Toxicity Following Laundry Detergent Pod IngestionAaron B. Schneir, MD,*Þ Landen Rentmeester, MD,*Þ Richard F. Clark, MD,*Þ

and F. Lee Cantrell, PharmDÞþ

Abstract: Laundry detergent pods (LDPs) have only recently becomeavailable in the United States, and there has been increasing concernregarding pediatric ingestions of them. We describe a 15-month-old fe-male infant who ingested an LDP and had a depressed level of con-sciousness, metabolic acidosis, pulmonary toxicity, and swallowingdifficulties. It is currently unclear what the exact etiologic agent(s) isresponsible for the toxicity associated with LDPs. The case demon-strates the potential for significant toxicity following the ingestion of anLDP. Clearly, measures should be taken to avoid ingestions of theseproducts.

Key Words: laundry, laundry detergent, laundry detergent pod,detergent, ethoxylated alcohol

(Pediatr Emer Care 2013;29: 741Y742)

Recently, there has been increasing concern regarding un-intentional pediatric exposures to laundry detergent ‘‘pods’’

(LDPs), also known as ‘‘packs’’ or ‘‘pouches.’’1,2 Laundry de-tergent pods contain concentrated liquid detergent surroundedby a water-soluble membrane. Laundry detergent pods havebeen available in Europe for the last decade, and multiple,mostly poison centerYbased reports there have detailed com-plications from exposures.2Y8 Laundry detergent pods have onlyrecently become widely available in the United States.1,9 A re-cent US poison centerYbased report demonstrated that certainadverse effects from LDPs (coughing or choking, drowsiness,and vomiting) were significantly more common than from ex-posures to more traditional laundry products.1 Laundry deter-gent pods are often colorful and have a size and consistency thatmay be enticing to children.1,6,7 Both UK and US studiesdemonstrate that exposures are seen more frequently in children5 years or younger.1,2 Complications of exposures have rangedfrom benign to quite serious. Topical exposures have includedrashes, conjunctivitis, and keratitis, all of which appear to self-resolve.1,2,7,8 More serious adverse effects have included pro-fuse vomiting, respiratory distress, central nervous system(CNS) depression, and subsequent swallowing difficulties.1Y6

We describe in depth the presentation, hospital course, and en-suing follow-up of a 15-month-old patient who ingested anLDP. The case highlights the potential for significant compli-cations associated with these products.

CASEA 15-month-old, 10-kg, previously healthy female infant

presented to a local emergency department (ED) after the

accidental ingestion of an LDP. The patient’s mother heard herdaughter coughing in an adjacent room and arrived to find herholding the remains of a single LDP (approximately three-fourths of the product gone). The mother immediatelyattempted to wash her daughter’s mouth out with water. Within10 minutes, the patient vomited twice and soon after developeda depressed level of consciousness. Emergency medical ser-vices were activated. Paramedics placed the patient on 100%oxygen by nonrebreather face mask; established intravenousaccess; checked a blood glucose, which was normal; andtransported her to the ED.

Upon ED arrival, the patient had the following vital signs:pulse 120 beats/min, blood pressure 88/50 mm Hg, respiratoryrate 10 breaths/min, temperature 97.9-F, and pulse oximeter100% (on oxygen). Physical examination was significant formiosis, shallow respirations with bilateral ronchi and wheezing,and a depressed level of consciousness (detailed to open eyes topain only and to withdraw to pain). One milligram of naloxonewas administered intravenously without any effect, and then thepatient was endotracheally intubated by rapid sequence induc-tion followed by continuous sedation. An orogastric tube wasplaced, and a blood-tinged aspirate was obtained. A post-intubation chest radiograph was unremarkable, with normal lungfields. Initial laboratory testing revealed the following: venouspH 7.25, PCO2 38 mm Hg; normal chemistry except for HCO3

