Clinical Toxicology (2014), 52, 220–225 Copyright © 2014 Informa Healthcare USA, Inc. ISSN: 1556-3650 print / 1556-9519 online DOI: 10.3109/15563650.2014.892122
POISON CENTRE
Serious adverse effects from single-use detergent sacs: Report from a U.S. statewide poison control system S. HUNTINGTON,1 J. HEPPNER,2 R. VOHRA,1,2 R. MALLIOS,2 and R. J. GELLER1 1California
Poison Control System, Children’s Hospital Central California, Madera, CA, USA of Emergency Medicine, UCSF Fresno Medical Education Program, Community Regional Medical Center, Fresno, CA, USA Clinical Toxicology Downloaded from informahealthcare.com by Nyu Medical Center on 05/25/15 For personal use only.
2Department
Background. In recent years, serious adverse effects to children from exposure to single-use detergents sacs (SUDS) have been recognized. While most exposures result in minor symptoms, there have been serious outcomes. This study aims to classify which types of serious outcomes follow SUDS exposures, and to assess, if possible, differences in toxicity between various SUDS products. Methods. An observational case series with data collected retrospectively was performed for cases of SUDS exposures reported to a statewide poison system’s records database from 1 January 2012 to 31 March 2013. Cases were identified and analyzed for clinical details and trends. A statewide database was queried for cases involving the American Association of Poison Control Centers (AAPCC) product-specific codes for SUDS products using following search terms: laundry pods, the AAPCC product-specific codes for Tide Pods®, Purex Ultrapacks®, ALL Mighty Pacs®, and a unique agent code (AAPCC ID: 6903138; Generic: 077900) created by AAPCC to track SUDS exposures. Results. A total of 804 cases of exposures to SUDS were identified, the majority of which were exploratory ingestions in young children with a median age of 2 years. Serious adverse effects resulted from 65 (9%) exposures and 27 (3%) exposures resulted in admission to hospital. Binary logistic regression demonstrated that the presence of central nervous system (CNS) or respiratory system effects were associated with more severe outcomes, with a model accuracy of 96.4%. There were significant differences in morbidity among the three most common brand-name products: when compared with Tide Pods®, odds ratios (OR) and 95% confidence intervals (CI) for severe outcome and admission rate were significantly greater following Purex Ultrapack® exposures (severity OR 5.1 [CI: 2.13–12.23]; admission OR 10.36 [CI: 3.23–33.22]) and ALL Mighty Pac® exposures (severity OR 11.22 [CI: 4.78–28.36]; admission OR 15.20 [CI: 5.01–46.12]). Conclusions. Serious complications from exposure to SUDS occur in a small number of exposures for unclear reasons. Respiratory and CNS effects are associated with more severe outcomes. Some brand-name products are associated with a relatively higher risk of severe adverse effects and rates of admission.
have generated multiple media reports.1,2 Growing concern prompted warnings by the American Association of Poison Control Centers (AAPCC), the Centers for Disease Control Morbidity and Mortality Weekly Report, and the US Consumer Product Safety Commission that these exposures may make children very ill.1–3 The AAPCC created a database code on May 17, 2012 for poison control use to allow better tracking of these cases in the National Poison Data System. A complete epidemiology of these exposures in North America is still developing. SUDS have been commercially available in Europe for several years, and studies from poison center records in Europe reflect an increasing trend in calls over this time.4–6 In the US, the clinical experience with these agents has been the subject of case reports and small case series describing mainly pediatric exploratory exposures.7–12 Overall, the published literature suggests that pediatric exposure to SUDS can result in complications involving multiple organ systems, often with severe presentations not usually associated with exploratory exposures from conventional detergent products available in multiuse packaging.13
Introduction In March 2012, the California Poison Control System began to receive calls about exposures to a new type of laundry detergent product, referred to as “liquitabs,” “laundry detergent capsules,” “laundry pods,” or “packets.” These single-use detergent sacs (SUDS) are composed of liquid or granular material surrounded by a polyvinyl membrane that dissolves in water of any temperature (Supplementary Appendix Figure 1 online at http://informahealthcare.com/ doi/abs/10.3109/15563650.2013.892122: SUDS Photo). The most popular commercially available products include Tide Pods®, Purex Ultrapacks®, and All Mighty Pacs®. In addition to raising clinical and parental concerns, the number and severity of exposures to these products in recent months
Received 18 September 2013; accepted 3 February 2014. Address correspondence to Rais Vohra MD, Department of Emergency Medicine, UCSF Fresno Medical Education Program, Community Regional Medical Center, 155 N Fresno St, Fresno, CA 93701, USA. Tel: (559) 499-6440. Fax: (559) 622-2303. E-mail:
[email protected] 220
Single use detergent sac exposures 221 The major objectives of the present study were to determine demographic details, clinical effects, and outcomes of patients exposed to SUDS, to differentiate toxicity between SUDS products, and to characterize risk factors or associations that could help clinicians identify higher risk exposures.
