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Automatic dishwasher detergent poisoning: opportunities for prevention

Automatic dishwasher detergent poisoning: opportunities for prevention Barry J. Parsons Pharmacy Department, Rqal Childrens Hospital, Melbourne and Victorian Poisons Infmation Centre, ’ Melbourne Malcolm D. Dobbin Department of Health and Community Seruices, Melbourne Abstraa: We investigated the antecedents of ingestion of dishwashing machine detergent to enable the development of effective countermeasures. Parents who had sought advice from the Victorian Poisons Information Centre about dishwasher detergent poisoning exposures of their children were interviewed by telephone. Almost all the children (94 per cent) were aged between 6 and 29 months. Of the 61 children included in the survey, 53 (87 per cent) gained access to the detergent from the dishwasher. Of these, 50 (94 per cent) took the detergent from the dispenser on the internal surface of the door of the machine, and 38 (76 per cent) of these ingested detergent remaining in the dispenser after operation of the machine. Parents were present in the room on 78 per cent of occasions at the time of ingestion. Most parents (72 per cent) were aware of the toxicity of the detergents. Relocation of the dispenser or redesigning it to prevent access both before and after operation would have prevented most of the exposures to detergent. Altering the detergent to prevent caking or sludging might prevent many of the exposures to detergent remaining in the dispenser after operation of the machine. The level of prior knowledge about toxicity suggests that education or additional warnings are unlikely to contribute Substantially to prevention of poisoning. Telephone call-back to identified cases is a useful method of investigating complex poisoning prob lems and developing effectivecountermeasures. (Aust N ZJPublic Health 1996; 20: 278-83) OISONING continues to be a major paediatric problem.’ It is one of the leading causes of hospital attendance and admissions for injury in children, particularly for the 0 to 4 years age group.*4 Childhood poisoning problems are often complex, particularly when opportunities for exposure occur at a number of different stages in the normal use of poisoning agents. This makes the design of countermeasures difficult unless good data about the circumstances of poisoning are available. While substantial progress has been made in the prevention of poisoning, it remains a dynamic area as domestic technologies change, potentially poisonous domestic chemicals are introduced, and others are replaced. In Australia, strongly alkaline dishwashing machine detergents (automatic dishwasher detergents) have emerged as agents responsible for severe corrosive injury in children aged one to three years.5 It is estimated that one in five Australian households possesses a dishwashing machine.6 Most dishwashing machine detergents are formu- Correspondence to Barry J. Parsons, Director of Pharmacy, Pharmacy Department, Royal Children’s Hospital, Flemington Road, Parkville, Vic 3052. Fax (03) 9349 1261. Now at Pharmacy Department, Geelong Hospital, Geelong. lated from a mixture of alkaline salts, and are strongly caustic, with a pH of more than 11.5 in a 1 per cent solution. Caustic substances cause liquefaction necrosis of tissue, and ingestion may result in corrosive injury to the lips, mouth, pharynx and upper aerodigestive tract, with the potential for severe morbidity requiring complex and prolonged surgical management.’” Caustic ingestions are a major public health problem, accounting for an estimated 26 000 ingestions of corrosive agents each year in the United state^.^ Long-term sequelae for injured children include chronic oesophageal stricture and a greatly increased risk of cancer of the oesophagus in adult life.’o-’2It has been estimated that the incidence of oesophageal carcinoma in patients suffering from caustic stricture is at least 1000-foldthat in the general population.” This form of poisoning incurs a considerable cost to the health care system, both in the acute stage when patients require assessment by oesophagoscopy and hospitalisation,I3and in the prolonged and complex management of those who sustain corrosive injury of the upper aerodigestive tract. Characteristics of dishwashing machines make them effective vehicles for delivering this caustic AUSTRALIAN AND N W ZEALAND JOURNAL O WBUC HEALTH 1996 voc. 20 NO. 3 E F DISHWASHER DETERGENT POISONING chemical to toddlers: they are usually located in one of the busiest rooms in the house, where parents may be distracted when the machine is open; the detergent dispenser is usually located on the door, within the visual field and easy reach of crawling children when it is open; and the dispenser snaps open with light finger-tippressure, attracting a curious toddler’s attention. Toddlers are curious about mechanical devices and like to copy their parents. They are curious about the taste and mouth feel of materials like powders and liquids, and have sufficient mobility and motor skills to gain access to these detergents unrestrained by the sense of caution that comes with experience. In 1987 it became evident that dishwashing detergents were poisoning a substantial number of young children. ‘The National Health and Medical Research Council recommended that the states and territories amend their legislation to require liquid and gel forms of these detergents to be supplied in packs fitted with child-resistant closures, and all packs (including those of powdered detergents) to feature prominent warnings on the label indicating the hazard. Victorian Poisons Information Centre data indicate that, apart from the major agents which are the