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InFocus: Adverse Effects Rising from Not-So-Benign Detergent Pods

Roberts, James R. MD

doi: 10.1097/01.EEM.0000480791.08126.0d
InFocus

Dr. Robertsis a professor of emergency medicine and toxicology at the Drexel University College of Medicine in Philadelphia. Read the Procedural Pause, a blog by Dr. Roberts and his daughter, Martha Roberts, ACNP, CEN, athttp://bit.ly/ProceduralPause, and read his past columns athttp://bit.ly/RobertsInFocus.

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Pediatric exposure to common household laundry detergents is usually relatively benign. At most, the substances produce mild irritation of the eyes and throat and occasionally some initial vomiting. The older granular and liquid detergents may attract the attention of inquisitive youngsters, who have a penchant to put everything in their mouths, but exposure rarely produces life-threatening complications.

Not so with the newer laundry and dishwasher detergents. They tend to be more concentrated and more toxic. But these caustics are also packaged in enticing and colorful packets, pouches, and pods. Recently, laundry detergent pods have become widely available in the United States with a concomitant rise in adverse effects, occasionally overshadowing the frequently encountered minor coughing, choking, or GI/pulmonary toxicity. Highly concentrated detergents pods, covered by a thin and readily dissolvable membrane, are designed to break down quickly in water when placed into dishwashers and washing machines. Making things even more difficult, the actual substances found in these detergents are unknown and poorly publicized. No longer is a toddler's exposure to caustic detergents only a minor annoyance.

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Laundry Detergent “Pod” Ingestions: A Case Series and Discussion of Recent Literature

Beuhler MC, Gala PK, et al.

Pediat Emerg Care

2013;29(6):743

This is one of only a few articles detailing clinical complications from childhood exposure to now widely available single-use laundry packets or pods. The authors discuss four pediatric patients who required intensive care management after ingestion of laundry pods, emphasizing the ability of these pretty packages to produce ugly toxicity.

A poorly supervised toddler in each of these cases ingested laundry detergent contained in a new water-soluble packet. Curiously, all patients demonstrated CNS abnormalities shortly after choking, coughing, or vomiting. All patients had an abnormal mental status, ranging from irritability to lethargy. All had at least some minor respiratory distress. This is distinctly unusual following exposure to the old-fashioned liquid or granular detergents that are usually supplied in big bottles or large boxes. All of these patients had some somnolence, and three of four required oral intubation for airway protection.

Most curiously, all patients developed a metabolic acidosis. Often a chest x-ray revealed opacities consistent with atelectasis or aspiration. The pharynx and larynx demonstrated varying degrees of inflammation or injury during endoscopy. All children were subject to an extended period of hospitalization, up to a week, requiring prolonged ventilator support or other aggressive airway attention. The exact cause of the CNS depression and acidosis was unknown, but was so impressive that a variety of additional tests were undertaken, including head CT, toxicology screening, and extensive laboratory testing.

The authors suggest eschewing a blasé approach for a child exposed to these toxins. The best clinical interventions are not yet ferreted out, but these pediatricians emphasize a significant difference, particularly the degree of drowsiness and lethargy, acidosis, and pulmonary insult between these pods and standard detergents. Propylene glycol is one additive that may be responsible for some of the toxicity. Propylene glycol is metabolized to lactate, and could account for the metabolic acidosis seen in these reports. Ethoxylated alcohols also may be toxic. The authors also question the manufacturers' suggested first aid administration of water to dilute the caustic effects.

Comment: Our toxicology service has been consulted on a number of pod exposures. So far, we have not seen any disasters like those depicted in this report. Most exposures to the newly packaged caustics will likely do well, but caution is necessary.

A toddler may walk right past a large box of granular detergent on the laundry floor, but no child can resist the nifty appearance of these soft and cuddly laundry pods. No form of resistant packaging has yet been instituted by manufacturers, and the pods are easily retrieved by children. They look like candy or some other attractive plaything, and rapidly find their way to the toddler's mouth. The thin protective covering is easily penetrated with teeth or fingers, releasing a very concentrated detergent into the airway and GI tract. The rapid development of an altered mental status and acidosis are indeed curious, and no cause has been pinpointed.

