HOW AND WHY ARE LIQUID LAUNDRY DETERGENT CAPSULES TOXIC? Allister Vale MD National Poisons Information Service (Birmingham Unit) and West Midlands Poisons Unit, City Hospital, Birmingham, and University of Birmingham, UK
LIQUID LAUNDRY DETERGENT CAPSULES Liquid detergent packets Liquid detergent capsules Liquid laundry pods Liquid sachets Liquigel capsules Liquid tablets Liquitabs
LIQUID LAUNDRY DETERGENT CAPSULES In 2001, the cleaning products industry launched liquid detergent capsules in Europe Since 2001, over 10 billion capsules have been sold in the UK Currently 1 billion capsules are sold annually in the UK These products were first marketed in the US in 2011
LIQUID LAUNDRY DETERGENT CAPSULES Europe US
LIQUID LAUNDRY DETERGENT CAPSULES A capsule of concentrated liquid laundry detergent in a water soluble polyvinyl alcohol membrane The capsules are mechanically strong when dry On contact with moisture (e.g. from saliva, a moist hand or water) they can release their contents prematurely
LIQUID LAUNDRY DETERGENT CAPSULES Liquid laundry capsules contain: anionic detergents (20-35%; 10% in US) nonionic detergents (10-20%; 75% in US) propylene glycol (8-20%) ethanol (2-5%) They have a ph of 7-9
LIQUID LAUNDRY DETERGENT CAPSULES The liquid volume of each capsule varies between 32-43 ml (24-45 ml in US) For some manufacturers, the US product is different from that sold in Europe Some US formulations could not be marketed in Europe without an environmental warning
LIQUID LAUNDRY DETERGENT CAPSULES This presentation includes data on 3,578 exposures (2,157 of these exposures have been published in CT)
YEARLY EXPOSURES TO LLDCs REPORTED TO THE UK NPIS 2008-2015 500 Number of exposures 450 400 350 2008 2009 2010 2011 2012 2013 2014 2015 Year
LIQUID LAUNDRY DETERGENT CAPSULES 96.1% of 3,578 cases concerned children 5 years Exposure to these capsules occurred as a result of: ingestion alone (81.7%) eye contact alone (7.6%) skin contact alone (1.3%) Multiple routes of exposure were involved in 9.4% of cases
LLDCs: POISONING SEVERITY SCORE PSS n=3,578 % of known PSS (n=3,540) PSS 0 (none) 1,255 35.5 PSS 1 (minor) 2,192 61.9 PSS 2 (moderate) 82 2.3 PSS 3 (severe) 10 0.3 PSS 4 (death) 1 <0.1 PSS unknown 38 N/A
TOXICITY AFTER INGESTION Ingestion was involved in 2,923 cases alone and 3,229 cases in all The majority (97.1%) were 5 years Vomiting occurred in 45.2% Coughing in 4.2% Drowsiness developed in 3.2% as early as 20 min after exposure Stridor occurred in 1.0%
DROWSINESS 3.2% of 3,229 cases of ingestion developed varying degrees of drowsiness 97.1% were children aged 3 years 74.5% were aged 1 year One elderly patient with dementia was reported to have ingested multiple capsules and developed drowsiness, hypotension and melaena
WHY DO LLDCs CAUSE DROWSINESS? Drowsiness may have occurred in very young children due to the presence of: ethanol (maximum concentration 1.7 g per 43 ml capsule) propylene glycol (maximum concentration 8.6 g per 43 ml capsule) nonionic surfactant concentration (Zerkle et al. 1987)
TOXICITY TO THE EYE Eye contact was the sole route of exposure in 272 cases but was involved in 500 of 3,578 cases 92.2% were children aged 5 years Features n=500 % Conjunctivitis 330 66.0 Corneal ulceration 14 2.8 Unknown 16 3.2 No eye features 140 28.0
WHY ARE LLDCs TOXIC TO THE EYE? Ex vivo data using the isolated chicken eye test have shown that the contents of an LLDC causes: slight swelling slight to moderate opacity superficial loosening of corneal epithelia slight to moderate erosion of the corneal epithelium
WHY ARE LLDCs TOXIC TO THE EYE? Ophthalmic damage is primarily due to the concentration of surfactants The ph, which in some formulations is 9, may exacerbate the surfactantinduced damage In in vitro studies the higher the surfactant concentration the greater the cytotoxicity (Yang and Acosta 1994)
WHY ARE LLDCs TOXIC TO THE EYE? Surfactants (Yang and Acosta, 1995; Jester et al.1998a and 1998b) can: Elevate intracellular Ca ++ Cause intracellular acidification Dissipate the mitochondrial membrane potential Decrease ATP production Induce cell death
TOXICITY TO THE SKIN Dermal exposure was the sole route of exposure in 45 cases (1.3%) but was involved in 244 of 3,578 (6.8%) cases 96.3% of those dermally exposed were children 5 years 32.0% of 244 cases developed a rash or skin irritation 5.7% developed a chemical burn
LIQUID LAUNDRY DETERGENT CAPSULES: CONCLUSIONS Ingestion may result in: drowsiness (3.2%) stridor (1.0%) Ocular exposure may lead to: conjunctivitis (66.0%) corneal ulceration (2.8%) Dermal exposure may result in: rash/skin irritation/burn (38%)
LIQUID LAUNDRY DETERGENT CAPSULES: CONCLUSIONS The temporary eye damage and CNS depression are due to surfactants As 96% of these exposures occurred in children aged 5 years of less, parents have a vital role to play in ensuring that these products are stored safely at all times
ACKNOWLEDGEMENTS The contribution of each NPIS Unit in providing these data: Birmingham Cardiff Edinburgh Newcastle The assistance of Rachael Day, NPIS (Birmingham Unit) in analysing these data
DECLARATION OF INTEREST The NPIS has received two unrestricted educational grants from the UK Cleaning Products Industry Association (UKCPI) to undertake studies on the toxicity of household products