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Materials and methods This was a retrospective study approved by the Institutional Review Board of the UCSF-Fresno Medical Center and the Research Committee of the California Poison Control System. We analyzed calls received to our foursite poison control system with an annual call volume of approximately 300,000 cases serving a population of 38 million persons. The source database was the CPCS electronic database (Visual DotLab©), which was queried from January 1, 2012 to March 31, 2013 for all calls with the following search terms: laundry pods, the AAPCC product-specific codes for Tide Pods®, Purex Ultrapacks®, ALL Mighty Pacs®, and a unique agent code (AAPCC ID: 6903138; Generic: 077900) created by AAPCC to track SUDS exposures. Data abstracted included the following: patient age and gender, location of exposure incident, co-ingestants, brand name and approximate dosage of SUDS involved, route of exposure, whether the caller was a healthcare worker or layperson, whether any referral was made for further evaluation at a healthcare facility (HCF), disposition, observed clinical effects, therapeutic interventions, and severity of outcome. All cases were included unless the following exclusion criteria were met: nonhuman ingestions, informational calls only, non-SUDS exposures, and cases with only demographic
information and no clinical data. Duplicate cases were merged with originals. Relevant demographic and clinical information fields on de-identified patient records were abstracted by two persons who both analyzed 10% of the cases with a mean kappa score of 0.76. Following this step, any inconsistencies in definitions or assignment were resolved by generating a guiding rubric (Table 1: Definitions and Variables). Descriptive analysis was used initially in order to characterize the study population. Data were statistically analyzed with Predictive Analytics Software Statistics v18 (IBM SPSS, Inc., Chicago IL). Binary logistic regression between outcome severity and the remaining data fields was performed to determine which clinical factors or interventions were most associated with moderate to severe outcomes. Further statistical analysis focused on the brand of SUDS product: odds ratios for risk of admission or severe outcome were calculated for each of the top three SUDS brands.
Results The California Poison Control System received 856 calls regarding SUDS exposures between January 1, 2012 and March 31, 2013. A total of 52 cases were excluded based on exclusion criteria, leaving 804 cases for analysis. Monthly totals showed an increase in the number of reported cases over the first half of the study period, followed by a decline and a then a second peak in the last month of the study period (see Fig. 1: Cases by Month). Demographic and clinical factors of included cases are summarized in Table 2. The majority of cases involved oral exposures to SUDS products in the home environment, in
Table 1. Definition of variables used in this study. Variable Outcomes No effect Minor effect Moderate effect Severe effects Clinical effects Airway/Pulmonary Cardiac Gastrointestinal Ocular Dermatologic Metabolic Central nervous system Interventions Observation only Decontamination/Fluids/ Ocular irrigation Referred to Emergency Department Vomiting induced Respiratory intervention Activated charcoal Ocular intervention
Definition No symptoms post exposure Included: emesis, diarrhea, gagging, self-resolving cough Included: persistent cough, respiratory compromise, corneal abrasion Included: respiratory compromise requiring intubation, persistent sedation, corneal ulceration, positive chest x-ray, positive endoscopy or bronchoscopy results Effects on the Respiratory tract (coughing, wheezing, shortness of breath, respiratory compromise) Effect on the cardiovascular system (changes in heart rate/rhythm, changes in blood pressure) Effect on the gastrointestinal tract (nausea, vomiting, gagging, corrosive injury) Effect on the eyes (redness, irritation, blurred vision) Effects on the skin (rash, redness, irritation) Metabolic effects (acidosis, increase anion gap, increased lactate) Effect on the central nervous system (sedation, lethargy, lose or decreased level of consciousness) No treatment executed Flushing of eyes and/or skin and/or administration of oral fluids CPCS recommendation to take a patient exposed to SUDS to healthcare facility Forced vomiting at home by any means (i.e.: finger down the throat, drinking salt water) Treatment to improve pulmonary function (i.e.: nebulizers, oxygen/positive pressure, intubation) Single dose activated charcoal given in HCF Treatments for ocular injury after irrigation (i.e.: antibiotic ointment/drops)
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MONTH Tide Pods®
Purex Ultrapacks®
ALL Mightypacs
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Fig. 1. Case Count and SUDS Type by Month. Exposures were tracked beginning in March 2012. There was a steady increase in calls over the initial 5 months. Tide Pods brand was the most commonly involved product.
