TOXCard: Laundry Detergent Pods (LDPs)

Author: Stephanie T. Weiss, MD, PhD, (Medical Toxicology Fellow, Assistant Instructor of EM, UTSW / Parkland Memorial Hospital), James Dazhe Cao, MD (@JamesCaoMD, Assistant Professor of EM, Assistant Medical Toxicology Fellowship Director, UTSW / Parkland Memorial Hospital) // Edited by: Cynthia Santos, MD (Assistant Professor, Emergency Medicine, Medical Toxicology, Rutgers NJMS), Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital), and Brit Long, MD (@long_brit)

Case

An 18-month-old male presents to the emergency department (ED) after biting into a laundry detergent pod (LDP).  His mom had left the container of pods on top of her washing machine when she was temporarily called out of the room to answer the telephone; she came back into the room to find the patient vomiting and “foaming at the mouth.”  After arrival to the ED, the patient subsequently became more obtunded and began to have difficulty breathing, requiring intubation and admission to the pediatric intensive care unit.

Questions

• What effects can laundry detergent pods cause when ingested or sprayed into the eyes or on the skin?
• Are LDPs uniquely dangerous compared with other types of detergents?

Background

• Laundry detergent pods (LDPs) are small, single-use packets containing concentrated detergent enclosed within a water-soluble polyvinyl alcohol membrane.¹ Specific components include ethoxylated alcohols, propylene glycol, and linear alkylbenzene sulfonates.^2,3
• Exposure to LDPs may result in more severe symptoms than exposure to other types of laundry detergents or to non-laundry cleaning pods such as dishwasher detergent pods.^1,2,4-9
• Despite the recent publicity blitz by the United States media and the American Association of Poison Control Centers warning medical providers and the public about the “Tide Pod Challenge” involving teenagers deliberately biting into LDPs,¹⁰ the vast majority of LDP exposures are accidental exploratory ingestions that involve toddlers.^{4,5,7,8,11-17}

Presentation:

• LDPs cause severe central nervous system (CNS) and respiratory effects as well as gastrointestinal (GI) symptoms.^1,4-8
• The most common symptoms seen after LDP ingestion or eye exposures in several retrospective poison control center studies done in multiple US states and other countries include vomiting, coughing or choking, ocular irritation or conjunctivitis, and drowsiness or lethargy.^{3,4,7,8,12-16,19,20}
• Some case reports, case series, and Poison Control Center data also report incidents of dermal rash, dermal burns, and lactic acidosis.^{3,7,8,12-14,16-18,20}
• Other rarer but severe clinical effects of LDP ingestion or ocular exposure include coma, seizures, corneal abrasions or burns, hematemesis, pulmonary edema, respiratory arrest, and gastric burns.^{1,3,5,7-9,12,13,15-17,19-23}
• Most LDPs on the US market are not strongly alkaline in pH, and injuries after LDP ingestion rarely result in caustic GI tract burns.^2,3,9,15,23
• While various theories and LDP ingredients have been proposed to explain the cause of CNS depression and respiratory depression in some patients who have ingested LDPs, the mechanism behind these severe symptoms is not well understood.^1,2,13,15,16 However, CNS or respiratory depression is unlikely to be simply due to ingestion of alcohols such as 1,4-butanediol or propylene glycol, although propylene glycol may be the cause of lactic acidosis.^1,3,9,16,17  Given the near-neutral pH of most LDPs, caustic-like ocular or dermal injuries are more likely due to the surfactant components of LDPs.^1,3,13,16,21

Management:

• Treatment for LDP ingestion or ocular exposure is primarily supportive:
  • Adequate decontamination of children with dermal or ocular exposures should be performed in order to limit the chemical injury that can occur with prolonged exposure.^18,21
  • For ocular exposures, the provider should check ocular pH and perform a fluorescein examination to check for corneal epithelial defects.
  • Laboratory evaluation should be guided by clinical presentation and may include a basic metabolic panel, venous blood gas, or lactate as clinically indicated.
  • Monitor symptomatic children for respiratory depression and secure the airway with endotracheal intubation if necessary. Published case reports and case series suggest that GI symptoms tend to occur quickly, within 15-30 minutes of ingestion, while respiratory or CNS depression may be delayed for up to 1-2 hours after ingestion.^1,4,16,17,22  Symptomatic children should be observed for 4-6 hours to ensure that CNS and respiratory symptoms are not progressing.  Overnight observation for children who present in the evening is recommended to ensure that they are adequately monitored while sleeping.
  • For LDP ingestions with stridor or a combination of pain, vomiting, and/or drooling, the provider should consult the GI service for potential endoscopy within 24 hours to assess for esophageal burns.^9,23,24
  • Discussion with the Poison Control Center is recommended.
• Emergency providers and Poison Control Center specialists should educate caretakers about keeping all detergent pods out of the reach of young children or elderly adults, as well as warning adolescents about the dangers of taking the “Tide Pod Challenge.”

