Serious injuries from dishwasher powder ingestions in small children

Household cleaning product-related ocular exposures reported to the United States poison control centres

Background/objectives

To investigate ocular exposures associated with household cleaning products in the United States.

Subjects/methods

A retrospective analysis of ocular exposures associated with household cleaning products was conducted using data from the National Poison Data System from 2000 through 2016.

Results

From January 2000 through December 2016, poison control centres in the United States received 319,508 calls for household cleaning product-related ocular exposures, averaging 18,795 exposures annually. The annual frequency of exposures decreased significantly by 28.8% during the study period. The rate of exposures per 100,000 US residents was 28.4 among young children (<6 years), 4.8 among older children (6–12 years), 4.2 among teenagers (13–19 years), and 4.2 among adults (≥20 years); children 2 years old had the highest rate of exposure (62.8). Bleaches (25.9%), wall/floor/tile cleaners (13.4%), disinfectants (10.8%), laundry detergents (6.1%), and glass cleaners (5.3%) were the non-miscellaneous product subcategories most commonly associated with ocular exposures. The product subcategories associated with the greatest proportion of major medical outcomes were drain cleaners (1.4%), oven cleaners (1.1%), and automatic dishwasher detergents (0.4%).

Conclusions

On average, the United States poison control centres received approximately two reports of household cleaning product-related ocular exposures every hour during the 17-year study period. Although the annual number and rate of exposures declined during this time, the number of these exposures remains high, especially among young children, underscoring the need for additional prevention efforts. Contrary to the overall trend, ocular exposures to laundry detergent packets have increased significantly and merit special preventive action.

Safety Interventions and Liquid Laundry Detergent Packet Exposures

OBJECTIVES

To investigate exposures to liquid laundry detergent packets among children <6 years old in the United States and to evaluate the impact of the American Society for Testing and Materials voluntary product safety standard.

METHODS

Data from the National Poison Data System involving exposures to liquid laundry detergent packets from 2012 to 2017 were analyzed.

RESULTS

From January 2012 to December 2017, there were 72 947 single and polysubstance exposures to liquid laundry detergent packets. Most exposures (91.7%) were documented among children <6 years old. The annual number and rate of exposures for children <6 years old increased by 110.4% and 111.9%, respectively, from 2012 to 2015. From 2015 to 2017, the number and rate of exposures in this age group decreased by 18.0%. Among individuals ≥6 years old, the annual number and rate of exposures increased by 292.7% and 276.7%, respectively, from 2012 to 2017. Annual hospital admissions among children <6 years old increased by 63.4% from 2012 to 2015 and declined by 55.5% from 2015 to 2017. Serious outcomes among children <6 years old increased by 78.5% from 2012 to 2015 and declined by 32.9% from 2015 to 2017.

CONCLUSIONS

The number, rate, and severity of liquid laundry detergent packet exposures have decreased modestly in recent years among children <6 years old, likely attributable, in part, to the voluntary product safety standard and public awareness efforts. Exposures among older children and adults are increasing. Opportunities exist to strengthen the current product safety standard to further reduce exposures.

Is rigid endoscopy necessary with childhood corrosive ingestion? a retrospective comparative analysis of 458 cases

The aim of this study was to determine the necessity of endoscopy in cases in which a corrosive substance was ingested and to find a practical way to avoid unnecessary endoscopies for similar cases in the future. The clinical records of 458 hospitalized cases with clinical histories of corrosive substance ingestion between January 2007 and December 2013 were retrospectively reviewed. The demographics of the cases, the ingested substances, and the rigid endoscopy findings were evaluated. The three most commonly ingested corrosive agents were household bleach (22.9%), household degreaser (15.9%), and drain cleaner (13.1%). Rigid esophagoscopy was performed in 367 of the 458 cases. Corrosive agents were grouped according to their purpose of household use; eight groups were created. The degree of corrosive injury observed in the different groups was compared with the degree of injury caused by household bleach. Among the corrosive agent groups, dishwashing machine products (Gr.1), laundry products (Gr.2), liquid cleaners (Gr.3), and household bleach (Gr.4) did not cause high-grade injuries. The resulting injuries and esophagoscopy results among the above groups, whether symptomatic or not, did not differ from one another. Corrosive agents such as drain cleaner (Gr.6), household degreaser (Gr.7), and several other acidic products (Gr.8) caused high-grade injuries in the esophagus; however, lime remover/HCl (Gr.5) did not. Thus, hospitalization and rigid endoscopy seem unnecessary to assess esophageal injury in most cases, if the ingested corrosive agent fits into group 1, 2, 3, or 4 and if the patient can be easily fed. Esophagoscopy is useful to shorten the hospitalization times in cases where strong corrosive agents were ingested, such as those in groups 5, 6, 7, and 8.

