The Journal of Emergency Medicine, Vol. 47, No. 5, pp. 532–538, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2014.06.034

Selected Topics: Toxicology

REFERRAL OF PEDIATRIC LAUNDRY DETERGENT PACK EXPOSURE REPORTED TO POISON CENTERS Mathias B. Forrester, BS Department of State Health Services, Austin, Texas Reprint Address: Mathias B. Forrester, BS, Epidemiology and Disease Surveillance Unit, Texas Department of State Health Services, 1100 W 49th Street, Austin, TX 78756

, Abstract—Background: Concentrated laundry detergent packs are new products that may be more likely to cause adverse effects and serious medical outcomes among young children than traditional laundry detergent products. Objective: The intent of this study was to examine whether certain factors might be associated with the referral of pediatric laundry detergent pack exposures by poison centers. Methods: Cases were laundry detergent pack exposures involving patients age 5 years or younger reported to Texas poison centers during February 2012 to August 2013. The health care facility referral rate was calculated for selected factors. Results: Of 912 exposures, 720 were managed on site and 192 were referred to a health care facility. The referral rate was 16.1% for patients with not serious outcomes and 71.6% for serious outcomes. The referral rate was 32.0% for patients age younger than 1 year and 14.3% to 22.1% for the older age groups. 31.0% of PurexTM, 25.5% of AllTM, and 19.3% of TideTM product exposures were referred. The referral rate was 33.3% for ocular exposures, 19.4% for dermal contact, and 20.2% for ingestions. The most common clinical effects and their referral rates were vomiting (30.5%), cough or choke (45.1%), ocular irritation (34.6%), red eye (25.4%), nausea (25.4%), drowsiness or lethargy (67.5%), oral irritation (16.7%), and dermal edema (68.4%). Conclusions: Pediatric exposures to laundry detergent packs were more likely to be referred to health care facilities if the laundry detergent pack brand was PurexTM, the exposure was ocular, or particular ocular,

respiratory, dermal, or neurologic clinical effects were present. Ó 2014 Elsevier Inc. , Keywords—laundry detergent; pediatric; poison center; referral

INTRODUCTION In February 2012, multiple manufacturers began selling a new type of laundry detergent product in the United States (1,2). These products consist of small, single-use packs (ie, pods, packets, capsules) that contain concentrated liquid detergent within a water-soluble membrane. Examples include TideTM Pods, PurexTM Ultra Packs, and AllTMMighty Packs (3–6). Because their appearance and size resemble candy or toys, these laundry detergent packs might be attractive to children (5,6). Around May 2012, United States poison centers began to observe potentially serious exposures to laundry detergent packs among young children (1,3,5,6). Symptoms included vomiting, cough or choking, eye irritation or pain, red eyes, drowsiness or lethargy, nausea, respiratory distress, and seizure-like activity (1,3,4,6,7). Through July 2013, > 12,000 pediatric exposures to the products had been reported to poison centers nationally. In August 2013, a 7-monthold child died after eating a laundry detergent packet, although causality had not been confirmed (8). Reports have suggested that these laundry detergent packs may be more likely to cause adverse effects and

The Department of State Health Services institutional review board considers this analysis exempt from ethical review.

RECEIVED: 17 November 2013; FINAL SUBMISSION RECEIVED: 15 March 2014; ACCEPTED: 30 June 2014 532

