Abstract
Purpose Detergent pod-related aerodigestive/ocular chemical burns/ingestion poisoning injuries are a group of injuries of concern to parents/guardians of young children as well as oral healthcare professionals. Each year detergent pod injuries result in thousands of emergency department (ED) visits and significant oral, eye, airway, and digestive trauma. The purpose of this study was to investigate trends in detergent pod injuries resulting in ED visits in children ages >0 to <18 years from 2016-2020.
Methods This cross-sectional study used data collected from the National Electronic Injury Surveillance System (NEISS). A secondary data analysis was performed on the NEISS data from 2016-2020 for children ages >0 to <18 years. Injuries were identified as detergent pod-related oral-aerodigestive/ingestion poisonings, detergent pod-related ocular injuries, or other product-related injuries among children. Time trends and demographic characteristics were analysed by age, sex, and race.
Results There were an estimated 13,176 detergent pod-related oral-aerodigestive injuries/ingestion poisonings and 8,654 detergent pod-related ocular injuries with ED visits during 2016 - 2020. In adjusted logistic regression, white children were more likely to have oral-aerodigestive injuries/ingestion poisonings than black children (p=0.0006). Time trend (p=0.4358), and sex (p=0.3905) failed to reach significance. Children, ages 5 to<18 years, were less likely to have ED visits for oral-aerodigestive injuries/ingestion poisonings, or any detergent pod-related injury than younger children. Children, ages 3 to ≤5 years, were more likely to have detergent pod-related ocular injuries than younger or older children.
Conclusion Time trends for detergent-pod related injuries requiring ED visits remained unchanged from 2016-2020 for oral-aerodigestive injuries/ingestion poisonings. Given the significant health risks associated with detergent pods and the fact that the injuries have not declined, there is a need for improved parent/guardian education and practices in safeguarding detergent pods from children. Dental hygienists are well positioned to provide anticipatory guidance on this safety issue.
INTRODUCTION
Detergent pods were introduced into the United States in 20101-3 as convenient, single-use packets of concentrated liquid detergent. The water-soluble membranes dissolve easily, which is a requirement to be useful in washing machines and dishwashers.3-4 However, due to the risks of chemical exposure and their high pH (pH=10-12), detergent pods have the potential for harm.5 Being very alkaline, they are corrosive and damaging to oral and other tissue.4 When placed into the mouth, the detergent pod membrane dissolves very quickly,2,5 causing chemical burns of the oral tissue and rapid edema resulting in the possibility of upper airway blockage, lung damage, esophageal perforation, necrosis of the tracheobronchial tree, mediastinitis and death.4 Detergent pods that burst caused 480 ocular injuries in 20156; approximately 35, 150 ingestion injuries from 2012-20177; and required hospitalization in 12.5% of the detergent pod injuries from 2012-2014.3
Brightly colored detergent pods resemble attractive candy to young children.8 In 2015, the ASTM International (formerly the American Society of Testing Materials) recommended standard F3159-15, that the detergent pod outer membrane have an unpleasant fragrance, could withstand minimum compression, would not dissolve immediately; and that the container’s packaging be opaque and childproof.9 The ASTM committee consists of 1000 participants including industry, consumer groups, and government. Additionally, in the United States (US) there are federal statutes that regulate detergents under the Federal Hazardous Substance Act, Consumer Protection Safety Act, and the Poison Prevention Packaging Act. Regulations were initiated in 2015 to help prevent the injuries.10 Although many manufacturers have complied with the standards introduced by the ASTM and follow the law, detergent pod exposures continue to be frequent and the resulting injuries in children are still unacceptably high.7
Oral health care professionals are charged with community engagement and patient education/anticipatory guidance to improve systemic and oral health. In addition to in-office oral hygiene instructions, dental professionals routinely provide diet counselling (particularly refined carbohydrates); screenings for blood pressure, depression, obstructive sleep apnea, tobacco use, anorexia, and safety at home (child/elder abuse, intimate partner violence); and discussions about safe practices to prevent injuries such as seat belt use, mouthguard use, helmet use, drugs/alcohol, and poisoning. Oral health care professionals, particularly dental hygienists, have the unique opportunity to speak with parents and children about a wide range of health topics during relatively long, routine care appointments.