Pediatric Exposures to Laundry and Dishwasher Detergents in the United States: 2013-2014

OBJECTIVE

This study analyzes and compares pediatric exposures to packet and nonpacket forms of laundry and dishwasher detergents in the United States.

METHODS

Data from the National Poison Data System involving exposures to laundry and dishwasher detergents among children younger than 6 years old from 2013 through 2014 were analyzed.

RESULTS

There were 62 254 children younger than 6 years old exposed to laundry and dishwasher detergents from 2013 to 2014. The number of exposures to detergent increased over the study period, but the increase was greatest for laundry detergent packets (17.0%) and dishwasher detergent packets (14.0%). Eighty-five percent of children were exposed through ingestion. The odds of clinical effects (3.9-8.2), hospitalization (4.8-23.5), intubation (6.9-71.3), and serious medical outcomes (8.4-22.6) were significantly higher for laundry detergent packet exposures than for other types of detergent. There were 117 children who required intubation, and 104 of these were exposed to laundry detergent packets. There were 2 deaths, and both were associated with laundry detergent packets.

CONCLUSIONS

This national study demonstrates that pediatric laundry detergent packet exposures are more severe than laundry detergent nonpacket and dishwasher detergent (packet and nonpacket) exposures. Pediatric exposures to laundry detergent packets increased by 17% during the study period nationally and should be closely monitored to assess the effectiveness of the newly adopted voluntary safety standard; this standard should be strengthened if the number of exposures does not demonstrate a substantial decrease.

Impact of acute exposure to WTC dust on ciliated and goblet cells in lungs of rats

Clinical studies and the World Trade Center (WTC) Health Registry have revealed increases in the incidence of chronic (non-cancer) lung disorders among first responders (FR) who were at Ground Zero during the initial 72 h after the collapse. Our previous analyses of rats exposed to building-derived WTC dusts using exposure scenarios/levels that mimicked FR mouth-breathing showed that a single WTC dust exposure led to changes in expression of genes whose products could be involved in the lung ailments, but few other significant pathologies. We concluded that rather than acting as direct inducers of many of the FR health effects, it was more likely inhaled WTC dusts instead may have impacted on toxicities induced by other rescue-related co-pollutants present in Ground Zero air. To allow for such effects to occur, we hypothesized that the alkaline WTC dusts induced damage to the normal ability of the lungs to clear inhaled particles. To validate this, rats were exposed on two consecutive days (2 h/d, by intratracheal inhalation) to WTC dust (collected 12-13 September 2001) and examined over a 1-yr period thereafter for changes in the presence of ciliated cells in the airways and hyperplastic goblet cells in the lungs. WTC dust levels in the lungs were assessed in parallel to verify that any changes in levels of these cells corresponded with decreases in host ability to clear the particles themselves. Image analyses of the rat lungs revealed a significant decrease in ciliated cells and increase in hyperplastic goblet cells due to the single series of WTC dust exposures. The study also showed there was only a nominal non-significant decrease (6-11%) in WTC dust burden over a 1-yr period after the final exposure. These results provide support for our current hypothesis that exposure to WTC dusts caused changes in airway morphology/cell composition; such changes could, in turn, have led to potential alterations in the clearance/toxicities of other pollutants inhaled at Ground Zero in the critical initial 72-h period.

Dishwasher-related injuries: survey and literature review

Domestic injuries are quite common among children aged 0-4 years old. Hazards lurking in the kitchen area can cause serious injuries in children. Through this study, we aim to raise public awareness of the potential and underreported risk of injuries related to dishwashers. Anonymous questionnaires consisting of 12 questions were distributed to adult females with children under 5 years old, including nurses, secretarial staff and outpatients. Commonly used dishwashers were surveyed by visiting high-street stores, and each brand's user manual was studied. A literature search using Medline and Pubmed was conducted for examining reported dishwasher-related sharp injuries. Forty households filled out survey questionnaires. Their responses indicated that 10% and 12.5% of children participate in unloading or loading dishwashers, respectively. Results showed that the incidence of related injuries was 12.5% among adults and 5% among children, and young children are at risk of sharp injuries in households with dishwashers. The dangerous loading and unloading of sharp objects and the direct involvement of toddlers should be discouraged, with the help of manufacturers.