children aged 5 years or less, with 576 (72%) exposures in children less than 2 years of age. There were 27 exposures (3%) reported for older children (6–17 years old), and 11 cases (1%) in adults older than 18 years. Three hundred and
eighty-three (48%) patients were male. Three hundred and thirteen (42%) patients were seen in a HCF, and one hundred and eighty-two (23%) calls to the poison control center originated from a HCF.
Fig. 2. Clinical Outcomes by Brand of SUDS. See Table 1 for definitions of Severe, Moderate, and Minor Effects. Percentages are used to allow comparisons; the actual numbers of cases for each brand are shown below each column.
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Table 2. SUDS Exposures Reported to the California Poison Control System March 2012–March 2013 (N ⫽ 804).
Brand Name of SUDSa Tide Pod® Purex Ultra Pac® ALL Mighty Pac® Generic Branda Unknown Brand Amount of SUDS ingested Less than one SUDS One whole SUDS Greater than one SUDS Disposition from Health Care Facility Treated & Released from ED Admitted to Non-Critical Care Admitted to Critical-Care Referred to ED Not seen in ED In ED but lost to follow-up Route of Exposure Ingestion Ocular Ingestion & Ocular Dermal Ingestion & Dermal Ocular & Dermal Ingestion, Ocular & Dermal Clinical Effects (75.9% of cases)b Gastro-IntestinaI Airway/Pulmonary Effects Ocular Central Nervous System Dermatologic Metabolic Cardiac Interventionsc Observation Only Decontaminations/Fluids/Ocular Irrigation Referred to ED Vomiting induced Respiratory Intervention Ocular Intervention Activated Charcoal Outcome No Effect Minor Effect Moderate Effect Severe Effect
N (raw data)
%
616 35 30 7 116
76.60 4.40 3.70 0.90 14.40
461 201 4
69.20 30.20 0.60
265 14 17 64 435 8
33.00 1.70 2.10 8.00 54.20 1.00
678 63 24 8 9 7 13
84.50 7.90 3.00 1.00 1.10 0.90 1.60
424 107 86 59 15 13 3
52.70 13.30 10.70 7.40 1.90 1.60 0.40
183 581 89 12 17 14 2
22.80 72.40 11.10 1.50 2.10 1.80 0.20
185 449 39 24
26.50 64.40 5.60 3.40
aGeneric brands include: Kirkland®, Safeway® and other grocery store brands bPercentage of cases that exhibited listed clinical effects. A single case often had multiple effects. cPercentage of cases that had listed intervention. A single case often had multiple interventions
Although 114 (14%) cases were lost to subsequent follow-up, 628 (91%) of the remaining 690 cases were noted to have minor or no effects as a result of exposure, while 62 (9%) resulted in more severe outcomes. A number of clinical effects were observed, either alone or in combination, in 612 (75.9%) cases (Table 2). Gastrointestinal signs, particularly vomiting, were the most commonly observed effects (424 cases, 53%). The second most common effects involved airway or pulmonary tissues (107 cases, 15%). Ocular effects were seen in 86 (11.9%) exposures, and central nervous Copyright © Informa Healthcare USA, Inc. 2014
system (CNS) effects (e.g. lethargy) were observed in 59 (7.4%) cases. A total of 13 cases (1.9%) were diagnosed with metabolic acidosis. Other details about clinical effects are listed in Table 2. Transcribed descriptions of these effects indicate a rapid onset, within minutes or an hour, for most of these complications following exposure to SUDS products. The most common intervention, done in 581 (72%) cases, was the use of decontamination, which included dermal washing, oral fluid administration, and/or ocular irrigation in exposures affecting the skin, oral mucosal membranes, and eyes, respectively. Two (0.2%) patients received activated charcoal, and 183 (23)% of patients were managed with observation only. Disposition and interventions Overall, 304 cases (38%) were seen in a HCF, of which 265 cases (33%) were treated and released from the emergency department. The poison control center referred 88 cases (11%) into a HCF, typically when a patient was reported to have developed lethargy, persistent coughing, ocular irritation, or gagging/vomiting. Twenty seven patients were admitted, and their clinical details are provided in an online supplementary table (see Supplementary Appendix Table 1 online at http://informahealthcare.com/doi/abs/10.3109/ 15563650.2013.892122: Clinical Details of Admitted Patients). In 628 cases of oral exposure, binary logistic regression was performed, using four types of clinical effects (respiratory/airway, gastrointestinal, CNS, and metabolic) as independent variable and dichotomous clinical outcomes (moderate/severe versus minimal/none) as the dependent variables. The presence of any of these four clinical effects types accurately predicted moderate/severe clinical outcome vs no/minimal outcome in 97.0% of cases. When only respiratory and CNS effects were included as predictor variables, the