Additionally, oral health care professionals provide community health education programs with anticipatory guidance to specific target groups. These presentations often include addressing the risks associated with accidental or intentional poisonings/injuries from drugs or other substance misuse such as with bath salts, the sniffing of volatile products, and recently the need to address the detergent pod social media “challenge” to swallow detergent pods. For parents of young children, the presentations could also address accidental swallowing or puncturing of detergent pods. It is important for oral health care professionals to have current knowledge and facts for such presentations. Detailed approaches to anticipatory guidance with detergent pods are provided in Appendix 1. The purpose of this study was to determine existing trends in detergent pod-related injuries among children, ages >0 to <18 years, specifically oral-aerodigestive injuries/ingestion poisonings resulting in emergency department (ED) visits from 2016-2020. The results of this study will help inform presentations to patients and groups about the dangers of detergent pod injuries.
METHODS
Study Design/Data Source
This study received acknowledgement as non-human subject research by the West Virginia University Institutional Review Board. A cross-sectional design was implemented using data from the National Electronic Surveillance System (NEISS). A secondary data analysis was performed on the NEISS data from 2016-2020. The NEISS surveys have been conducted for >45 years by the Consumer Product Safety Commission (CPSC). In 2000, the CPSC included data on all injuries for the Centers for Disease Control and Prevention (CDC).11 The NEISS survey design has a sampling frame of children’s hospitals, and general hospitals of varying sizes, excluding psychiatric hospitals, penal hospitals, or hospitals with ≤ 6 beds.11
The number of cases in the data set is the true count of collected data from the reporting hospitals. Depending upon the query, the number of cases and estimates may differ from published CPSC reports when other factors or information is considered.12 The NEISS caveat is that when working with the data, unweighted values (true counts) <20, or weighted values <1,200, or coefficient of variance >33% provide unstable calculated results and should be used with caution.
Variables
For this study, the outcome variable was detergent pod-related injuries resulting in ED visits (yes: related to oral-aerodigestive injury/ingestion poisoning/related to ocular injuries; and no: other product-related ED visit). All narratives associated with NEISS injury code 949 (detergents) were read and reviewed for identification whether the injury was related to a detergent pod. Words included “pod,” “pac,” “pack,” “capsule,” and “ball”.13 Injuries were categorized into detergent pod-related oral-aerodigestive injuries/ingestion poisonings, detergent pod-related ocular injuries, or other product related injuries.
The primary independent variable was “year” to determine differences in detergent pod-related injuries over time among children. The years included were 2016, 2017, 2018, 2019, and 2020. The following variables were investigated: sex (male, female); age (0 to <3 years, 3 to ≤5 years, >5 to <18 years); location (home, other); and race (White, Black, other). Although NEISS ED reports included options for Asian, American Indian/Alaska Native, and Native Hawaiian/Pacific Islanders, the sample sizes for these individual racial/ethnic groups were too small to conduct robust analysis; therefore, the sample was categorized into three groups (Black children, White children, and other children). Hospitalization was dichotomized to yes (treated with admission, treated with transfer, observation, died in facility, or dead on arrival) and no (treated and released, not seen, questionable). These definitions have been used in previous research.3 The NEISS data set is a limited data set and does not contain other variables which would have been of interest (for example, education, income, and healthcare coverage).
Statistical Analysis
Data analyses included descriptive statistics presented as frequencies and percentages. A Rao-Scott chi-square analysis was conducted to test associations between detergent pod-related oral-aerodigestive injuries/ingestion poisoning and ocular injuries. Logistic regression analyses were conducted to compare associations for the entire sample, subsamples by year, and trend over 5-years. Three types of logistic regression analyses were completed in unadjusted and adjusted logistic regressions: 1) injuries/ingestion poisonings vs. combined ocular and other detergent pod injuries; 2) detergent pod-related ocular injuries vs. combined aerodigestive injuries/ingestion poisonings; 3) other detergent pod injuries; and any detergent pod-related injury vs. combined aerodigestive injuries/ingestion poisonings and ocular injuries. Sex, race, location, and age were included in the adjusted analyses.