subject of poisoning inquiries (paracetamol, cough and cold preparations, benzodiazepines, oral contraceptives, cleaning agents, cosmetics), most callers inquire about ingestions of drugs or chemicals accounting for less than 2 per cent of calls. Dishwasher (detergentis in this category, accounting for about 1.3 per cent of calls concerning actual poisoning exposures of children aged 0 to 4 years. Nevertheless, because of the potential for severe morbidity, dishwasher detergent is a worthy subject for investigation. It was also recognised at that time that most exposures resulted from children gaining access to the detergent from the machine (T. Nolan, personal communication),5 so a recommendation for a warning label on dishwashing machines was referred to the National Consumer Products Safety Committee, since this was considered to be outside the area of responsibility of poisons legislation. In 1990 7Jictorian injury prevention personnel recognised that insufficient progress had been made in preventing further poisoning. This occurred despite efforts to warn parents of young children with media releases, a leaflet and adhesive warning label, and attempts to persuade authorities responsible for regulating the safety of electrical goods to address the problem. Since this experience was seen to be symptomatic of general liimitations of present systems to prevent poisoning, it was decided to call together injury prevention personnel representing various agencies with an interest in poisoning prevention. At the initial meeting the Victorian Committee on Poisoning Prevention was formed. Its purpose was to develop a collaborative approach to poisoning prevention by collecting data aimed at developing preventive interventions. Since the initial impetus for the formation of the committee was the problem of dishwasher detergent poisoning, it was decided to use methods developed to prevent this poisoning as a model for further activities. Two Australian case series indicated that toddlers were gaining access to the detergent at several stages in its chain of use: directly from the pack; from the dispenser in the machine prior to its operation; and from a sludge remaining in the machine after completion of its ~ p e r a t i o n The design of effective .~ countermeasures required more information about the circumstances of exposure. More complete data about the circumstances of poisoning were required to enable the development of specific poisoning prevention interventions. The Victorian Poisons Information Centre undertook to collect more specific data about the circumstances resulting in exposure. This paper reports detailed data collected from a sample of cases identified by the Centre from telephone inquiries about dishwashing machine detergent ingestions. Method The Victorian Poisons Information Centre is located in the Pharmacy Department of the Royal Children’s Hospital in Melbourne. The Centre is staffed by pharmacists and receives about 46 000 telephone calls per year seeking advice about acute and chronic poisoning. It provides information on poisons and the safety and appropriate use of chemicals and drugs. Calls are received from medical staff, allied health professionals and the general public. The Centre supplies a service to Victoria, which has a population of about 4.4 million. Between 1June 1991 and 1 March 1992, a sample of 70 calls of a total of 179 calls received from the general public about acute exposure or poisoning with dishwashing machine detergents were selected for detailed analysis of the circumstances of the incident and the sequelae. Cases were selected in sequence in four time blocks during the nine-month period. Treatment was recommended by the Centre’s pharmacists based on symptoms reported, estimated amount consumed, and on the parent’s own assessment. At the time of receipt of the call, and following poisoning management advice, callers were invited to participate in a follow-up survey using a preformulated questionnaire about the circumstances of the poisoning. Those agreeing were asked for their contact telephone numbers, but not their names, so they remained anonymous. Callers were contacted, usually within six to eight weeks of the initial call. The interviewing pharmacists indicated that they were calling from the Victorian Poisons Information Centre and were conducting a survey of dishwashing machine detergent ingestions. People contacted were informed that the survey was anonymous, that it would take about 10 to 15 minutes to complete, and that their involvement was voluntary. It was explained that the reason for the survey was to prevent poisoning with these products by defining aspects of packaging, product formulaW. AUSTRALIAN AND N W ZEALAND JOURNAL OF PUBLIC HEALTH 1996 E 20 NO.3 CORNISH ET AL. Table 1: Estimated amount of automatic dishwasher detergent consumed and reported source of treatmen! Amount consumed Teaspoonful ‘Finger lick’ n 010 n Oh Exposure to detergent All exposures Treatment Mouth rinse General practitioner Hospital Total,. Note: (0)53 children obtained detergent from the machine and 6 obtained i t from the packet 1 to 11 12to23 24to35 Age in months over35 Table 2: Access to automatic dishwasher detergent dispenser by children: time of access and reported source of treatment Time of access Before cycle Aher cycle n % n % Figure 1 : Percentage of inquiries, by age, for children exposed to automatic dishwasher detergent, and for all poisoning inquiries for children under 15 years Treatment tion and dishwasher design associated with the poisoning. The questions focused on six issues: means of access to detergents; quantity consumed; adult supervision at the time of the incident; knowledge of the dangers of dishwasher detergents by