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serious medical outcomes than traditional laundry detergent formulations (1,5,6). Possible reasons for this include differences in ingredients, concentration, or delivery mechanism (1). The packets have been reported to contain highly concentrated chemicals, such as ethanolamine, alcohol ethoxylate, and benzenesulfonic acid (8). In addition, one study found that exposures to laundry detergent packs were more likely than traditional laundry formulations to be referred to health care facilities by Texas poison centers (7). Poison center and other health care provider guidelines for deciding whether to refer patients to health care facilities that were created for traditional laundry detergent exposures might not be as useful for laundry detergent pack exposures. In a survey of 12 US poison centers, 5 possessed formal laundry detergent pack triage guidelines (9). The intent of the present investigation was to examine whether certain demographic or clinical factors might be associated with the referral of pediatric laundry detergent pack exposures by a large poison center system. Because the known or anticipated outcomes of an exposure might be expected to affect whether a patient is referred to a health care facility, the same factors were examined with respect to medical outcomes. It is hoped that such information might prove useful in designing referral guidelines for these exposures. METHODS The Texas Poison Center Network (TPCN) is a system composed of six poison centers that together service the entire state, a total population currently > 25 million, > 3 million of which are children 5 years old or younger. The TPCN is a telephone consultation service that provides information on and assists in the management of potentially adverse exposures to a variety of substances, including laundry detergents. The six poison centers use a single computer database to collect a variety of demographic and clinical information on each call in a consistent manner. The data fields and allowable data options in the database are standardized by the American Association of Poison Control Centers (AAPCC) (10). Cases for this retrospective study were laundry detergent pack exposures involving patients age 5 years or younger reported to the TPCN during February 2012 to August 2013. Details for how laundry detergent pack exposures were identified are provided elsewhere (11). No laundry detergent pack exposures were reported to the TPCN before February 2012. Calls received from outside of Texas were excluded. Exposures involving other substances in addition to the laundry detergent pack (n = 1) were included. The management site field in the TPCN database includes codes for the following options: managed on site (non–health care facility), patient already in (en route

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to) health care facility when poison center called, patient was referred by poison center to a health care facility, other, and known. This investigation was limited to the exposures where the management site was managed on site (non–health care facility) and patient was referred by poison center to a health care facility because these are the options where the poison center could influence whether the patient was referred to a health care facility or not. According to the AAPCC reference manual, the medical outcomes or severity of an exposure are assigned by the poison center staff and are based on all of the information available when the case is closed, primarily the observed adverse clinical effects (10). Medical outcomes are classified according to the following criteria: no effect (no symptoms due to exposure), minor effect (some minimally troublesome symptoms, eg, mild gastrointestinal symptoms, drowsiness, skin irritation, transient cough), moderate effect (more pronounced, prolonged symptoms, eg, corneal abrasion, high fever, disorientation, isolated brief seizures, gastrointestinal symptoms causing dehydration), major effect (symptoms that are life-threatening or cause significant disability or disfigurement, eg, repeated seizures, ventricular tachycardia with hypotension, cardiac arrest, respiratory arrest, ventricular fibrillation, esophageal stricture, cerebrovascular accident), and death. A portion of exposures are not followed to a final medical outcome because of resource constraints or the inability to obtain subsequent information on the patient. In these instances, the poison center staff record the expected outcome of the exposure. These expected outcomes are grouped into the following categories: not followed but judged as nontoxic exposure (symptoms not expected), not followed but minimal symptoms possible (no more than minor symptoms possible), and unable to follow but judged as a potentially toxic exposure. Another medical outcomes category is unrelated effect, where the exposure was probably not responsible for the symptoms. Those exposures not followed to a final medical outcome were included in this study because they accounted for almost 37% of the total exposures; excluding these exposures might bias the analysis. Preliminary analysis suggested that exclusion of these exposures would not seriously affect the results of the analysis; however, the referral rate for cases followed to a final medical outcome was 27.1%, and the referral rate for cases not followed to a final medical outcome was 10.9%. In addition, a final medical outcome is not necessarily known when poison center staff are deciding whether to refer a patient to a health care facility. For convenience, the medical outcomes were grouped into those known or expected to not be serious (no effect, minor effect, not followed and judged nontoxic, not followed and judged minimal

