what to do if child eats tide pod
J Med Toxicol. 2014 Sep; x(3): 286–291.
Laundry Detergent Pod Ingestions: Is At that place a Demand for Endoscopy?
Erika Smith
University of Alabama, 1600 seventh Artery Southward Lowder 618, Birmingham, AL 35233 USA
Erica Liebelt
University of Alabama, 1600 seventh Artery South Lowder 618, Birmingham, AL 35233 USA
January Nogueira
University of Alabama, 1600 7th Avenue South Lowder 618, Birmingham, AL 35233 USA
Abstract
Introduction
Laundry detergent pod (LDP) exposures in children have resulted in several referrals to the emergency department. Signs and symptoms can include gastrointestinal symptoms (airsickness, drooling), neurological symptoms (depressed sensorium), or metabolic changes (lactic acidosis). There is express literature on esophageal injury post-obit LDP ingestions.
Case Serial
We reviewed three cases of pediatric LDP ingestions that underwent an upper endoscopy in a 3rd care pediatric hospital. All of our patients were younger than iii years old. The upper endoscopies revealed superficial esophageal erosions in two patients and erythema in the other. None of the patients had oral burns. Two of them developed swallowing dysfunction. Follow-upwards upper GI studies were normal.
Case Give-and-take
Our 3 patients ingested laundry detergent pods and all of them adult some degree of esophageal injury despite the absence of oral erythema, ulcers, or swelling. A review of literature suggests LDP exposures are more than severe than non-pod detergents. Reasons every bit to why this may exist remain unclear, although investigation into the ingredients and mode of delivery may help the states to better understand. In a literature review, no esophageal strictures have been reported after LDP ingestion. We reviewed esophageal injury classification systems in an effort to predict who may be at greatest risk for stricture based on initial findings.
Conclusion
Our case serial demonstrates it is hard to predict esophageal injury based on signs and symptoms. Based on a literature review, long-term esophageal stricture is unlikely, but if gastrointestinal symptoms persist, it is reasonable to evaluate with an upper endoscopy. Larger studies are needed.
Keywords: Laundry detergent pods, Tide pods, Esophageal injury, Esophageal stricture, Single-use detergent sacs
Introduction
Laundry detergent pod (LDP) ingestions accept get an surface area of business organisation within the U.s. pediatric medical customs since their naissance in 2010. In 2012, the Centre for Disease Control published data collected from the Carolinas Poison Command and the Children's Hospital of Philadelphia Poison Control Center. Over a one-month period, they establish 485 laundry detergent pod exposures. Most of the patients were less than 5 years of historic period (94 %), highlighting the importance of pediatrician awareness [i]. In that location have been several reviews that have compared LDP to not-pod detergent ingestions and found the clinical manifestations of LDPs to exist more astringent [2]. Some of the symptoms of LDP ingestions include gastrointestinal symptoms, such as nausea, vomiting, drooling, and swallowing dysfunction; pulmonary symptoms, such as choking, coughing, increased work of breathing, and respiratory failure; metabolic acidosis; and altered mental status. Few of the studies nosotros have reviewed take focused on endoscopic findings secondary to pod ingestions. There is no consensus as to whether or not these patients should undergo endoscopy to evaluate for esophageal injury. In this paper, we present three cases of LDP ingestions at Children's of Alabama and highlight the differences in their clinical presentations. The purpose of our manuscript is to talk over our endoscopic results post-obit LDP ingestions and consider if there is any potential for long-term esophageal sequelae.
Case 1
A 13-month-onetime, 10-kg, male with no past medical history presented to the emergency department (ED) ane 60 minutes afterwards ingesting an All Mighty Pack®. His father found him in the laundry room with the container of detergent pods. He looked in his mouth and saw the pod dissolving. The child began vomiting soon thereafter and became difficult to agitate. His father promptly took him to the ED. On the way to the ED, the child began to have audible inspiratory stridor. In the ED, his vital signs were as follows: pulse 148 beats per minute (bpm), claret pressure 138/86 mmHg, oral temperature 97.eight °F, respiratory rate 28 breaths per infinitesimal, and oxygen saturation of 98 % on room air. On the md's exam, the baby was in acute distress, with audible stridor, grunting, and diffuse crackles. He had no oropharyngeal burns or edema noted. Labs obtained showed his venous blood gas was as follows: pH 7.32, bicarbonate 16.2 mmol/L, lactate 8 mmol/L (normal <two.1 mmol/L). His complete blood prison cell count showed a normal white blood cell count of 9,300/uL and platelets of 256,000/uL. His glucose was elevated at 199 mg/dL. Due to his deteriorating respiratory and neurologic condition, the patient was intubated through rapid sequence and transferred to the pediatric intensive care unit. Overnight, he was febrile to a maximum of 102.2 °F. Inside 8 hours, his acidosis worsened, with a pH 7.1, bicarbonate xv mmol/L, and a base arrears of 12 mmol/Fifty. His eye rate was 220 bpm, and he had a significantly delayed capillary refill. He was empirically started on vancomycin and piperacillin-tazobactam and aggressively hydrated.