the adults present at the time of the incidenc first-aid measures used; and storage of the detergent. Respondents were also given the opportunity to comment on how such poisoning might be prevented in the future. Mouth rinse General practitioner Hospital Total” Note: (a) For 50 children for whom time of access was known Results Of the 70 callers, 61 were included in the survey. We were unable to contact four callers, and five callers declined to be included in the survey: four of these stated that they did not have enough time and one was not willing to discuss the incident. Information obtained at the time of the initial call to the Centre indicated that the circumstances of these poisonings were similar to those of the remainder of the sample. Data about the callers obtained at the time of the initial call did not otherwise enable comparison between participants and nonparticipants in the study. A greater proportion of exposures (66 per cent) occurred among the age group 12 to 23 months, compared to all poisoning inquiries (34 per cent) (Figure 1). Almost all children exposed to dishwashing machine detergent (94 per cent) were aged between 6 and 29 months, with a peak incidence in the age group 12 to 17 months (46 per cent). Male children accounted for 57 per cent of the exposures. This ratio is consistent with all poisoning inquiries about children received by the Centre. There was little difference in incidence of exposures between days of the week. Most children (86 per cent) exposed to the detergent consumed a ‘finger lick’ quantity (Table 1) and were usually treated at home with a mouth rinse. Of the eight children reported to have consumed larger quantities, six (75 per cent) attended a general practitioner or hospital emergency department for assessment. The proportion of children attending hospital was slightly higher for those children obtaining access to the powder detergent from the dispenser before commencement of the washing cycle, compared to those obtaining access to the detergent sludge remaining after completion of the cycle (Table 2). Of the 61 children included in the survey, 53 (87 per cent) obtained access to the detergent from the machine, six (10 per cent) from the packet, and 2 (3 per cent) in other ways. Of the 53 children who took the detergent from the machine, 50 (94 per cent) took the detergent from the detergent dispenser on the internal surface of the front door. The door to the dishwasher had been opened by an adult on 89 per cent of occasions and by the child on 11 per cent of occasions. Other access to detergent before commencement of the cycle were from the base of the machine (two children) and from detergent spilt on the surface of the door (one child). Information about the formulation of the detergent involved in exposures was collected (Table 3). In 46 out of the 50 cases (92 per cent) for whom information was available, a solid formulation (powder or granules) was involved. A higher proportion of exposures to the solid form (powder and granules) than for the liquid form occurred after completion o dishwasher operation. f 20 NO. 3 AUSTRALIAN AND N W ZEALAND JOURNAL OF WBUC HEALTH 1996 vot. E DISHWASHER DETERGENT POISONING Table 3: Access to automatic dishwasher detergent dispenser by children: time of access and formulation of detergent Time of access Before cycle After cycle n % n % ond child required two oesophagoscopies during a two-day admission. A third child was transferred to the Royal Children’s Hospital intensive care unit, underwent oesophagoscopy, and required follow-up oesophageal dilation. Formulation Liquid Powder Granule Total Nofe: 2 25” (a) Includes one case involving a detergent tablet Of the 50 children for whom information was available, 38 (76 per cent) obtained detergent from the machine after completion of the cycle, as a result of sludge forming in the machine, or failure of the machine to wash detergent from the dispenser. Six children took the detergent from the packet: two children opened the child-resistant closure (one was opened by a one-year-old child), two children opened the container (not a child-resistant packet), and two children chewed through the box. On three occasions the container was in its normal storage place (under the sink), and for the other three incidents, the detergent was in use and left accessible (in two cases on a benchtop). There werle only two other incidents in which the detergent was not taken from either the machine or the packet. In one incident an older sister allowed a five-year-old to fill the detergent dispenser, some detergent was spilt and then accidentally wiped across the child’s mouth. In the other incident, a child consumed liquid detergent from a milk contain’erused for temporary storage and left on the benchtop. This child had severe gastro-oesoplhagealburns requiring extensive treatment and follow-up. For 48 (78 per cent) of the 61 exposures, a parent was present in the room at the time of ingestion: 36 were filling or emptying the dishwasher and 12 were engaged in other activities. Of the remainder, inges tion occurred in eight cases when the child was left alone, in five cases for five minutes or less. The majority (72 per cent) of parents or supervisors were aware of the toxicity of dishwashing machine detergents. Of those who were aware of the toxicity, 90 per cent had stored the detergent out of reach of children in a high cupboard (more than 1.5 metres high) or in a locked cupboard. Of those unaware of the toxicity, only 50 per cent had stored the detergent out of reach. At the time of contact, three of the six patients who attended hospital were reported to have been managed initially in the emergency department and discharged after oral examination and