Article Text
PDF
Abstract
Objective Previous studies have reported that children are at risk of severe injuries from exposure to laundry detergent pods. For the first time, this study sought to compare demographic and exposure characteristics and risk among children exposed to pod and non-pod laundry detergents presenting to emergency departments (EDs).
Methods Data from the National Electronic Injury Surveillance System (NEISS) from 2012–2014 were used. All observations with injuries involving laundry detergent (NEISS code 0949) were included in this study. The χ2 test was used for bivariate analysis and logistic regression was used to determine the OR and 95% CI of hospitalisation for pod related versus non-pod laundry detergent exposures.
Results From 2012–2014, there were an estimated 26 062 non-pod and 9814 pod laundry detergent related exposures among those aged 18 years and younger. For pod detergent, children aged 0–5 years had the most injuries. Poisoning (71.3%) was the most common diagnosis for pod detergent while contact dermatitis (72.2%) was most common for non-pod detergent. Hospitalisation occurred in 12.5% of pod detergent cases and just 3.0% of non-pod cases. Compared with non-pod detergent, those exposed to pod detergent were 4 times as likely to be hospitalised (OR 4.02; 95% CI 1.96 to 8.24).
Conclusions A greater effort should be made to appropriately educate the public about the dangers of laundry detergents, specifically pods, so a safe home environment can be established. While new regulations such as childproof containers, opaque packaging, and less appealing and colourful pods could reduce the number of pod related ED visits for children, caregivers should store detergents, along with other chemicals, in a secure location where children cannot easily access them.
Statistics from Altmetric.com
Introduction
Liquid laundry detergent pods have become commonplace among consumers due to their convenience in assisting with household tasks. Pods were first marketed in the USA in 2011 after being sold in Europe starting in 2001.1 ,2 Pods contain highly concentrated detergent encapsulated in a water-soluble membrane, and are designed to be used in washing machines.1 ,2 The capsule is made of polyvinyl alcohol, and the detergent varies with a blend of anionic detergents, non-ionic detergents, propylene glycol and ethanol.1 ,2 While these items are popular, the potential hazard associated with the pods was noted when in 2012 the US Consumers Product Safety Commission saw an increase in poisonings among younger children.3 In 2015, a product safety group went as far as not recommending the use of laundry detergent pods in homes with children under 6 years.4
To date, most of the available information regarding pod laundry detergent medical visits is from case reports and case series, many of which involve patients less than 2 years who ingested pods, required intubation and were admitted.2 ,5–7 Of six patients presented in a case report at a children's hospital, two required intubation, four had respiratory issues and all had episodes of emesis.8 Non-ingestion exposures have also occurred and include corneal injuries.9 ,10 Case reports seem to advise that medical situations involving pod detergent are more severe when compared with non-pod detergent.11
Using data from calls made to the UK National Poisons Information Service, two studies published in 2012 and 2014 reported that children under 5 years accounted for approximately 95% of pod cases and that ingestion occurred in approximately 80%; eye contact occurred in 9.4% and 7.4% of cases in each respective study.1 ,12 In 2012, a study using data from US poison centres reported that 48% of laundry detergent related inquiries involved pods. Of pod cases, 94% were 5 years old or less and ingestion accounted for 90% of the exposures.13 Using the National Poison Data System from 2012 to 2013 and cases only involving pod detergent, Valdez et al14 found 17 230 cases of children under 6 years were exposed to laundry detergent pods, the majority of which were ingestion (79.7%) and ocular (7.2%). Of the cases, 4.4% required hospitalisation.
Prior literature examining non-pod and pod detergent related cases, on a national level in the USA, has focused primarily on poison centre data. The purpose of this study is to determine the frequency and severity of pod and non-pod laundry detergent visits to emergency departments (EDs) among youth 18 years and younger in the USA.
Methods
Data source
For this study, the National Electronic Injury Surveillance System (NEISS) database from 2012–2014 was used. NEISS uses a national probability sample of 100 hospitals in the USA under the Consumer Product Safety Commission (CPSC). At participating hospitals, information is recorded for patients presenting at EDs with injuries involving various consumer products. All data are collected by a NEISS trained coordinator at the facility, and entries are reviewed by CPSC staff to confirm entered data match patient narratives.15 ,16
The frequencies produced from this database are estimates based on the statistical weight of the sample. As outlined by NEISS, product code 0949 was used to identify cases of laundry detergent related ED visits.17 Cases were limited to those aged 18 years and less as previous studies noted children as having more frequent exposures compared with adults.1 ,12–14 To determine if an ED visits was related to laundry pod detergent, the narratives for each observation were searched for the following words: pod, pacs, packs, pouch, capsule and ball. The narrative for each case was reviewed to determine if it involved a dissolvable, single use pod. For example the narratives ‘Child was playing with liquid detergent that was in a plastic pouch, squirted in eyes’ and ‘3YO F ingestion detergent, bit into a premade detergent packet at laundromat’ were both excluded because it was unclear if the pouch or packet were water-soluble or were simply a single use package made from plastic or foil. Since the aim of this study was to examine only water-soluble single use pods, cases where narratives were questionable were deemed non-pod detergent related. Of all laundry detergent related ED visits, 365 observations were deemed pod related and the remaining cases, 749 observations, were categorised as non-pod detergent related.
