Health Hazards Associated with Laundry Detergent Pods — United States, May–June 2012

Health Hazards Associated with Laundry Detergent Pods — United States, May–June 2012

Weekly

October 19, 2012 / 61(41);825-829

During May and early June 2012, the Carolinas Poison Center and the Poison Control Center at the Children's Hospital of Philadelphia received four reports of children with vomiting, mental status changes, and respiratory distress after ingesting the contents of laundry detergent pods. Laundry detergent pods are single-load capsules that contain concentrated liquid detergent within a water-soluble membrane that dissolves when in contact with moisture (1). Laundry detergent pods were introduced in the U.S. market in 2010, and multiple manufacturers now sell laundry detergent packaged in pods (2–4). On May 17, 2012, CDC and the American Association of Poison Control Centers (AAPCC) began tracking and characterizing reported exposures to laundry detergent from pods. During May 17–June 17, 2012, poison centers reported 1,008 laundry detergent exposures to the National Poison Data System (NPDS), of which 485 (48%) exposures involved laundry detergent pods. Age was recorded for 481 exposures, of which 454 (94%) exposures involved children aged ≤5 years. Among children aged ≤5 years, a significantly greater proportion of those exposed to laundry detergent from pods had gastrointestinal and respiratory adverse health effects and mental status changes compared with those with non-pod laundry detergent exposures. Parents and caregivers should keep laundry detergent pods, as well as other household cleaning products, out of reach and out of sight of children. Health-care providers should be aware that exposure to laundry detergent from pods might be associated with adverse health effects more often than exposure to non-pod laundry detergents.

Case Reports
Charlotte, North Carolina. In early May 2012, the Carolinas Poison Center received reports of two critically ill young children who had been exposed to laundry detergent from pods. The first patient was aged 20 months and found spitting, but otherwise appeared well, after ingesting the liquid contents of a punctured laundry detergent pod. Within 10 minutes, he developed profuse vomiting. He subsequently developed respiratory distress, became unresponsive, and developed seizure-like activity. He was intubated and later found to have a right perihilar infiltrate on chest radiography. He rapidly improved and was discharged 36 hours after the exposure. The second patient was aged 15 months and was brought to an emergency department after biting into a laundry detergent pod. He soon began to vomit profusely, had depressed sensorium, and required intubation for airway protection. The breathing tube was removed 6 hours later. The child's chest radiograph was clear and he was discharged 24 hours after the exposure. Poison center staff members followed up with the child's parents 4 days later and the only complaint was a sore throat.

Philadelphia, Pennsylvania. In early May 2012, the Poison Control Center at Children's Hospital of Philadelphia received notification of a boy aged 17 months who had bitten into a laundry detergent pod and soon began to vomit. He developed marked somnolence and respiratory distress requiring intubation for 1 day. In early June 2012, a girl aged 10 months was brought to a local health-care facility with vomiting, difficulty breathing, and drooling after biting into a laundry detergent pod and was admitted to the intensive care unit. She experienced respiratory distress, was found to have epiglottic swelling on radiography, and underwent emergency endoscopy. She was treated with racemic epinephrine and steroids, but did not require intubation. Both Philadelphia patients had subsequent swallowing dysfunction requiring nasogastric feeds, but eventually were discharged home on thickened foods with outpatient speech therapy follow-up.