Minor caustic detergent exposure is a common pediatric dilemma. Vomiting is near universal, as is some coughing or gagging, but these symptoms usually abate quickly and all is well. Many kids can be handled at home. Half the battle is won if the exposure is obvious. Any child who presents with an unknown ingestion, however, perhaps not recognized by the parents, brings up a litany of potential etiologies. The child in one case was treated with naloxone because it appeared to be an opioid overdose.

Caustic detergent ingestions rarely require any specific therapy. Albuterol is certainly appropriate for a child with wheezing or cough, and steroids can potentially be used to ameliorate topical injury. The value of steroids for caustic ingestions has been debated for years, and the argument would probably have been settled a long time ago if they were of particular benefit.

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Toxicity Following Laundry Detergent Pod Ingestion

Schneir AB, Rentmeeser L, et al.

Pediatr Emerg Care

2013;29(6):741

This single case report appeared in the same journal as the above series. It describes a previously healthy 15-month-old who came to the ED after accidental ingestion of a laundry detergent pod. Within a few seconds of being left alone, the child found the attractive pod and inhaled and ingested much of its contents. The child developed a depressed level of consciousness and bilateral ronchi and wheezing in only about 10 minutes. A blood-tinged gastric aspirate was subsequently noted. The initial venous pH was 7.25, and the WBC count was 15,000/uL.

The unusual presentation prompted a variety of investigative techniques, including a drug screen and multiple blood tests. The child was intubated for an amazing five days. He required inhaled bronchodilators and supplemental oxygen, and eventually displayed a plural effusion and an abnormal chest x-ray. The radiographic findings were delayed, but the clinical insult to the respiratory tract was clinically obvious immediately. These authors were unable to pinpoint many of the chemicals contained in the laundry pod, and were at a loss to explain some of the clinical findings.

Comment: Children exposed to the old-fashioned laundry detergents often had irritation to the eyes, mouth, and upper respiratory tract, but they certainly didn't become lethargic, require intubation, or demonstrate metabolic acidosis. In fact, many such exposures were easily evaluated in the ED or over the phone by a poison specialist and subsequently discharged or left at home. All that will change with significant exposure to the single-use detergent pods that contain a more caustic formulation covered by a water-soluble wrapping.

The contents of the various products likely vary, and little is known about many of the additives. Designed to make laundry and dishwashing easier, less messy, and more portable, the single-use pods quickly dissolve in water, including saliva. These pods have a soft and pliable texture and easily burst with minimal manipulation. They are available for dishwashers and washing machines, and their colorful appearance is irresistible to toddlers. These single pods are a readily available cache of concentrated caustics, the large boxes of granular laundry detergent or large bottles of liquid often fail to attract a toddler altogether.

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What then is the clinician or parent to do when a child is found playing with a laundry or dishwasher pod? If the security of the pod has been violated, one must assume that a potentially serious exposure has occurred. Children who have immediate, significant symptoms, usually respiratory or gastrointestinal, should be taken to the hospital for evaluation. Inside the body, these substances may not be just minor irritants, so a quick in-and-out is not always appropriate. A nice overview of current knowledge is found in the same journal as the articles above. The editorial, entitled “Household ‘Hazmat.’ Pediatric Exploratory Ingestion of a Single-Use Detergent Sac,” presents a typical case as well as a discussion of what is currently known. (Pediatr Emerg Care 2013;29[6]:773.)

No criteria for risk stratification from such exposures currently exist. Current evidence demonstrates potential gastrointestinal, pulmonary, CNS, ocular, and metabolic effects. Transient vomiting, choking, and coughing are common side effects that may not always be a harbinger of more serious toxicity. No further intervention is usually required if minor symptoms clear and the child can drink without problems. But unlike prior exposures, more advanced pulmonary, CNS, metabolic, and GI and laryngeal pathology are real possibilities with the new products. It is possible that packaging that can suddenly burst has contributed somewhat to the significant pulmonary and esophageal pathology. Like other caustic ingestions, lack of findings in the mouth does not negate problems further down the GI tract or in the lungs.

Perhaps the most puzzling aspect of these cases is a sudden and profound drowsiness and CNS depression, findings not seen with traditional detergent ingestion exposure. It can occur in up to about 10 percent of cases and be extant and quite prominent within a few minutes of exposure. Full CNS recovery is the norm, but the change in mental status can cause the unwary clinician to assume drug overdose, trauma, or other etiologies. Emergency clinicians should consider exposure to laundry pod detergents worthy of their clinical respect.

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