model’s accuracy was 96.4%, indicating that these were the two most important contributors to outcome severity. Brand comparisons There were significant differences when SUDS brands were compared in terms of total exposure number, outcome severity, and admission rates. Tide Pods® accounted for a majority of exposures (616/804 cases, or 77%), but accounted for a minority of hospital admissions. Among cases evaluated in an emergency department, eleven (5%) exposures involving Tide Pods were admitted (11/202), compared to six (35.5%) for Purex Ultrapacks® (6/17 exposures), eight (44.4%) for ALL Mighty Pacs® (8/18 exposures), and zero (0/3) exposures for generic brand products (see Fig. 2: Clinical Outcomes by Brand). From these brand data, odds ratios for severe outcomes (“severity OR”) and admission rate (“admission OR”) were generated, with 95% confident intervals (CI). These odds ratios confirmed brand differences in risk of severe outcomes and admission. Compared to Tide Pods®, Purex Ultrapacks® showed a severity OR of 5.10 (CI: 2.13–12.23)
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and admission OR of 10.36 (CI: 3.23–33.22). Similarly, compared to Tide Pods, the ALL MightyPacs® product had a severity OR of 11.22 (CI: 4.78–28.36) and admission OR of 15.20 (CI: 5.01–46.12) favoring admission. No significant difference between Purex Ultrapacks® and ALL Mighty Pacs® for either severity (OR 2.20, CI 0.74–6.72) or admission (OR: 1.47, CI: 0.38–5.72) was found. These odds ratios were not changed when age or gender were applied as possible confounders (data not shown).
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Discussion Over the past 18 months in the US and for several years in Europe, SUDS have been the focus of numerous clinical reports, describing exposures with a variety of adverse effects, including CNS depression, respiratory compromise, endotracheal intubation, metabolic acidosis, oropharyngeal mucosal burns, and prolonged hospitalization.1,4–12 During a 3-month period in early summer 2012, AAPCC data indicated that 48% of calls involving laundry detergents were due to SUDS products, which were significantly more likely to have clinical effects when compared to conventional laundry detergent products packaged in multiple use containers.1 Although a clear picture of the range of toxicity from agents is still emerging, there are currently few explanations about why these agents are as variably hazardous as observed, sometimes rapidly resolving in their toxic effects, and in other cases lasting for many days. The water-soluble, poly-vinyl SUDS wrapping is pliable up to a point after which it can burst open through mechanical pressure and distribute contents unpredictably. Ranging in pH from 6.8 to 11, the contents in SUDS products contain highly concentrated mixtures of surfactants, fatty acid esters, ethoxylated alcohols, glycerin, ethanol, propylene glycol, and multiple other chemicals.14–16 A recent investigation of ALL Mighty Pacs showed over 50 different chemical signals on GCMS analysis, but the authors concluded that the toxins causing metabolic acidosis remain elusive.17 The Materials Safety Data Sheet information on these products lists the potential for gastrointestinal effects, local irritation to mucosal/dermal tissues, and (for Purex Ultrapacks) “drowsiness in severe cases”.14–16 The majority of exposures in our study were unintentional exploratory ingestions by toddlers, and most resulted in minor or no effects. Admitted cases were characterized by the presence of one or more clinical effects on CNS, respiratory, GI, and metabolic organ systems. Mental status changes and respiratory symptoms were factors most closely associated with more severe outcomes, suggesting that risk stratification strategies for these products should focus on CNS effects and evidence of respiratory compromise. If these are absent, the presence of severe GI effects or metabolic acidosis could also help identify which cases require prolonged observation and/or inpatient admission. It is not clear why approximately one-third of admitted cases were characterized as having minor effects. Subjectivity in clinical decision-making, incomplete poison center records,