Investigation and Results
These reports of exposure prompted an investigation by the Carolinas Poison Center, the Poison Control Center at Children's Hospital of Philadelphia, and CDC to characterize pod-associated laundry detergent exposures reported to poison centers using NPDS, the national poison center reporting database, to help assess the extent of the problem. On May 17, 2012, AAPCC, working with CDC, developed a new, unique code specifically for laundry detergent pods and asked poison control staff members to use this code for any laundry detergent pod-related call. This made it easy to identify and track laundry detergent pod-related calls quickly in NPDS. The investigators sought to further characterize potential risk factors associated with laundry detergent pod exposures and any related health effects. For comparison, the investigators identified and characterized all non-pod (i.e., granules, liquids, bars, and tablets) laundry detergent exposures that were reported to NPDS during the same period.
When sufficient information is available, poison centers classify the medical outcome of an exposure into the following categories: minor, moderate, major, death, no effect, or unrelated effect (5). Any reported exposure for which poison centers could not determine the final clinical outcome, that was ultimately determined to have an effect unrelated to the exposure, or that was ultimately determined to not have occurred based on poison center follow-up activities was excluded from this analysis (5).
Descriptive statistics for whether the exposure was unintentional, route of exposure, age, medical outcome, and the most frequent signs and symptoms associated with pod-exposure and non-pod exposure were calculated for pod and non-pod laundry detergent exposures. Categorical data comparisons were performed using the chi-square test or, when cell sizes were <5 a="a" applied="applied" are="are" as="as" bonferroni-holm="bonferroni-holm" bonferroni="bonferroni" continuous="continuous" controlling="controlling" correction="correction" data="data" defined="defined" distributed.="distributed." error="error" exact="exact" familywise="familywise" fisher="fisher" ilcoxon="ilcoxon" in="in" more="more" nonparametric="nonparametric" normally="normally" not="not" p="p" pairwise="pairwise" performed="performed" powerful="powerful" rank="rank" rate.="rate." resulting="resulting" s="s" significance="significance" step-down="step-down" still="still" sum="sum" test.="test." test="test" testing="testing" tests="tests" than="than" that="that" the="the" was="was" were="were" when="when" where="where" while="while"> During May 17–June 17, 2012, a total of 1,008 laundry detergent exposures were reported to poison centers. Of these, 485 (48%) were exposures to laundry detergent contained in pods, and 523 (52%) were non-pod laundry detergent exposures. Among pod-related laundry detergent exposures, 482 (99%) were unintentional (defined as occurring from an unseen or unplanned event, such as when a child gains access to a toxic substance and does not realize the danger of the action), compared with 494 (94%) of non-pod laundry detergent exposures (p<0 .001=".001" 114="114" 14="14" 175="175" 422="422" 435="435" accounted="accounted" also="also" among="among" and="and" associated="associated" at="at" between="between" compared="compared" detergent="detergent" detergents="detergents" differences="differences" exposure.="exposure." exposure="exposure" exposures="exposures" eye="eye" for="for" in="in" ingestion="ingestion" inhalational="inhalational" laundry="laundry" least="least" no="no" non-pod="non-pod" noningestion="noningestion" of="of" one="one" overall="overall" p="p" pod-related="pod-related" pod="pod" potential="potential" related="related" routes="routes" significant="significant" skin="skin" the="the" these="these" to="to" were="were" with="with"> Among all 992 laundry detergent exposures for which age was recorded, the median age was 2 years (range: 7 months–85 years), and the mean age was 3 years for the 481 persons with pod-related laundry detergent exposure. For the 511 persons with non-pod–related exposure, the median age was 2 years (range: 19 days–90 years), and the mean age was 7 years. Age data were not normally distributed. The pod-exposed persons were significantly younger than the non-pod laundry detergent exposed persons (Wilcoxon rank sum p=0.006).
To account for significant differences in age data, an additional analysis compared exposure as a function of age using four categories: ≤5 years, 6–10 years, 11–20 years, and >20 years. Among exposures, 868 (88%) occurred among persons aged ≤5 years. Children aged ≤5 years represented 454 (94%) of 481 pod exposures and 414 (81%) of 511 non-pod laundry detergent exposures. A significant difference in pod versus non-pod laundry detergent exposure was noted between age groups (overall chi-square p<0 .001=".001" 11="11" aged="aged" and="and" those="those" with="with" years="years">20 years being significantly less likely to be exposed to laundry detergent pods compared with children aged ≤5 years (p<0 .001=".001" class="callout-pink" span="span">Table 1
). Given the difference in age groups among the pod-exposed and non-pod–exposed groups, to account for confounding by age, subsequent analyses of medical outcomes and specific clinical signs and symptoms focused on children aged ≤5 years. Among pod-exposed persons, a minor, moderate, or major medical outcome was noted for 364 (80%) of persons, and no effect was noted for 90 (20%) persons. Among non-pod laundry detergent exposed persons, 261 (63%) had a minor, moderate, or major medical outcome, while 153 (37%) were noted to have no effect. Compared with non-pod laundry detergent exposed persons, pod-exposed persons were significantly more likely to have a minor, moderate, or major medical outcome compared with no effect (p<0 .001=".001" among="among" deaths="deaths" exposed="exposed" no="no" non-pod="non-pod" or="or" p="p" persons.="persons." pod-exposed="pod-exposed" reported="reported" were="were"> The most frequently reported signs and symptoms of laundry detergent exposure (excluding the symptom category labeled "other") included vomiting (pod-exposed: 251, 55%; non-pod–exposed: 139, 34%), coughing or choking (pod-exposed: 70, 15%; non-pod–exposed: 45, 11%), eye irritation or pain (pod-exposed: 51, 11%; non-pod–exposed: 68, 16%), red eyes/conjunctivitis (pod-exposed: 38, 8%; non-pod–exposed: 36, 9%), drowsiness or lethargy (pod-exposed: 34, 7%; non-pod–exposed: nine, 2%), and nausea (pod-exposed: 26, 6%; non-pod–exposed: 18, 4%). Only vomiting (p<0 .001=".001" and="and" association="association" between="between" choking="choking" common="common" compared="compared" comparison="comparison" conjunctivitis="conjunctivitis" coughing="coughing" detergent="detergent" detergents.="detergents." drowsiness="drowsiness" exposures="exposures" eye="eye" eyes="eyes" for="for" found="found" in="in" irritation="irritation" laundry="laundry" more="more" nausea="nausea" no="no" non-pod="non-pod" or="or" p="p" pain="pain" pod="pod" pods="pods" red="red" reported="reported" significant="significant" significantly="significantly" the="the" to="to" was="was" were="were" when="when" with="with">0.05) (Table 2).