The pediatric pulmonary and gastroenterology teams were consulted after he was stabilized. Bronchoscopy showed tracheal edema and secretions in both the left and right lobes. No foreign torso was visualized. Esophagogastroduodenoscopy showed superficial erosions throughout the esophagus (Fig.1). His stomach and duodenal mucosa were normal. The patient was aggressively resuscitated, and throughout the post-obit twenty-four hours, his lactate normalized. Blood cultures remained negative. Thin-layer chromatography was only pregnant for ranitidine. He was extubated and transferred to the floor. Modified barium swallow showed silent aspiration of sparse and nectar consistencies. He was discharged afterwards 8 days in the hospital with a steroid taper and thickened feeds. A follow-upwards barium swallow 1 week after discharge showed no improvement.
Esophagitis secondary to pod ingestion
Ii weeks later, he returned to the ED with respiratory distress. He had completed his steroid taper seven days prior. Mom noticed that over the past week, his breathing progressively worsened and he was refusing to eat. He went to his pediatrician the day before access and was started on albuterol every iv hours, but his symptoms did not better. In the ED, his exam showed a pulse of 164 bpm, rectal temperature 100.0 °F, respiratory rate of xl breaths per minute, and oxygen saturation of 92 % on room air. He was in acute distress and agitated. On lung exam, he had diffuse wheezing. A chest radiograph obtained was concerning for chronic aspiration versus a viral process. His venous blood gas showed a pH seven.45, bicarbonate xviii.seven mmol/L, lactate 1.4 mmol/L, glucose 114 mg/dL, and a normal WBC count. He was admitted overnight but never required oxygen. The pulmonologist was consulted and felt this could exist pneumonitis after steroid removal versus acute bronchiolitis in addition to his recent lung injury. He recommended fluticasone and a 12-day steroid taper.
6 weeks afterward the inciting event he had an upper GI series that was normal. A repeat EGD 2 months afterward the initial event showed grossly normal mucosa. He did not show up for his follow-upwards modified barium consume or his pulmonary and GI appointments.
Case 2
A ii-year-former male ingested a Tide Pod® at home. His mother constitute him with an empty Tide® packet and detergent on his face and apparel. She called toxicant control who recommended giving him sips of water and to call up if any symptoms developed. Forty-v minutes subsequently the ingestion, he developed not-bilious, non-bloody emesis. He was taken to the ED where he connected to throw up. Vital signs showed a blood pressure of 99/68 mmHg, pulse 120 beats per infinitesimal, oral temperature 98 °F, respiratory rate of 32 breaths per minute, and an oxygen saturation of 98 % on room air. No visible oral ulcers. Labs did not show an acidosis, and his glucose was 77mg/dL. Chest radiograph showed lung hypoaeration. He was admitted for IV hydration. Given his persistent vomiting, an upper endoscopy was performed which showed superficial mucosal sloughing throughout the esophagus (Fig.2). His gastric mucosa was normal. He was discharged dwelling house within 36 hours on sucralfate and omeprazole. Four weeks later, the patient was asymptomatic and an upper GI series was normal.