Acute poisoning in children under the age of six: a two-decade study of hospital admissions and trends

AIM

To evaluate the incidence, clinical features and outcome of acute poisoning in children of less than 6 years of age in northern Finland.

METHODS

Children hospitalized with acute poisoning at the Oulu University Hospital between 1991 and 2010 were retrospectively evaluated from hospital records.

RESULTS

There were 334 hospital admissions due to acute poisoning during the study period, with an overall incidence rate of 5.2 per 10 000 per year, decreasing slightly from 6.7 in 1991-1995 to 4.5 in 2006-2010. Mean length of a hospital stay was 1.2 (SD ± 1.26) days. The most common substances ingested were terbutaline (12.3%), benzodiazepines (12.0%) and dishwasher powder (9.3%). Almost half of the patients were admitted to the paediatric intensive care unit, but most only required supportive care. Specific antidotes were administered in 16 cases. Three patients suffered from aspiration pneumonia as a result of ingesting poison, but no children died during the study.

CONCLUSION

Poisoning is a fairly common cause of hospital admission in children under the age of six. In most cases, their clinical condition is good, and they can be discharged after a short surveillance period.

Reactive airways dysfunction syndrome from acute inhalation of a dishwasher detergent powder

Reactive airway dysfunction syndrome, a type of occupational asthma without a latency period, is induced by irritating vapour, fumes or smoke. The present report is the first to describe a case of reactive airway dysfunction syndrome caused by acute exposure to dishwater detergent containing sodium metasilicate and sodium dichloroisocyanurate. The diagnosis was based on exposure data, clinical symptoms and signs, as well as respiratory function tests. A 43-year-old nonatopic male apprentice cook developed respiratory symptoms immediately after exposure to a cloud of detergent powder that was made airborne by vigorous shaking of the package. In spirometry, combined obstructive and restrictive ventilatory impairment developed, and the histamine challenge test revealed bronchial hyper-responsiveness. Even routine handling of a strongly caustic detergent, such as filling a dishwasher container, is not entirely risk free and should be performed with caution.

Pediatric eye injuries treated in US emergency departments, 1990-2009

This study investigates activity- and consumer product-related eye injuries treated in US hospital emergency departments among children <18 years old using National Electronic Injury Surveillance System data from 1990 through 2009. An estimated 1,406,200 (95% confidence interval = 1,223,409-1,588,992) activity- and consumer product-related pediatric eye injuries occurred during the study period, averaging 70,310 annually. The annual number of injuries declined significantly by 17%. Patients ≤ 4 years of age accounted for 32% of all injuries and had the highest mean annual eye injury rate (11.31 per 10,000 population). Eye injuries associated with sports and recreation (24%) and chemicals (17%) occurred most frequently. The majority (69%) of eye injuries occurred at home. Opportunities exist to further decrease these injuries. Pediatricians should educate child caregivers and children about risks for eye injuries in the home and about use of appropriate protective eyewear during sports.

Features and management of esophageal corrosive lesions in children in Sierra Leone: lessons learned from 175 consecutive patients

PURPOSE

This study aims to highlight the peculiar presentation and management of children's corrosive ingestions in developing countries associated with malnutrition, delay in management, lack of technology, and sporadic follow-up.

METHODS

An observational study was carried out since 2005 on all children (<15 years old) admitted for caustic soda ingestion to the "Emergency" Surgical Center in Sierra Leone, either in the acute postinjury phase or for dilatation of esophageal strictures. Complications, mortality, stricture recurrence, and ability to swallow were the main outcome measures. Improvement in nutritional status (ie, gaining weight) and sustained esophageal patency were both considered reference points to successful treatment.

RESULTS

In 4 years (2005-2009), 175 children were admitted, 53.7% at more than 1 month after ingestion. Dilatations were carried out in 77.7%, and a gastrostomy was placed in 64%. Perforations and death rate were 4.5% and 2.8%, respectively. Sixty-two patients (35.4%) required more than 7 dilatations, whereas 15 (8.5%) were unable to maintain a satisfactory luminal diameter. Follow-up (range, 1-36 months; median, 7 months) was possible in 52.7%. Long-term success according to the aforementioned criteria was observed in only 16%.

CONCLUSIONS

Delayed presentations and complex strictures with repeated postdilatation recurrence are characteristics of children's corrosive ingestion in developing countries. Malnutrition is common, and gastrostomy is frequently compulsory. Esophageal patency with improvement in nutritional state is achieved only in a small percentage of patients.