Reported by

Michael C. Beuhler, MD, Carolinas Poison Center, Charlotte, North Carolina. Fred M. Henretig, MD, Payal Gala, MD, Peter Meaney, MD, Heather Wolfe, MD, Poison Control Center at the Children's Hospital of Philadelphia, Pennsylvania. Lauren Lewis, MD, Joshua Schier, MD, Royal Law, MPH, Mohan Punja, MD, Stephanie Kieszak, MPH, Div of Environmental Hazards and Health Effects, National Center for Environmental Health; Satish K. Pillai, MD, EIS Officer, CDC. Corresponding contributor: Satish K. Pillai, vig8@cdc.gov, 770-488-3411.

Editorial Note

In 2010, according to NPDS data, 180,493 exposures to household cleaning products were reported in the United States. Laundry detergents, irrespective of delivery form, accounted for 8,685 (4.8%) of these exposures (5). In 2000, NPDS data indicated that laundry detergents accounted for 5.7% of the exposures to household cleaners, suggesting no substantial change has occurred in the last 10 years based on poison center data (6). An analysis of National Electronic Injury Surveillance System data from 1990–2006 found that the total number of emergency department visits for children exposed to household cleaning products dropped by 46%. Visits for all types of detergent exposures, which included laundry detergents, accounted for 7.2% of these emergency department visits for the period 1990–2006, and similarly declined during the 17-year period (7). These data do not suggest that laundry detergent exposures, as a whole, have increased in the United States; they might be decreasing.
Laundry detergent pods, a specific type of laundry detergent product, were introduced in the U.S. market in 2010. Since the beginning of 2012, multiple manufacturers have begun selling additional laundry detergent pod products in the United States (2–4). In Europe, laundry detergent pods (also known as capsules, liquitabs, or sachets) were introduced a decade ago. Although direct comparisons between poison center data from different countries might not be possible, the experiences from Europe can provide some additional context. Exposures to laundry detergent pods represented the highest percentage of household cleaning product exposure in a recent national poison center study from the United Kingdom (8). Among these laundry detergent pod exposures, 96% occurred in children aged ≤5 years. Ingestion was the route of exposure in 80% of the children in this age group; reported signs and symptoms included nausea and vomiting, coughing, drowsiness, and rash (8). A study of laundry detergent pod exposures conducted during 2010–2011 by the poison control center in Milan, Italy, found that persons exposed to liquid laundry capsules were more likely to be symptomatic (76%) compared with those exposed to traditional laundry detergent products (27%) (1).
As found in Europe, this initial analysis of NPDS data suggests that laundry detergent pod exposures in the United States have occurred more frequently among children aged ≤5 years. In this age group, pod-related laundry detergent exposures are more likely to occur by ingestion and to be associated with clinical signs and symptoms than non-pod–related exposures. Children might be attracted to the pods because their colorful appearance and size are similar to candy (1,4,9). It remains unclear whether the significant adverse health effects observed with laundry detergent pod exposures relate to unique ingredients, differences in pH or other chemical properties (e.g., concentration), or the delivery mechanism.
Recently, the largest manufacturer of laundry detergent pods in the United States added a double-latch lid safety feature to the container in which its pods are sold (10). The company also is collaborating with poison centers to collect data and identify risk factors and health outcomes associated with laundry detergent pod exposure (J Colvin, Drug and Poison Information Center, Cincinnati Children's Hospital Medical Center, personal communication, 2012).
The findings in this report are subject to at least five limitations. First, NPDS relies on data voluntarily reported to poison centers by health-care providers. Exposures not reported to poison centers were not captured or analyzed in this dataset. Second, health-care providers and parents might be more likely to contact poison centers for new products with which they are unfamiliar, such as laundry detergent pods. Third, NPDS data consist of a variety of different codes used to describe the features (e.g., product type, clinical effects, and outcome) of the exposure. Although, poison center staff members across the country are trained in uniform coding techniques and undergo continuous training and review of documentation, unintentional coding errors might have occurred, which could have affected the results. Fourth, this report excluded exposures that were not followed by poison centers beyond the initial consultation. This can occur when poison centers are unable to obtain additional information regarding outcome of the case or if the patient leaves against medical advice. Finally, information regarding how often households with children aged ≤5 years used laundry pods versus non-pod laundry detergent was not available, which might limit the ability to extrapolate the results to the population at large.
Clinicians should be aware that all household cleaning products and detergents have the potential to cause illness, but that laundry detergent pod exposures might represent an emerging public health concern because laundry pod exposures had an increased frequency of adverse signs, symptoms, and health outcomes versus non-pod laundry detergent exposures in a vulnerable population. Parents and caregivers should be particularly aware that young children might be drawn to laundry detergent pods because of their candy-like appearance, and that exposure to laundry detergent from pods has been associated with more severe adverse health effects. Parents need to ensure they can prevent children from gaining access to household cleaning products, particularly laundry detergent pods. Clinicians and caregivers are encouraged to report laundry detergent exposures and cases of associated illness to their local poison center by calling 1-800-222-1222.

Acknowledgments

Alvin C. Bronstein, American Association of Poison Control Centers. Mary Ann McEachern, Kristi Stout, Carolinas Poison Center, Charlotte, North Carolina. Jonathan Colvin, Drug and Poison Information Center, Cincinnati Children's Hospital Medical Center, Ohio.

References

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