, H. C.: Treatment of petroleum distillate ingestion. Modern Treatment, 4:697709,1967. 19. Upholt, W. M., and Kearney, P. C.: Pesticides. New Eng. J. Med., 275:1419-1426,1966. 20. Zavon, M. R: Diagnosis and treatment of pesticide poisoning. Arch. Environ. Health, 9:615-620, 1964. University of Utah Medical Center Salt Lake City, Utah 84112