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effects) and those known or expected to be serious (moderate effect, major effect, unable to follow and potentially toxic). There were no deaths. Exposures where the medical outcome was considered unrelated effect were not included in either category. Other variables included in this analysis were time period of exposure, patient sex and age, most common brand of laundry detergent pack, most common route of exposure, and most frequently reported adverse clinical effects. For analysis of time period, the 19 months were grouped into three roughly equal time periods: February 2012 to August 2012 (7 months), September 2012 to February 2013 (6 months), and March 2013 to August 2013 (6 months). A given exposure might involve multiple routes. For this investigation, such an exposure would be included in each route subgroup. Information on clinical effects is documented in the electronic records in a set of check boxes for specific clinical effects, as well as in a text notes (narrative) field. Because such information is not consistently recorded in the notes field, the analyses of clinical effects was restricted to information recorded in the check boxes. The specific clinical effects examined in this study, along with the AAPCC reference manual explanations or definitions for the clinical effects, are as follows: vomiting (the reflex action of ejecting the contents of the stomach through the mouth), cough/choke (a form of violent exhalation by which irritant particles in the airways can be expelled; interruption of respiration by obstruction; includes ‘‘gagging’’), ocular irritation/pain (any degree of eye irritation, pain or stinging), red eye/conjunctivitis (redness or inflammation of the mucous membrane covering the anterior portion of the eyeball and the lining of the eyelids), nausea (the feeling that one is about to vomit), drowsiness/lethargy (fatigue or sleep or minor levels of central nervous system depression from which the patient can be awakened with a stimulus), oral irritation (undue sensitivity in the oral cavity, usually characterized by redness or swelling), dermal edema (the presence of abnormally large amounts of fluid in the intercellular tissue spaces; includes diffuse or localized swelling) (10). The serious outcomes rate and health care facility referral rate were determined for each subgroup within a variable and comparisons made between the subgroups. Differences in the rates between subgroups within a variable were analyzed for statistical significance by calculating the rate ratio (RR; ratio of the rate for a particular subgroup to the rate for a reference subgroup, the subgroup with the largest number of cases) and 95% confidence interval (CI) by the Newcombe-Wilson method without continuity correction. The RRs were considered statistically significant if the 95% CI excluded 1.00. The p values were not calculated.

M. B. Forrester

The Texas Department of State Health Services Institutional Review Board considers this analysis exempt from ethical review. RESULTS There were 1280 total pediatric exposures to laundry detergent packs reported to the TPCN during February 2012 to August 2013 from inside Texas. Of these, 358 (28.0%) of the patients were already in (en route to) a health care facility when the poison center called, 7 (0.5%) had other management site coded, and 3 (0.2%) were at an unknown management site. Of the remaining 912 exposures that met the study criteria, 720 (78.9%) were managed on site and 192 (21.1%) were referred to a health care facility by the poison center. Of the 827 exposures with not serious outcomes, 133 (16.1%) were referred to a health care facility. Of the 81 exposures with serious outcomes, 58 (71.6%) were referred to a health care facility (RR = 4.45; 95% CI 3.62–5.48). Table 1 presents the serious outcomes rate for various factors. The rate declined slightly during the three time periods, although this change was not statistically significant. The serious outcomes rate among females was slightly more than half that for males, a difference that was statistically significant. The serious outcomes rate varied among the different age groups, but there was no clear pattern and none of the differences were statistically significant. The rates were greater for AllTM and PurexTM products than for TideTM products. The rate was substantially higher for ocular exposures than for ingestions; there was no significant difference in the rates between ingestions and dermal contact. The serious outcomes rates for the three most common gastrointestinal effects (ie, vomiting, nausea, and oral irritation) were similar, and the rates for all of the most frequently reported ocular, respiratory, dermal, and neurologic effects were higher than the rates for the gastrointestinal effects. Table 2 shows the health care facility referral rates for selected variables. The referral rate decreased somewhat during the three time periods, but this change was not statistically significant. The rate was similar for males and females. The referral rate was highest for patients aged 1 year or younger and lowest for patients age 4 to 5 years. Compared with the referral rate for TideTM products, the rates for AllTM and PurexTM products were 32% and 61% higher, although this difference was only statistically significant for PurexTM products. The rate for ocular exposures was substantially higher than for ingestions; ingestions and dermal contact had similar referral rates. The referral rates for the most frequently reported gastrointestinal effects were similar and lower than the rates for most of the common effects involving other organ systems.

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Table 1. Serious Outcomes Rate for Pediatric* Exposures to Concentrated Laundry Detergent Packs Reported to the Texas Poison Center Network During February 2012 to August 2013 Variable