Data from NEISS provides cluster, strata, and weights for data analyses which were used to account for the survey design. Weights provided by NEISS were ratio-adjusted in the 5-year logistic regression analyses14,15 where 2016 to 2020 weights were multiplied by 0.212; 0.218; 0.207; 0.200; and 0.163, respectively; however, they were not ratio-adjusted in the year variable for frequency. All analyses were conducted in a statistical software program (SAS, version 9.4; SAS Institute Inc. Cary, NC, USA).
RESULTS
Table I presents the 5-year combined data (years 2016-2020) comparing ED visits for detergent pod-related oral-aerodigestive injuries/ingestion poisonings, detergent pod-related ocular injuries, and other product-related injuries. An estimated (weighted) 13,176 oral-aerodigestive injuries/ingestion poisonings, 8,654 ocular injuries, and 21,145,073 other product-related injuries resulted in ED visits over the 5 years for children ages >0 to <18 years. The primary independent variable, year, was not statistically significantly associated with ED visits from detergent pod-related oral-aerodigestive injuries/ingestion poisonings, detergent pod ocular injuries, and all other product-related injuries (p = 0.0558).
Five-year detergent pod-related oral-aerodigestive injuries/ingestion poisoning and ocular injuries resulting in emergency department visits 2016-20, ages >0 to <18*
Males and females were also not significantly different in ED visits from detergent pod-related oral-aerodigestive injuries/ingestion poisonings, ocular injuries, and all other product-related injuries (p = 0.0847). However, race, age, physical location of the injury, and need for hospital admission were significantly different among the injury types.
Table II presents the logistic regression analyses associated with subsets of ED visits from specific injuries in the 2015-2020 NEISS data. These include 1) a subset only including detergent pod-related oral aerodigestive injuries/ingestion poisonings; 2) a subset only including detergent pod ocular injuries; and 3) a subset only including detergent pod injuries (any type).
Logistic regression analyses on detergent pod injuries resulting in emergency department visits, NEISS, 2016-2020, ages >0 to <18*
For detergent pod-related oral-aerodigestive injuries/ingestion poisonings resulting in ED visits, the variable of interest, year, was similar among all years compared with year 2020 (p = 0.4358 in adjusted analysis). Sex also failed to reach significance in the adjusted analysis for oral-aerodigestive injuries/ingestion poisoning. However, race was significantly associated with ED visits for oral-aerodigestive injuries/ingestion poisonings for Black children compared with White children, (adjusted odds ratio [AOR] 0.45, 95% CI: 0.29, 0.70; p = 0.0006) but not for other race/ethnicity compared with White children (AOR 0.83, 95%CI:0.46,1.51; p = 0.5416). Age was also significantly associated with ED visits for oral-aerodigestive injuries/ingestion poisonings. Children, ages 0-2 years, were over 28 times as likely to have ED visit for an oral-aerodigestive injury as children age >5 to <18 years (AOR 28.58, 95% CI: 12.24, 66.73; p < 0.0001). Children, ages 3 to ≤ 5 years, were 18 times as likely to have an oral-aerodigestive injury/ingestion poisoning as children, ages >5 years (AOR 18.91,95%CI: 8.47, 42.21; p < 0.0001).
For detergent pod-related ocular injuries resulting in ED visits, year was associated in overall adjusted analysis (p = 0.0434). It should be noted that the years 2018 and 2019 were not significantly different from year 2020. Sex and race relationships with detergent pod ocular injuries failed to reach significance. For detergent pod ocular injuries and age, the relationship was significant. Children ages 3 to ≤5 years were over more likely to have an ocular injury as children, ages >5 to <18 years, (AOR 2.20, 95%CI: 1.43, 3.38; p = 0.0005).