of 16 mmol/L (anion gap 15), white blood cells 15,000/HL,hematocrit 31%, and a normal platelet count. Serum salicylateand acetaminophen were not detected. A urine drugs-of-abusescreen by immunoassay was negative for amphetamines, barbitu-rates, benzodiazepines, benzoylecgonine (cocaine metabolite),ethanol, methadone, opiates, phencyclidine, and 11-nor-delta-9-thc-9-carboxylic acid (cannabinoid metabolite). Urinalysis re-vealed rare bacteria but was otherwise unremarkable. Albuteroland ipratropium were administered by nebulization for wheez-ing. The patient was noted by a pediatric intensive care transportteam to have intermittent spontaneous movements. She wasgiven additional sedation, paralyzed, and transported to a pedi-atric intensive care unit. An initial arterial blood gas theredemonstrated a PO2 of 176 mmHg despite 50% inspired oxygen.Repeat chemistry analysis (approximately 4 hours following theinitial laboratory tests) demonstrated resolution of the initial meta-bolic acidosis and a normal lactate concentration of 0.6 mmol/L.A serum osmolarity was never performed.

The patient remained intubated for the next 5 days. Duringthis time, she required 50% to 60% inspired oxygen. Inhaledbronchodilators were intermittently administered for what wasinterpreted as bronchospasm. Over the first few days, the pa-tient had episodes of oxygen desaturations that were correctedwith suctioning and ventilator adjustments. Mild abnormalitieswere found beginning on day 3 of hospitalization on serial chestradiographs. Decreased aeration of bilateral lung bases wasinitially noted with subsequent development of basilar atelec-tasis in the left lung base with a small left pleural effusion. Onday 4, bibasilar opacities were noted on chest radiograph,greater on the left, which subsequently improved. Clindamycinwas temporarily administered for possible aspiration pneumonia

ILLUSTRATIVE CASE

Pediatric Emergency Care & Volume 29, Number 6, June 2013 www.pec-online.com 741

From the *UC San Diego Health System and †San Diego Division, CaliforniaPoison Control System, San Diego; and ‡Dept. of Clinical Pharmacy, Univer-sity of CaliforniaYSan Francisco School of Pharmacy, San Francisco, CA.Disclosure: The authors declare no conflict of interest.Reprints: Aaron B. Schneir, MD, UC San Diego Medical Center, 200 W

Arbor Dr, San Diego, CA 92103 (e-mail: aschneir@ucsd.edu).Copyright * 2013 by Lippincott Williams & WilkinsISSN: 0749-5161

but was stopped when respiratory cultures grew normal respi-ratory flora. A respiratory viral screen was negative for respi-ratory syncytial virus, adenovirus, influenza A, influenza B,parainfluenza 1, parainfluenza 2, and parainfluenza 3. An initialurine culture grew Klebsiella pneumoniae that was treated un-eventfully with ceftriaxone; initial blood cultures did not growan organism. A proton-pump inhibitor was begun because ofthe initial blood-tinged gastric aspirate that persisted for 2 days.On day 2, esophagogastroduodenoscopy was performed thatrevealed mild erythema in the distal esophagus near the gas-troesophageal junction with small mucosal-colored circularraised lesions. No ulcers or breaks in the mucosa were seen.Dexamethasone was administered before extubation. The pa-tient required 2 L of nasal cannula oxygen to maintain normaloxygen saturations for 1 day following extubation and thenremained on room air. Following extubation, the patient haddifficulty swallowing; drooling was occasionally described, anda weak cry and persistent hoarseness were noted. A fluoroscopicswallowing study was performed on day 9 that demonstratedevidence of aspiration of nectar-thick liquids, but normalswallow without aspiration of honey-thick liquids and paste. Aflexible fiberoptic laryngoscopy was performed on day 10 thatrevealed normal vocal cords but arytenoid and postcricoidedema with some pooling of secretions. The patient wasdischarged home on day 13 on a proton-pump inhibitor withinstructions for upright feeding with a honey-thick diet. Afollow-up fluoroscopic swallowing study was performed ap-proximately 1 month later, which was normal.

The material safety data sheet noted the ingredients to in-clude C12-C15 ethoxylated alcohols (60%Y70%), propyleneglycol (PG) (10%Y15%), and glycerine (10%Y15%). The pH ofthe detergent was tested with pH paper and estimated to be inthe 8 range.