Evaluation of caustics and household detergents exposures in an emergency service

OBJECTIVE

The aim of this study was to analyse the caustic and household detergent exposure cases were admitted to the Department of Emergency Medicine at Dokuz Eylul University Hospital (EMDEU) between 1993 and 2008.

METHODS

Age, sex, reason of exposure, clinical signs, rate of endoscopy in oral exposures, treatment attempts, length of hospital stay and outcome were evaluated. A chi-square test was used to analyse statistical differences.

RESULTS

Caustic exposures accounted for 8.5% (1160 cases) and 4.1% (1988 cases) of all poisonings in children and adults, respectively. Female/male ratio of caustic exposure poisonings was 0.8. Most of the exposures were unintentional (158, 86.8%). Intentional exposures were common in cases between 19 and 29 years old (χ(2) = 25.685, p < 0.001). The most common caustic substance was alkaline (106, 58.3%) followed by acidic (47, 25.8%) and other household detergents (28, 15.4%). Vomiting (35.7%), nausea (14.8%) and sore throat (13.1%) were the most common clinical signs. The patients who had endoscopy, the most frequent finding was first-degree damage (58.7%). A 48-year-old man died from intentional hydrochloric acid ingestion.

CONCLUSION

Because of the large number of unintentional caustic exposures, parent education is very important to decrease the caustic exposures in children.

Aerosol container-related eye injuries in the United States: 1997-2009

PURPOSE

To quantify and characterize eye injuries related to aerosol container consumer products treated in United States hospital emergency departments (EDs) from 1997 through 2009.

DESIGN

Retrospective study.

METHODS

Descriptive analysis of aerosol container-related eye injury data derived from the National Electronic Injury Surveillance System, a stratified probability sample of hospital-affiliated United States EDs. Data collected included demographic variables (gender and age), locale, diagnoses, and hospital disposition associated with aerosol container-related eye injuries treated in United States EDs from 1997 through 2009. Products associated with injury and mechanisms of injury also were extracted and analyzed.

RESULTS

There were an estimated 10 765 (95% confidence interval [CI], 9842 to 11 688) visits to United States EDs for aerosol container-related eye injuries during the study period; 6756 (95% CI, 5771 to 7742; 63%) patients were male; 5927 (95% CI, 4956 to 6897; 55%) injuries occurred in children (age < 18 years). The most common product was spray paint, accounting for 2048 (95% CI, 1402 to 2694; 19%) injuries. The most common mechanism of injury was self-inflicted spray to the eye, occurring in 4649 (95% CI, 3746 to 5552; 43%) cases. The most common diagnosis was dermatitis or conjunctivitis, occurring in 3880 (95% CI, 2995 to 4765; 36%) cases.

CONCLUSIONS

This study suggests that most aerosol container-related eye injuries in the United States occur in men and children and that self-inflicted spray to the eye is the most common mechanism of injury. Further research is needed to devise effective prevention strategies for these types of injuries.

Household cleaning product-related injuries treated in US emergency departments in 1990-2006

OBJECTIVE

The goal was to examine comprehensively the patterns and trends of household cleaning product-related injuries among children treated in US emergency departments.

METHODS

Through use of the National Electronic Injury Surveillance System database, cases of unintentional, nonfatal, household cleaning product-related injuries were selected by using product codes for drain cleaners, ammonia, metal polishes/tarnish removers, turpentine, dishwasher detergents, acids, swimming pool chemicals, oven cleaners, pine oil cleaners/disinfectants, laundry soaps/detergents, toilet bowl products, abrasive cleaners, general-purpose household cleaners, noncosmetic bleaches, windshield wiper fluids, caustic agents, lye, wallpaper cleaners, room deodorizers/fresheners, spot removers, and dishwashing liquids. Products were categorized according to major toxic ingredients, mode of action, and exposure.

RESULTS

An estimated 267 269 children<or=5 years of age were treated in US emergency departments for household cleaning product-related injuries. The number of injuries attributable to household cleaning product exposure decreased 46.0% from 22 141 in 1990 to 11 964 in 2006. The product most-commonly associated with injury was bleach (37.1%). Children 1 to 3 years of age accounted for 72.0% of cases. The primary mechanism of injury was ingestion (62.7%). The most common source or container was spray-bottles (40.1%). Although rates of household cleaner-related injuries from regular bottles or original containers and kitchenware decreased during the study period, spray-bottle injury rates showed no decrease.