Key Points:

• Respiratory depression may be the most life-threatening effect of LDP ingestions, and its timing is often delayed compared to the onset of GI symptoms.
• Ocular and dermal exposures require adequate decontamination.
• Gastroesophageal burns are rare but should be considered in symptomatic patients.
• Caretakers of young children should be educated to store LDPs in opaque, secure containers that are placed “up and away” out of the child’s reach.

References/Further Reading:

1. Beuhler MC, et al (2013) “Laundry Detergent “Pod” Ingestions.” Pediatric Emergency Care, 29(6): 743-747
2. Dye LR, Murphy C, Calello DP, Levine MD, Skolnik A, eds. “Laundry Pod Ingestion in an Adult.” Case Studies in Medical Toxicology. Springer International Publishing; 2017. doi:1007/978-3-319-56449-4, pp. 1-8.
3. Yin, S. et al (2015) “Laundry Pack Exposures in Children 0-5 Years Evaluated at a Single Pediatric Institution.” Journal of Emergency Medicine, 48(5): 566-572.
4. Centers for Disease Control and Prevention. (2012) “Health Hazards Associated with Laundry Detergent Pods.”  MMWR, 61(41): 825-829
5. Forester, M.B. (2013) “Comparison of Pediatric Exposures to Concentrated “Pack” and Traditional Laundry Detergents.” Pediatric Emergency Care, 29(4): 482-486.
6. Swain, T.A. et al (2016) “Laundry pod and non-pod detergent related emergency department visits occurring in children in the USA.” Prev. 22: 396-399.
7. Davis, M. G. et al (2016) “Pediatric Exposures to Laundry and Dishwasher Detergents in the United States.” Pediatrics, 137(5): 1-10.
8. Settimi, L. et al (2018) “Surveillance of paediatric exposures to liquid laundry detergent pods in Italy.” Injury Prevention, 24: 5-11.
9. Smith, E. et al (2014) “Laundry Detergent Pod Ingestions: Is There a Need for Endoscopy?” Med Toxicology, 10: 286-291.
10. AAPCC Alerts: “Intentional Exposures among Teens to Single-Load Laundry Packets.” http://www.aapcc.org/alerts/intentional-exposures-among-teens-single-load-laun/ Accessed March 15, 2018.
11. AAPCC Alerts: “Laundry Detergent Packets and Children.” http://www.aapcc.org/alerts/laundry-detergent-packets/ Accessed March 15, 2018.
12. Valdez et al (2014) “Pediatric Exposure to Laundry Detergent Pods,” Pediatrics; 134(6): 1-9.
13. Williams, H. et al (2014) “Reported toxicity in 1486 liquid detergent capsule exposures to the UK national Poisons Information Service 2009-2012, including their ophthalmic and CNS effects.” Clinical Toxicology, 52: 136-140.
14. Huntington, S et al (2014) “Serious adverse effects from single-use detergent sacs.” Clinical Toxicology, 52: 220-225.
15. Stromberg, P.E. et al (2015) “Airway compromise in children exposed to single-use laundry detergent pods.” American Journal of Emergency Medicine, 33: 349-351.
16. Schneir, A.B. et al (2013) “Toxicity Following Laundry Detergent Pod Ingestion.” Pediatric Emergency Care, 29(6): 741-742.
17. Lim, R. et al (2013) “Laundry Detergent Pod Ingestion.” Pediatric Emergency Care, 29(9): 1053.
18. Russell, J.L. et al (2014) Significant Chemical Burns Associated with Dermal Exposure to Laundry Pod Detergent.” Medical Toxicology, 10(3): 292-294.
19. Gray, M.E. and West, C.E. (2014) “Corneal injuries from liquid detergent pods.” Journal of AAPOS, 18(5): 494-495.
20. Fontane, E. (2015) “Ingestion of Concentrated Laundry Detergent Pods.” Journal of Emergency Medicine, 49(1): e37-e38.
21. Whitney, R.E. et al (2015) “Diffuse Corneal Abrasion after Ocular Exposure to Laundry Detergent Pod.” Pediatric Emergency Care, 31(2): 127-128.
22. Kamit-Can, F. et al (2016) “The need for mechanical ventilation in a child exposed to a laundry detergent pod.” Turkish Journal of Pediatrics, 58: 323-326.
23. Sjogren, P. P. et al (2017) “Upper Aerodigestive Injuries from Detergent Ingestion in Children.” The Laryngoscope, 127: 509-512.
24. Crain, E.F. et al (1984) “Caustic Ingestions.” AJDC; 138: 863-865.