Variable definition
NEISS data were collected on the patient's age, gender, race, incident locale, body part affected and diagnosis. Observations were placed into three age categories: 0–1 year, 2–5 years and 6–18 years. Incident locale was categorised as home and other. ‘Home’ encompassed home, farm/ranch and mobile/manufactured home. Locales listed as ‘Other’ included street/highway, other public property, industrial, school, and place of recreation, or sports. Injuries to the head, face (including eyelid, eye area and nose), mouth (including lips, tongue and teeth), neck, ear, upper trunk, shoulder, lower arm, elbow, wrist, upper arm, hand, finger, knee, lower leg, ankle, upper leg, foot, toe, pubic region, lower trunk, 20–50% of body, not recorded and internal were classified as ‘Other.’ ‘Greater than 50% of body’ included observations with injuries to more than 50% of the body, and ‘Eye’ encompassed injuries sustained to the eyeball. As dictated by NEISS standards, the body region injured category of ‘greater than 50% of body’ must be cited when the case involves an injury diagnosis of poisoning.17
For diagnosis, the three groups included contact dermatitis, poisoning and other. Poisoning, a diagnosis assigned by NEISS personnel to cases, was defined as having either swallowed or inhaled a substance.17 Included under dermatitis were cases with a diagnosis of dermatitis, conjunctivitis or chemical burns. Diagnosis of strain/sprain, laceration, fracture, foreign body, contusions/abrasions, concussion, ingested foreign object or other diagnoses were classified as ‘Other.’ Hospitalisation was defined as the patient being treated and transferred to another hospital, treated and admitted (same facility), held for observation, died in facility, or dead on arrival.
Statistical analysis
For patient demographic and diagnosis characteristics, frequencies using weighted estimates, which follow NEISS guidelines and account for the sampling employed by NEISS, were used with 95% confidence limits based upon the SE of the weighted estimates.15 ,16 A χ2 test was used to compare these characteristics between ED visits due to pod and non-pod laundry detergent. Crude and age-adjusted logistic regression models were used to calculate the odds of hospitalisation among those exposed to pod laundry detergent compared with non-pod laundry detergent.
Results
From 2012 to 2014, there was an estimated total of 26 062 non-pod and 9814 pod laundry detergent related ED visits among adolescents aged 0–18 years in the USA (table 1).
Comparison of non-pod and pod laundry detergent related emergency department (ED) visits, 2012–2014
A higher proportion of cases were aged 0–1 year for pod related exposures compared with non-pod exposures (48.2% vs 32.1%, p<0.001). In all, those aged 5 years and under accounted for 93.8% of all pod laundry detergent exposures compared with 71.8% for non-pod exposures. No significant differences were observed for race, gender or incident locale.
The majority of exposures associated with non-pod detergent were diagnosed as contact dermatitis (72.2%) while 71.3% of pod related exposures were diagnosed as poisoning (p<0.001). Damage to the eyeball occurred more frequently with pod (24.7%) compared with non-pod exposures (15.0%) (p<0.001). Pod detergent related cases were more frequently hospitalised (12.5% of cases) than non-pod detergent related cases (3.0%) (p=0.002); this association remained after adjusting for age (OR 4.02; 95% CI 1.96 to 8.24) (table 2).
Hospitalisations comparing laundry pod to non-pod detergent related injuries 2012–2014
Discussion
The results of the current study suggest that exposures related to laundry detergent pods disproportionately affect children aged 5 years or younger; in addition, the pod related exposures were more likely to result in hospitalisation of the child, a marker of injury severity. In contrast to these results, Valdez et al,14 analysing pod related exposures only, found that ingestion occurred in 79.7% of cases and only 4.4% of pod cases were hospitalised. While informative, the findings of Valdez et al are ambiguous since the total number of exposures for all laundry detergent types was not established, resulting in an inability to compare the risk of non-pod and pod detergent exposures. The importance of the need to compare the two is highlighted by the fact that this study determined there were almost triple the number of ED visits associated with non-pod laundry detergent (26 062) compared with pod detergent (9814). Another study, comparing both detergent types among children under 6 years, found ingestion among those exposed to pod detergent to be higher (85% of cases); however, they similarly established the odds of hospitalisation for those exposed to non-pod detergent was 4.8 times as likely compared with those exposed to non-pod detergent.18
In accordance with results presented, analyses of UK poison centre data observed ingestion to be more common.1 ,12 Of particular interest, the current results indicate that the eyeball was the body part affected in 24.7% of emergency room visits involving pod detergents. This is higher than suggested in previous studies which found only 7.4% and 9.4% of exposures to laundry detergent pods resulted in eye damage.1 ,12 These inconsistencies are likely attributable to differences in data sources, as individuals would likely contact poison centres for advice on minor exposures and only pursue medical care at an emergency room for more severe exposures. This notion is supported by the fact that the total numbers of cases reported are substantially different between the studies, with more poison centre calls than estimated ED visits, suggesting that most exposures to pod detergent likely did not require an emergency room visit.