CONCLUSION

Although national rates of household cleaning product-related injuries in children decreased significantly over time, the number of injuries remains high.

Corrosive oesophageal strictures in children: outcomes after timely or delayed dilatation

BACKGROUND AND STUDY AIMS

Among benign oesophageal lesions, caustic strictures are the most difficult to dilate. In low-income countries, children suffering caustic oesophageal injury are frequently referred to the hospitals late, sometimes weeks after ingestion. Therefore, dilatation may be performed late and in highly fibrotic strictures. Reports about endoscopic and clinical outcome of such delayed dilatations are scanty. The aim of this study was to evaluate the safety and efficacy of late caustic stricture dilatations in children, comparing it with the results of timely dilatations, both performed at the Hospital of the Italian Non-Governmental Organization "Emergency" at Goderich, Sierra Leone.

PATIENTS AND METHODS

From December 2005 to May 2007, 78 children (<15 years) complaining alkaline caustic ingestion were submitted to oesophageal dilatation, mainly (97%) using Savary dilators. Two groups were identified: children (group 1) with a late treatment (>6 weeks, 37+/-12 weeks), having arrived to the hospital late after ingestion, and children (group 2) dilated timely, i.e. at <6 weeks (4+/-1.4 weeks) after injury.

RESULTS

Strictures were severe in all patients. Twenty-five children were dilated late after injury (6.4 dilatations/patient) with a follow-up of 11+/-2.5 months. A successful clinical outcome was observed in 91.6%. Four perforations (2.6% procedure-related) and one death (4.0%) were observed. Strictures recurred once in 72% of patients, twice in 31.8%. Thirty-one children were dilated timely (4.5 dilatations/patient) with a follow-up of 10+/-2.1 months and a clinical success rate of 96.7%. Procedure-related perforation rate was 0.7% with one death (3.2%). Stricture recurred once in 30% and twice in 3.3%.

CONCLUSIONS

Delayed dilatation of caustic oesophageal strictures in children carries a higher risk of perforation and a higher recurrence rate.

Corrosive esophageal injuries in children. A shortlived experience in Sierra Leone

OBJECTIVE

Children with caustic ingestions in developing countries are often treated at home, sometimes by traditional healers, or are referred, frequently late, to tertiary hospitals, which only seldom offer adequate endoscopic and dilatation facilities. Therefore, when dilatations are performed, the stricture is often already well established, making dilatation more difficult. The aim of this paper is to report our experience in the management of corrosive injuries in a group of children of Sierra Leone, all complaining accidental ingestion of caustic soda, many of them treated months after the ingestion.

METHOD

We considered all children admitted after corrosive ingestion, from November 2001 to November 2005, to the "Emergency" Surgical Center in Goderich-Freetown, Sierra Leone. In December 2005 the hospital was supplied with endoscopes and dilatation devices. The children still followed up clinically were recalled to submit them to an endoscopic follow-up and to a dilatation, if needed.

RESULTS

Forty children were admitted (mean age: 4.5 years): 16 (group A) after an esophageal perforation during dilatation performed elsewhere (death rate: 56%). Twenty-four children (group B) were observed after ingestion, 58% being submitted to a surgical gastrostomy. Death rate after ingestion was nil. The mean interval between ingestion and endoscopy was 8.8 months. Fifty-three dilatations were carried out in 17 children over a 3 months period. We report three perforations (17.6%) and a death rate of 5.8% (1/17). Two patients were lost to follow-up. Three patients (17.6%) did not show any improvement. Four children complained recurrent dysphagia after the first dilatation cycle. Overall, 10 children (58.8%) showed a clear-cut improvement at 6 months.

CONCLUSIONS

The majority of treated strictures were late, therefore difficult to dilate and at higher risk of perforation. Dilatation with Savary bougies seems safer than with balloon catheters. Recurrent strictures and a long-term dilatation treatment should be expected. Retrograde dilatations through gastrostomies should be the preferred method of treatment and surgical gastrostomies should be performed without hesitation. Esophageal replacement is unlikely in these countries, except in very few referral centres. Therefore, any effort should be made to treat caustic strictures by timely dilatation programs.

Emergency endoscopy in children

Endoscopy in children has developed along with pediatric gastroenterology over the last four decades. Introduction of endoscopic techniques in adults precedes application in children, and pediatric endoscopists do fewer procedures than their adult counterparts whether routine or as an emergency. Training for pediatric endoscopists therefore needs to be thorough. This article in particular highlights developments in pediatric gastroenterology of importance to emergency procedures.