Total, n

Serious† Outcomes, n

Serious† Outcomes Rate, %

Rate Ratio‡

95% CI§

252 291 365

23 26 32

9.1 8.9 8.8

1.04 1.02 Reference

0.62–1.74 0.62–1.67

482 423

53 26

11.0 6.1

Reference 0.56

75 269 319 154 63 24

7 22 31 11 5 2

9.3 8.2 9.7 7.1 7.9 8.3

0.96 0.84 Reference 0.74 0.82 0.86

711 110 57

56 13 7

7.9 11.8 12.3

Reference 1.50 1.56

0.85–2.65 0.75–3.26

839 96 93

69 15 7

8.2 15.6 7.5

Reference 1.90 0.92

1.13–3.19 0.43–1.93

405 81 78 63 59 40 36 19

40 14 14 10 6 7 3 5

9.9 17.3 17.9 15.9 10.2 17.5 8.3 26.3

Reference 1.75 1.82 1.61 1.03 1.77 0.84 2.66

1.00–3.06 1.04–3.18 0.85–3.05 0.46–2.32 0.85–3.69 0.27–2.59 1.19–5.98

Time period February 2012 to August 2012 September 2012 to February 2013 March 2013 to August 2013 Patient sex Male Female Patient age, y Younger than 1 1 2 3 4 5 Product brand TideTM AllTM PurexTM Exposure routejj Ingestion Ocular Dermal Common clinical effects Vomiting Cough/choke Ocular irritation/pain Red eye/conjunctivitis Nausea Drowsiness/lethargy Oral irritation Dermal edema

0.36–0.88 0.44–2.10 0.50–1.42 0.38–1.42 0.33–2.02 0.22–3.37

CI = confidence interval. * Pediatric is considered age 5 years or younger. † Serious = moderate effect, major effect, unable to follow-potentially toxic. ‡ Ratio of current subgroup serious outcomes rate to reference subgroup serious outcomes rate. § If 95% CI does not include 1.00, then rate ratio is statistically significant. jj A given exposure might occur by more than one route and would be counted in all appropriate route categories.

DISCUSSION This study found that certain demographic and clinical factors appeared to be associated with referral or medical outcome of laundry detergent pack exposures reported to a large poison center system. This information might prove useful for devising referral guidelines for pediatric laundry detergent pack exposures. However, it must be emphasized that health care providers should use their best judgment when deciding whether to refer a particular child who has been exposed to a laundry detergent pack to a health care facility. When medical outcomes alone were examined, patients with serious outcomes were significantly more likely to be referred to health care facilities. This would be expected because poison center staff would be likely to believe that patients with more serious outcomes needed to be managed at health care facilities. However, it might be that, in some cases, if poison center staff referred a patient to a health care facility they might be

more likely to classify the medical outcomes as serious. One sixth of the patients with not serious outcomes were also referred to health care facilities by the poison centers. Of the 81 cases with serious outcomes, 28% of these were not referred to a health care facility but were managed on site. The serious cases that were managed on site and referred to a health care facility were similar in that the majority of the patients were male (56.5% vs. 69.0%) and aged 2 to 3 years (52.2% vs. 54.5%), most involved TideTM (73.9% vs. 67.2%), and involved ingestion of the product (78.3% vs. 87.9%). However, the serious cases managed on site had lower rates of vomiting (30.4% vs. 56.9%) and cough/choke (8.7% vs. 20.7%), but higher rates of ocular irritation (21.7% vs. 15.5%) and red eye (17.4% vs. 10.3%). Whether or not a particular serious exposure was referred to a health care facility might depend on the particular clinical effects that were observed. Alternately, it might be that the decision whether or not to refer a cases classified as serious was due to other factors not included in this investigation.

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M. B. Forrester

Table 2. Health Care Facility Referral Rate for Pediatric* Exposures to Concentrated Laundry Detergent Packs Reported to the Texas Poison Center Network during February 2012 to August 2013 Variable Time period February 2012 to August 2012 September 2012 to February 2013 March 2013 to August 2013 Patient sex Male Female Patient age, y Younger than 1 1 2 3 4 5 Product brand TideTM AllTM PurexTM Exposure route§ Ingestion Ocular Dermal Common clinical effects Vomiting Cough/choke Ocular irritation/pain Red eye/conjunctivitis Nausea Drowsiness/lethargy Oral irritation Dermal edema