and a changing pattern of knowledge and accumulated clinical experience regarding these products are possible explanations. This trend may also reflect variability in the approach to risk stratification among toxicology experts and emergency clinicians for new or unknown toxins. Notably, all three of the brand name products had at least a few cases of moderate or severe outcomes, underscoring the potential for this entire class of products to cause harm. However, our analysis found significant differences among SUDS product brands with regards to the risk of severe outcomes and the need for admission. Although Tide Pod® exposures were the most numerous in our sample, serious outcomes and higher rates of admission occurred more frequently with ALL Mighty Pacs® or Purex Ultrapacks®. More studies about the toxic mechanisms of these products and the specific chemicals responsible for their adverse effects may help to explain the clinical outcome differences between brands in our patient population. Some SUDS manufacturers have taken steps to mitigate the hazard posed by their products by introducing changes in color and packaging,18 and some retail stores have placed warning labels on product packages or near the store shelves where these items are being displayed in response to increased media and agency bulletins regarding these hazards. It is too early to tell whether these changes in packaging, consumer warning efforts, and increased media scrutiny are affecting the rates of pediatric exposures to these products.
Limitations This study utilized a partly subjective classification to initially distinguish outcome severity, which may have influenced the validity of some findings related to outcome severity. The quality telephone-reported information, missing or unchecked laboratory results and imaging data, and cases loss to follow-up are common limitations of poison control data to which this study is also vulnerable. Another limitation is that diagnostic and therapeutic strategies may have evolved over the study period as public health bulletins, clinical reports, and consumer complaints about these products mounted, thereby skewing the associations between clinical presentations, admission trends, and outcomes. Lastly, this study was not designed to assess whether this subset of patients was comparable in number and severity to those who are harmed by exposure to traditional laundry detergents.
Future directions Further clinical studies are needed to confirm how early symptoms and signs can be used to predict later injurious effects of SUDS. A better understanding of the toxic mechanisms following exposures to these products will hopefully help elucidate any specific antidotes or therapies for complications. Poison center-based data can also be used to track whether recent changes in packaging, in combination with greater consumer awareness, will decrease exposures. Clinical Toxicology vol. 52 no. 3 2014
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Conclusions
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SUDS have the potential to cause gastrointestinal, respiratory, CNS, and metabolic complications, and hospital admission may be required after accidental exposure in a small number of cases. Brand differences are evident but all types of SUDS in our study demonstrated the capacity to cause severe adverse effects. Clinical guidelines which might help medical toxicologists, emergency and pediatric clinicians, and poison control center staff to risk-stratify exposed patients should focus on rapidly observable CNS and respiratory examination findings and basic laboratory tests, which seem to correlate with overall severity rates.
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Declaration of interest
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The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.
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References 1. Centers for Disease Control and Prevention (CDC). Health hazards associated with laundry detergent pods–United States, May–June 2012. MMWR Morb Mortal Wkly Rep 2012; 61:825–829. 2. CPCS Safety Alert. Single-Load Liquid Laundry Packets: Harmful to Children. Available at: HYPERLINK “http://www.cpsc.gov/cpscpub/ pubs/390.pdf. Accessed January 3” http://www.cpsc.gov/cpscpub/ pubs/390.pdf. Accessed January 3, 2013. 3. American Association of Poison Control Centers. Warning About Concentrated Packets of Laundry Detergent. Available at: Accessed January 3” http://www.aapcc.org/alerts/laundry-detergent-packets. Accessed January 3, 2013. 4. Mathieu-Nolf M, Dehuel S, Nisse P. Liquid Detergent Capsules: A New Risk. 2007 International Congress of the European Association of Poison Centres and Clinical Toxicologists. Clin Toxicol 2007; 45:386. 5. Williams H, Bateman DN, Thomas SH, Thompson JP, Scott RA, Vale JA. Exposure to liquid detergent capsules: a study undertaken by the UK National Poisons Information Service. Clin Toxicol (Phila) 2012; 50:776–780 6. Celentano A, Sesana F, Settimi L, Milanesi G, Assisi F, Bissoli M, et al. Accidental exposures to liquid detergent capsules. 2012
Supplementary material available online Supplementary Appendices Figure 1 and Table 1.
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