In accordance with current results, the Centers for Disease Control and Prevention (CDC)13 reported significant differences among age categories comparing frequencies of those exposed to pod and non-pod laundry detergent. It is apparent that pod detergent exposure is most common in children under 5 years as CDC13 observed the same age group accounting for 94% of exposures, the same as currently reported. It is noteworthy that non-pod laundry detergent affected children under 5 years in 81% of cases studied by CDC13 and in 71.8% of cases in this analysis.
The high proportion of adolescents affected by both product types highlights the importance of product safety for both categories, not solely laundry detergent pods; however, results indicate that pod detergent is more likely to require hospitalisation. Although the exact cause of more severe reactions in exposed youth requiring hospitalisation is unknown, many postulate the higher concentration of pod detergent as being a major factor.1 ,11–13 Nevertheless, as suggested in previous studies, the differences in concentrations and chemical composition as they relate to paediatric exposure need to be better studied.14
The results of the current study should be viewed in light of certain strengths and limitations. First, this study is limited by the use of data from EDs; as a result, the reported estimates may be underestimates as individuals who did not require treatment, sought treatment at a different type of facility or who self-treated, are not included. The injury data were additionally limited, with data only on body region and diagnosis; therefore, a marker of injury severity (ie, hospitalisation) was used in analysis, though this may not be an accurate marker of injury severity as the hospitalisations may have simply been for observation rather than due to the severity of the injury. Injuries sustained to the eye, while still severe, are not as likely as poisoning to require hospitalisation; therefore, the odds of hospitalisation as a proxy for injury severity likely underestimate the true odds of a severe injury. Additionally, it is difficult to determine if only homes with younger children are more apt to use pod laundry detergent, and therefore increase the likelihood of exposure.
While it is beyond the scope of this study, it would be pertinent to examine if a decrease in pod detergent related ED visits occurs following market regulation requiring manufactures to produce products less appealing and accessible to children. Examples of such efforts are childproof containers, opaque packaging and removal of dyes.2 ,3 ,13 ,14 ,19–21 Parents should consider warnings issued by consumer safety groups which do not recommend the use of pods in homes with children under 6 years.4 Future study into pod laundry detergent needs to ensure a comparison is made to non-pod laundry detergent in order to ensure that an estimate of risk can be assessed. Furthermore, future study would be improved if the location of the detergent when it was accessed, chemical description of detergent, length of hospital stay, detailed diagnosis and listing of hospital procedures were recorded.
Conclusion
While the innovation of pod laundry detergent makes mundane home tasks easier, their use does require caution and vigilance to safety, especially in homes with young children. While regulation of the product appearance is occurring and could make pod products less enticing to adolescents, ultimately it is the responsibility of caregivers to ensure a child-safe environment. With the number of exposures to cleaning products in the USA remaining high each year—in 2012 alone there were 163 810 exposures to cleaning products reported to poison centres in the USA22—more effort should be made to educate the public about cleaning chemical hazards in homes and promote child safety.
What is already known on the subject?
Prior studies suggest children under the age of 6 years are at risk for injury from laundry detergent pods.
Ingestion is the most frequent exposure followed by eyes.
What this study adds?
For the first time, this study compares emergency department visits of laundry pods to non-detergent pod.
Poisoning (71.3%) was the most frequent diagnosis for laundry detergent pods while contact dermatitis (72.2%) was most common for non-pod laundry detergent.
The odds of hospitalisation were 4.02 (95% CI 1.96 to 8.24) times as likely for those exposed to laundry detergent pods compared with non-pod laundry detergent.
Telangana can improve road safety
Telangana, as the youngest state in India, may have the greatest potential to improve road safety. As Margie Peden (WHO) said, if the Telangana government could focus on law enforcement and reduce the number of accidents, it could become a role model for other states.
Footnotes
Contributors TAS conceived the study topic, performed the initial analysis, drafted the manuscript and approved the final manuscript for submission. GM assisted with development of the topic, reviewed and revised the analysis, edited, and approved the final manuscript for submission. RG assisted in development of the topic and determination of the study population, reviewed the analysis, edited the manuscript and approved the final manuscript for submission.
Competing interests None declared.
Ethics approval Institutional Review Board for Human Use, University of Alabama Birmingham.
Provenance and peer review Not commissioned; externally peer reviewed.