Total, n

Referral, n

Referral Rate, %

Rate Ratio†

95% CI‡

252 293 367

59 60 73

23.4 20.5 19.9

1.18 1.03 Reference

0.87–1.59 0.76–1.40

485 424

106 85

21.9 20.0

Reference 0.92

75 272 320 154 63 24

24 60 60 31 9 4

32.0 22.1 18.8 20.1 14.3 16.7

1.71 1.18 Reference 1.07 0.76 0.89

714 110 58

138 28 18

19.3 25.5 31.0

Reference 1.32 1.61

0.93–1.87 1.06–2.42

843 96 93

170 32 18

20.2 33.3 19.4

Reference 1.65 0.96

1.21–2.26 0.62–1.48

407 82 78 63 59 40 36 19

124 37 27 16 15 27 6 13

30.5 45.1 34.6 25.4 25.4 67.5 16.7 68.4

Reference 1.48 1.14 0.83 0.83 2.22 0.55 2.25

1.12–1.96 0.81–1.59 0.53–1.30 0.53–1.32 1.71–2.87 0.26–1.15 1.60–3.15

0.71–1.18 1.14–2.55 0.85–1.62 0.73–1.58 0.40–1.45 0.35–2.24

CI = confidence interval. * Pediatric is considered age 5 years or younger. † Ratio of current subgroup referral rate to reference subgroup referral rate. ‡ If 95% CI does not include 1.00, then rate ratio is statistically significant. § A given exposure might occur by more than one route and would be counted in all appropriate route categories.

This correlation between serious outcomes and health care facility referral tended to persist when specific demographic and clinical factors were examined, although there were some exceptions. Both serious outcomes and referral rates declined slightly during the time period included in the investigation. United States poison centers first became aware of the potential for serious outcomes with pediatric laundry detergent pack exposures in early 2012. As a consequence, poison center staff might have been cautious when managing laundry detergent pack exposures at the beginning, resulting in a higher proportion of the exposures to be considered as potentially serious and referring the patients to health care facilities. As time progressed and poison center staff became more familiar with laundry detergent pack exposures, they may have been less likely to consider them serious and in need of referral. Alternately, as the media and poison centers informed the public about the potential hazards of pediatric exposures to laundry detergent packs, the public might have been more likely to have re-

ported exposures to the poison centers. Heightened public concerns might result in a higher proportion of the reported exposures not being serious and, therefore, less likely to be referred to health care facilities. The number of laundry detergent pack exposures reported to Texas poison centers did increase during the study period. Although there was no clear pattern of serious outcomes rate and patient age, the referral rate was highest for patients aged 1 year or younger and lowest for patients age 4 to 5 years. It might be that, due to the patients’ young age, the poison center staff decided to be cautious and refer patients aged 1 year or younger to a health care facility even if no serious outcomes were expected. In addition, by this reasoning, the referral rate might be expected to decrease with increasing age, which was observed. Although the serious outcomes rate was significantly higher for males than for females, males were only slightly more likely to be referred to a health care facility. There is no clear explanation for this

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apparent contradiction. One possibility would be differences in sex distribution by patient age. The proportion of patients that were male was 42.7% for patients age younger than 1 year, 54.8% for age 1 year, 57.8% for age 2 years, 48.1% for age 3 years, 50.8% for 4 years, and 41.7% for 5 years. There was no obvious correlation between sex distribution for a particular age and serious outcomes rate. Exposures involving PurexTM products were more likely than exposures to TideTM and AllTM products to result in serious outcomes and to be referred to health care facilities. An analysis of laundry detergent pack exposures reported to California poison centers observed serious adverse effects in 8% of TideTM, 25% of PurexTM, and 42% of AllTM product exposures (12). The differences in serious outcomes rates might be due to differences in ingredients or concentrations between the different brands. Both serious outcomes and referral rates were higher for ocular exposures than for ingestions. The rates for dermal contact were slightly lower than for ingestions. In addition, the serious outcomes and referral rates for the more frequently reported gastrointestinal effects tended to be lower than the rates for the most common ocular, respiratory, dermal, and neurologic effects. It should be kept in mind that the adverse clinical effects are used by the poison center staff to assign medical outcomes. The presence of particular clinical effects might be instrumental when deciding whether to refer a patient to a health care facility. Limitations This investigation is subject to various limitations. The reporting of potentially adverse laundry detergent pack exposures to Texas poison centers is not mandatory. Therefore, those exposures that are reported might not represent all such exposures in the state. In addition, a pediatric exposure might be based solely on reports by the patient’s family or other caregivers and might have been ascribed solely on finding the child with an open laundry container. As a result, a portion of the cases might not have been actual exposures. This study was based on data from a single poison center system, albeit one that serves a population of 25 million. It would be useful if similar investigations were performed by other poison centers and health care providers. The criteria for assigning medical outcomes is somewhat subjective. In addition, there might exist differences among Texas poison center staff on what medical outcomes they would assign a particular exposure. In addition, this study only examined whether or not the patient was referred and not the particular treatments