DISCUSSIONThe case demonstrates the potential significant toxicity

(CNS depression, pulmonary toxicity, subsequent swallowingdifficulties) that can occur following the ingestion of an LDP.1Y3

The mechanisms and the exact etiology of the substance(s) re-sponsible for the major adverse effects of LDPs are currentlyunknown and may differ between products. Direct contact maycause irritation of the oropharynx and esophagus. Aspirationand resulting pulmonary toxicity may occur with or withoutcoincident CNS depression and vomiting. Certainly, the in-terventions required for management such as endotracheal in-tubation and extended time on a ventilator are not free ofcomplications. Some authors have suggested that ethanol and/orPG may contribute to the CNS depression.2 The product in thecase described did not contain ethanol, but did contain 10% to15% PG. Propylene glycol is converted to lactate,10 and al-though this was not checked at presentation when the patienthad a metabolic acidosis, it could have contributed to it. Withrespect to the presence of ethoxylated alcohols (a form of non-ionic detergents), animal studies demonstrate systemic absorption

following ingestion and the potential for gastrointestinal irritationand lethargy.11 The degree of ethoxylation may correlate withoral toxicity.11 We have not been able to obtain the specificethoxylated alcohol composition for the product in this case.It may be of significance that in the UK poison centerYbasedstudy, the maximum percentage of nonionic detergents was 20%,whereas in the product ingested by our patient, the product liststhem as 60% to 70%.2 Additional studies are warranted tofurther understand the toxicity of LDPs.

CONCLUSIONSThe case described highlights the potential for significant

toxicity following ingestion of an LDP. Clearly, measuresshould be taken to avoid exposures to young children. Thelargest US LDP manufacturer recently added a safety feature tothe container they are held in.12

REFERENCES

1. Centers for Disease Control and Prevention (CDC). Health hazardsassociated with laundry detergent podsVUnited States, MayYJune2012. MMWR. 2012;61:825Y829.

2. Williams H, Bateman ND, Thomas SH, et al. Exposure to liquiddetergent capsules: a study undertaken by the UK National PoisonsInformation Service. Clin Toxicol. 2012;50:776Y780.

3. Cooper GA, Thompson JP. Ingestion of liquitab contents by aone-year-old child [abstract]. Clin Toxicol. 2006;44:707Y708.

4. Mathieu-Nolf M, Nisse P. Liquid detergent capsules: a new risk[abstract]. Clin Toxicol. 2007;45:386.

5. Wood KL, Thompson JP. LiquitabsVa thorough and comprehensivereview of the UK national data [abstract]. Clin Toxicol. 2009;47:459.

6. Celentano A, Sesana F, Settimi L, et al. Accidental exposures to liquiddetergent capsules [abstract]. Clin Toxicol. 2012;50:353.

7. Horgan N, McLoone E, Lannigan B, et al. Eye injuries in children: anew household risk. Lancet. 2005;366:547Y548.

8. Fayers T, Munneke R, Strouthidis NG. Detergent capsules causingocular injuries in children. J Pediatr Opthalmol Strabismus. 2006;43:250Y251.

9. Forrester MB. Surveillance detection of concentrated laundry detergentpack exposures. Clin Toxicol. 2012;50:847Y850.

10. Huff E. The metabolism of 1,2-propanediol. Biochim Biophys Acta.1960;48:506Y517.

11. HERA.Alcohol Ethoxylates. Human&Environmental Risk Assessmenton ingredients of European household cleaning products. September2009. Available at: http://www.heraproject.com/files/34-F-09%20HERA%20AE%20Report%20Version%202%20-%203%20Sept%2009.pdf.Accessed November 21, 2012.

12. Wohl J. Update2-Tide to change pods lid over child safety concerns.Reuters. May 25, 2012. Available at: http://www.reuters.com/article/2012/05/25/procter-tide-idUSL1E8GP9PI20120525. AccessedNovember 21, 2012.

Schneir et al Pediatric Emergency Care & Volume 29, Number 6, June 2013

742 www.pec-online.com * 2013 Lippincott Williams & Wilkins