For the data analysis from the subset of any detergent pod-related injury resulting in ED visits, year was not significant (p = 0.2036). Sex was not statistically significant. However, race was significantly associated with ED visit for any detergent pod-related injury for Blacks compared to Whites (AOR 0.58, 95% CI: 0.35, 0.96; p = 0.0357) but not for other race/ethnicity compared with Whites (AOR 0.88, 95%CI:0.50,1.53 p = 0.6369). Age was also significantly associated with ED visits for any type of detergent pod-related injury.
Appendix 2 (supplemental tables I-III) provide results of additional analyses of the data. In the supplemental tables, NEISS data are stratified by year, age, and sex. It should be noted that due to the sample size, (unweighted values/true counts <20, or weighted values <1,200, or coefficient of variance >33%) some of the cells were suppressed and as a result some calculations could not be determined.
DISCUSSION
In this study of NEISS, 2016-2020 data, there was no change in rate of detergent pod-related injuries requiring ED visits among children for oral-aerodigestive injuries/ingestion poisonings, and any detergent pod injury by year. Ocular injuries had an overall slight decrease, however 2018 and 2019 were not significantly different from 2020. There are few studies on detergent pod-related injuries requiring ED visits with which to compare the trend results of this study. There were no differences in injuries by sex in this study for detergent pod-related oral-aerodigestive injuries/ingestion poisonings, ocular injuries, or any body part injuries. There are no studies to compare detergent pod aerodigestive injuries/ingestion poisonings. There was one study of ocular injuries due to detergent pods, and the results stratified by sex were similar to the results of this study.6
Black children were less likely to have detergent pod-related oral-aerodigestive injuries/ingestion poisonings and injuries in any body part compared with White children, while ocular injuries were not significantly different. Potential explanations for the differences may include preferences in detergent type in which Black adults were less likely to choose detergent pods. Financial considerations drive many decisions, and brand preference for cleaner type (liquid, powder, pod) is often a choice made of habit. Other possibilities for more detergent pod-related oral-aerodigestive injuries/ingestion poisonings among White children include purchases due to targeted product endorsements in the media. White children may be more likely to be present while laundry is being done or the dishwasher is being used. Also, there could be less awareness of detergent pod hazards amongst this group. Since the time frame of the study included the COVID-19 pandemic and people were at home for longer periods of time, it may be possible that more laundry was being done at home with detergent pods than in public laundromats.
By age, there were more detergent pod-related oral-aerodigestive injuries/ingestion poisonings, ocular injuries, and injuries to any body part in children, ages 3 to ≤5 years, as compared with children, ages >5 to <18 years. Children, ages 0 to ≤3 years were also more likely to have an oral-aerodigestive injury than children, ages > 5 to <18 years. The results for age and detergent pod-related oral-aerodigestive injuries/ingestion poisonings are similar to previous studies. For example, researchers of 804 exposures to detergent pods in California children reported that the median age was 2 years for ingestion of detergent pods.16 In another study of 131 cases related to detergent pods and requiring hospital care, the researchers of that study found ingestion injuries were the most common among children with a median age of 1.4 years.17 Researchers in another study reported detergent pod-related ocular burns were more common among patients, ages 2-5 years, compared to younger children.18 A review of 122 publications relevant to detergent pod ingestion and ocular exposure however, reported ingestion to be the most common (>85%), but produced no or only minor issues whereas ocular exposure resulting in injury was found to be less common and infrequent.13
Strengths and limitations
This research is based upon national data which is considered a study strength. Weights were ratio-adjusted in the 5-year logistic regression analysis. However, the types of information collected for the NEISS were not being collected specifically for research purposes. It should be noted that maturation of the study participants may have influenced the internal validity of the study results. It is likely that injuries associated with age are the result of older children being aware of the dangers of detergent pods and understanding that detergent pods are not candy, despite their candy-like appearance. Younger children may be more tempted to reach for the pods and be attracted by the pod’s colors and appearance and may actually think that these detergent pods are candy.