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that were recommended or performed on site or at the health care facility. Importantly, it should be pointed out that factors other than those examined might need to be taken into consideration when deciding whether to refer a patient to a health care facility. For example, if the family situation is of concern, then the patient might be referred to a health care facility even if a serious outcomes is not otherwise expected. It might not be possible to examine factors such as this using poison center data. CONCLUSION In conclusion, this study found that pediatric exposures to laundry detergent packs are more likely to result in serious outcomes or be referred to health care facilities if the laundry detergent pack brand was PurexTM, the exposure involved the eye, or particular clinical effects were present. Such factors might be considered when creating triage referral guidelines for pediatric laundry detergent pack exposures. Still, as with all guidelines, each case is unique and should be managed on an individual basis.

REFERENCES 1. Centers for Disease Control and Prevention. Health hazards associated with laundry detergent pods—United States, May–June 2012. MMWR Morb Mortal Wkly Rep 2012;61:825–9. 2. Scharman EJ. Liquid ‘‘laundry pods’’: a missed global toxicosurveillance opportunity. Clin Toxicol (Phila) 2012;50:725–6. 3. American Association of Poison Control Centers. AAPCC and poison centers issue warning about concentrated packets of laundry detergent. American Association of Poison Control Centers, Alexandria, Virginia, May 17, 2012. Available at: http://www.aapcc. org/dnn/Portals/0/Laundry%20Detergent%20Packs%205.17.2012. pdf. Accessed May 20, 2012. 4. Florida Poison Information Center—Tampa. Tox alert. Tampa, FL: Florida Poison Information Center–Tampa; 2012. 5. Merchant N. More kids eating detergent packs, docs report. Msnbc.com. May 24, 2012. Available at: http://www.msnbc.msn.com/id/47557814/ ns/health-childrens_health/. Accessed May 25, 2012. 6. O’Connor A. New detergent pods pose poisoning risk. The New York Times, June 27, 2012. Available at: http://well.blogs. nytimes.com/2012/06/27/new-detergent-pods-pose-poisoning-risk/. Accessed July 10, 2012. 7. Forrester MB. Comparison of pediatric exposures to concentrated ‘‘pack’’ and traditional laundry detergents. Pediatr Emerg Care 2013;29:482–6. 8. Wang Y. Hidden danger in your laundry? Houston Chronicle, September 9, 2013;112(331):A1, A11. 9. Colvin J, Rylander L, Behrman A, Yin S, Vasunia K. Triage guidelines and referral patterns associated with single-use laundry detergent packs. Clin Toxicol (Phila) 2013;51:605–6. 10. American Association of Poison Control Centers National Poison Data System (NPDS)Óreference manual part 2–system information manual. Alexandria, VA: American Association of Poison Control Centers; 2007. 11. Forrester MB. Surveillance detection of concentrated laundry detergent pack exposures. Clin Toxicol (Phila) 2012;50:847–50. 12. Heppner J, Huntington S, Vohra R, Geller RJ. Serious adverse effects from single use detergent sacs: report from a statewide poison system. Clin Toxicol (Phila) 2013;51:604.

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M. B. Forrester

ARTICLE SUMMARY 1. Why is this topic important? Healthcare provider guidelines for deciding whether to refer patients to healthcare facilities that were created for traditional laundry detergent exposures might not be as useful for laundry detergent pack exposures, which may have more serious outcomes. This study provides information that may be useful in crafting guidelines for laundry detergent packs. 2. What does this study attempt to show? This study examines whether certain demographic or clinical factors might be associated with the referral of pediatric laundry detergent pack exposures by poison centers. 3. What are the key findings? This study found that pediatric exposures to laundry detergent packs are more likely to result in serious outcomes and/or be referred to healthcare facilities if the laundry detergent pack brand was PurexTM, the exposure involved the eye, or particular clinical effects were present. 4. How is patient care impacted? The results of this study may assist healthcare providers when deciding whether to refer a patient who has been exposed to a laundry detergent pack to a healthcare facility.

Referral of pediatric laundry detergent pack exposure reported to poison centers.

Concentrated laundry detergent packs are new products that may be more likely to cause adverse effects and serious medical outcomes among young childr...
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