Sloughing of the superficial mucosa throughout the esophagus
Example 3
A iii-year-quondam male with no past medical history bit into an All Mighty Pack® while in the kitchen. His begetter entered the room and saw the one-half-eaten pod. He called poison command and was instructed to give the child h2o, simply the child refused and began interim lethargic. As the father was driving him to the ED, he started to hear wheezing and saw his son was developing perioral cyanosis. He was difficult to arouse. His father subsequently pulled over and called 911. In the ED, he remained lethargic, but was breathing on his own without oxygen. His oxygen saturation was 97 % on room air, blood pressure was 82/45 mmHg, pulse 89 beats per minute, oral temperature was 98.6 °F, and a respiratory rate of 24 breaths per minute. He was drooling, without visible oral ulcers. His renal console showed bicarbonate of xiii mmol/L, an anion gap of 26, and glucose of 159 mg/dL. A venous blood gas revealed pH vii.28, bicarbonate of 16 mmol/L, and lactic acid of 13.5 mmol/L. He was admitted, fluid-resuscitated, and observed overnight. He never required ventilatory assistance. The following 24-hour interval, his acidosis resolved. He had persistent drooling, and thus, an upper endoscopy was performed. It revealed very mild proximal erythema in the esophagus (Fig.iii), but was otherwise normal. Afterward acceptable oral intake, he was discharged dwelling house on sucralfate and omeprazole. He had a follow-upward appointment four weeks afterward where mom stated the drooling did not resolve until three days after discharge. At this time, his oral intake was not dorsum to baseline. An upper GI series did not reveal whatsoever abnormalities. A follow-upwardly appointment was scheduled to discuss possible repeat endoscopy merely the patient did not show up to his appointment.
Mild proximal esophageal erythema
Discussion
Laundry detergent pods have been in employ in the USA since 2010. They accept been available in Europe, nevertheless, for at least a decade. Near of the exposures have been ingestions, leading to several typical symptoms. A study in the UK reported 1,215 ingestions from May, 2009 to July, 2012 and showed that the most common symptoms were nausea and vomiting (59.3 %), coughing (4.iv %), and drowsiness (4.0 %) [iii]. In the U.s., the Centers for Disease Control (CDC) summarized information bachelor regarding pod ingestions from May to June, 2012. They found 485 patients, in which 80 % were symptomatic. Like to the Uk study, 55 % had vomiting, 15 % had cough or choking, 6 % had nausea, and 7 % had drowsiness [1]. A true gear up of criteria to appraise the severity of laundry detergent pod ingestions has even so to be determined [4]. In our word, we will review possible reasons for more than impressive signs and symptoms with LDPs compared to not-pod detergents. We will highlight the few studies that have discussed the endoscopic findings and swallowing dysfunction institute with pod ingestions. And lastly, we will attempt to determine if there are potential long-term esophageal sequelae after pod ingestions.
Traditional laundry detergent has been shown to accept less signs and symptoms compared to LDPs. In the CDC review, LDP exposures were significantly more than likely than non-pod detergent exposures to result in a modest, moderate, or major medical outcome (p < 0.001), including airsickness (p < 0.001), coughing (p = 0.048), and drowsiness (p < 0.001) [ane]. We compared LDPs to non-pod detergents in an effort to empathise why LDPs produce more signs and symptoms. Interestingly, in reviewing the data safety sheets of All®, Tide®, and Purex®, the not-pod laundry detergents were more alkaline (pH nine.53, pH 8.1–viii.six, pH 10.1–11.1, respectively) than the laundry detergent pods (pH vii.six, pH 6.8–7.4, pH 8–11, respectively) [v–10]. Thus, mayhap the more than impressive symptoms of vomiting, lactic acidosis, and CNS depression are secondary to the ingredients or the mode of delivery. One ingredient that is found in many LDPs only less in non-pod detergents is propylene glycol. Propylene glycol has a weight composition of vii–13 % in Tide Pods®, 5–15 % of Purex UltraPacks®, and 7–13 % in All Mighty Packs® [5, 8, ten]. Nosotros could not notice a weight composition within the non-pod laundry detergents. Propylene glycol is primarily metabolized by the liver, producing lactate, acetate, and pyruvate [eleven]. This may explain the lactic acidosis seen in LDP ingestions. Some studies accept attributed propylene glycol to CNS depression and lactic acidosis [xi], while others remain skeptical of the claims [12].
Alcohol ethoxylates are another ingredient that has a greater percentage of weight composition in LDPs compared to not-pod detergents. For case, Tide Pods® take a 10–30 % weight composition while Tide® detergent has a ane–5 % weight composition. Booze ethoxylates are non-ionic surfactants. The safety information available shows limited evidence in rodent studies that alcohol ethoxylates are harmful; however, at loftier doses, ingestion tin produce airsickness, diarrhea, lethargy, and increased piece of work of breathing [13]. Alternatively, possibly part of the increase in signs and symptoms is secondary to the ease in consuming larger quantities with prepackaged LDPs.