CONCLUSIONS
There was no decrease in the number of detergent pod-related injuries requiring ED visits among children for oral-aerodigestive injuries/ingestion poisonings, and any related detergent pod injury based on data from 2016-2020. The incidence of ocular injuries remained stable from 2018-2020. Detergent pod-related injuries remain a public health issue. Oral health care professionals can help prevent detergent pod-related injuries by educating parents/guardians about the dangers of these products.
Appendix 1 Approaches for Anticipatory Guidance with Detergent Pods
While the detergent pod-related injuries requiring an ED visit have stabilized over the previous years, there have been some reports of increase in these injuries during the pandemic with possibly more time spent inside the house.1 It is important for oral health care providers, as well as other health care providers and public health officials, to be vigilant in public health messaging and accurate reporting of such injuries. For preschool children under age 6 years, the third most common source of poisoning exposure is household cleaning supplies.2 Oral health care providers should talk with parents/guardians of young children about safety issues and recommend not letting children handle the detergent pods; keeping the detergent pods in their original containers and out of the reach or sight of children; keeping the container closed and dry; not puncturing or taking the packets apart; reading the package warnings and instructions; and, calling Poison Help (800-222-1222) Control immediately if the detergent pod is swallowed, or causes an ocular or other injury.3
Anticipatory guidance by dental professionals should also include the following points to parents/guardians about what to do if a detergent pod is swallowed:
Avoid inducing vomiting. Vomiting could further expose the tissue to the alkaline.
Avoid neutralizing with a weak acid such as vinegar. Weak acids could result in an exothermic reaction with thermal burns to the tissue.
Avoid activated charcoal. Activated charcoal delays healing.4
Seek emergency help immediately.
REFERENCES
1. Haring RS, Sheffield ID, Frattaroli S. Detergent pod–related ocular injuries among preschool-aged children. JAMA Ophthalmol. 2017 Mar;135(3):283-4.
2. CPSC. CPSC and ACC warn of poison dangers with liquid laundry packets. Release number 13-147 [Internet]. Bethesda (MD): Consumer Product Safety Commission; 2022 [cited 29 Aug 2022]. Available from: https://www.cpsc.gov/content/cpsc-and-accc-warn-of-poison-dangers-with-liquid-laundry-packets
3. Valdez AL, Casavant MJ, Spiller HA, et al. Pediatric exposure to laundry detergent pods. Pediatr. 2014;134(6):1127-35.
4. CPSC. Prevent Child Poisonings. Release number 15-100. 2015 [Internet]. Bethesda (MD): Consumer Product Safety Commission; 2022 [cited 29 Aug 2022]. Available from: https://www.cpsc.gov/content/cpsc-joins-global-effort-to-prevent-child-poisonings.
5. El Bahri, L. Keeping tabs on laundry detergent pod toxicity. Inflammation. 2014 Jun;13(15):16.
Appendix
Detergent pod-related oral-aerodigestive injuries/ingestion poisoning and ocular injuries resulting in emergency department visits by year (weighted frequencies)
5-year detergent pod-related oral-aerodigestive injuries/ingestion poisoning and ocular injuries resulting in emergency department visits by age, NEISS, 2016-2020
Five-year detergent pod-related oral-aerodigestive injuries/ingestion poisonings and ocular injuries resulting in emergency department visits by sex, NEISS, 2016-2020
Footnotes
NDHRA Priority area, Population level: Health services (epidemiology).
DISCLOSURES
Research reported in this publication was supported by the National Institute of General Medical Sciences of the National Institutes of Health under Award Number 5U54GM104942-04. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Data from the NEISS is publicly available through the United States Consumer Product Safety Commission at https://www.cpsc.gov/Research--Statistics/NEISS-Injury-Data.
- Received July 11, 2022.
- Accepted October 18, 2022.
- Copyright © 2023 The American Dental Hygienists’ Association