There is limited literature discussing esophageal injuries and swallowing dysfunction afterward pod ingestions. A review of 17 symptomatic pediatric patients in Trieste, Italia, showed merely one patient had oral burns on physical test. Five of these patients underwent an endoscopy for undisclosed reasons. Three had esophageal erythema, one had pseudomembranous lesions, and another had esophageal ulcers. None of the patients had esophageal stenosis at follow-upwardly [14]. Another UK study by Williams et al. showed only 0.8 % (n = 4/518) had pharyngitis and esophagitis. They likewise reported only one patient had esophageal "blistering" of the esophagus that resolved on repeat endoscopy 7 days afterwards [15].
Other case reports take demonstrated that some patients tin can have swallowing dysfunction as a effect of LDP ingestions. For example, a case report presented by Schneir et al. discussed the hospital grade of a patient later on a pod ingestion. The patient had an endoscopy that showed mild esophageal erythema and a raised distal esophageal lesion of unknown significance. A fluoroscopic swallowing study was performed a week after the incident which showed aspiration on nectar-thick liquids. A follow upward study 1 calendar month later demonstrated consummate resolution [16]. Beuhler et al. also demonstrated swallowing dysfunction. Their case series revealed that two of the four patients required nasogastric tube feeds in addition to thickened oral feeds [17].
Our three patients ingested laundry detergent pods and all of them developed some degree of esophageal injury and ii of them developed swallowing dysfunction. Of annotation, none of our patients had oral erythema, swelling, or ulcers. Case ane required intubation, had a significantly elevated lactate level, and an altered mental status. His upper endoscopy revealed esophagitis, and his modified barium consume displayed silent aspiration, requiring thickened feeds. The second instance showed no acidosis, no altered mental status, and no oxygen requirement, even so his esophagus was the most notable, showing sloughing of the superficial mucosa. Instance three had an impressive lactate, altered mental status, and drooling that lasted for several days. His endoscopy revealed the least-impressive injury.
Lastly, is endoscopy necessary in these patients? In our literature review, we have not been able to find any cases of esophageal stricture after laundry detergent pod ingestions. Notwithstanding, several cases, including our own, have been lost to follow-up. The only case series that showed a structural modify was published past Fraser et al., who revealed webbing of the song cords. This study looked at 5 pediatric patients, all of whom developed edema of the airway. I of them adult webbing of the anterior commissure of the vocal cords and required surgical intervention [xviii].
Without bear witness of stenosis, we looked to the Zargar classification organization of caustic esophageal injury to see if nosotros could predict those who would be at risk for developing strictures. According to the study washed past Zargar et al., after evaluating 381 endoscopic exams for various caustic ingestions, patients with class 0, 1, or 2a had no farther sequelae, whereas those with class 2b or to a higher place were more than likely to develop problems. Approximately seventy-one percent of patients with grade 2b adult strictures requiring intervention. In addition, the written report did not evidence a correlation between oropharyngeal findings and upper gastrointestinal findings [nineteen]. Knowing the grade of esophageal injury can help determine the likelihood of futurity stricture formation. In a large analysis of several studies, Contini et al. establish that information technology usually takes 8 weeks for stricture formation but information technology tin can occur sooner or take up to one yr [20]. In our instance serial, cases i and ii had a course 2a injury, whereas case 3 had a form 1 injury. According to the Zargar classification, our patients are unlikely to develop long-term complications.
Conclusion
Nosotros report 3 cases of LDP ingestions in which endoscopy demonstrated esophageal injury. Information technology may exist hard to predict who will accept worse esophageal injury by signs and symptoms. In addition, the lack of oral swelling or lesions does not dominion out esophageal injury. If a patient presents with significant gastrointestinal symptoms, including persistent airsickness, dysphagia, drooling, or oral disfavor, it is reasonable to evaluate with an upper endoscopy. Given the express information available and the Zargar classification, it appears there is a depression likelihood of developing long-term esophageal sequelae in LDP ingestions; withal, larger studies are needed.
Conflicts of Interest
No funding for this instance series. No conflicts of interest by any of the authors. This manuscript has not been presented to any conference equally of Apr 15, 2014.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4141927/
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