observation. One of these ,returned next day for a gastroscopy. Three children were reported to have required admission to hospital. One was admitted for nine days, and had been unable to swallow. Three oesophagoscopies were performed and the patient discharged for weekly oesophageal dilation. A sec- Discussion The data collected in this study relied on reports of the circumstances of exposure to dishwashing machine detergents by parents or other carers up to eight weeks after the event. Therefore, there is potential for recall bias owing to an interpretation of events that minimises the carer’s responsibility for the child’s exposure. It is also possible that the validity of recall was adversely affected by the delay of several weeks before the informants were contacted. These data indicate that children aged between 6 months and 29 months are most at risk of exposure to caustic dishwasher detergents. This age range is similar to those described in case series of children with corrosive injury of the oesophagus from the ingestion of caustic materialI4 and children attending hospital after ingestion of dishwasher deterg e n t ~This age distribution differs from that of all .~ children who are the subject of calls to the Victorian Poisons Information Centre: 76 per cent of children exposed to dishwasher detergents were aged under 23 months, but only 44 per cent of children the who were the subject of poisoning inquiries to the centre were under 23 months. This difference may reflect the ease of access to these detergents from the open bottom-hinged doors that deliver the loaded dispenser to within a few centimetres of the floor, within the visual range and easy reach of crawling infants or toddlers. The spring-loaded dispenser lid operated with light finger-tip pressure may provide an added attraction to curious toddlers. It may also reflect the more advanced mobility, climbing ability and fine motor skills of older children which allow them access to a wider range of drugs and domestic chemicals stored in packaging such as screw-top bottles and jars. This study confirms the findings of previous reports of case series that the major source of exposure to dishwashing machine detergents is the machine? Almost all of the subjects in this study gained access to the detergent from the machine, both before its operation and after completion of its cycle. Most of the children gaining access from the dispenser in the machine did so after the machine door had been opened by an adult. This suggests that child-resistant catches on the door of dishwashing machines would make a limited contribution to poisoning prevention. Twelve children gained access to detergent from the machine prior to its operation: four out of the nine for whom there was information opened the dispenser themselves. Information about the relative proportions of solid and liquid forms supplied to the public is not available, so it is not possible to draw any conclusion about the relative safety of liquid versus solid forms of this product, although it may be that the ,liquid form is less likely to form a sludge and remain in the VOL. AUSTRALIAN AND NEW ZEALAND JOURNAL OF WBUC HEALTH 1996 20 NO. 3 CORNISH ET AL machine after completion of its operation. Most children gaining access to detergent from the machine dispenser ingested sludge remaining after completion of the machine’s washing operation. This suggests the possibility of preventing many of these exposures by addressing the potential of these products to sludge or cake and adhere to the dispenser after operation of the machine. There is potential to decrease the likelihood of caking by changing the formulation of these products: granular forms of solid detergents have a smaller surface area and are less likely to cake; and different alkaline salts are more hygroscopic than others, and consequentially more likely to cake. The predominance of access from the dispenser strongly suggests that interventions focused on redesigning or relocating the dispenser have the most potential to prevent poisoning with this agent. The role of obstruction of water flow to the dispenser or prevention of rotation of spray arms by poorly stacked dishes also requires examination. The limitations of packaging are revealed by the small proportion of children who gained access to the detergent from the pack; two opened a child-resistant closure; two opened a pack without a child-resistant closure; and two chewed through a cardboard pack. These findings suggest that cardboard is not a suitable material for packs of these products. Unsafe storage and use offered the opportunity for exposure on several occasions: three children gained access to the detergent in the pack stored under the kitchen sink; and in three cases the detergent was in use on the benchtop. Most parents of children reported that they were aware of the dangers of these products. This suggests that a campaign to educate parents about the dangers of these products would not be likely to make a substantial contribution to prevention of poisoning with this agent. However, parents who were aware of this product’s toxicity reported that they were more likely to store it safely than the proportion of parents who were unaware. In most cases, a parent was present in the room when poisoning occurred, suggesting that the prob lem is more a matter of access than supervision, and that exposures are likely to continue to occur even if the adults are fully aware of the toxicity of these products. Additional efforts to educate the parents about toxicity may not be effective in preventing poisoning with these agents. Children reported to ingest a greater amount of detergent appeared to require a more intensive level of treatment, Most children ingesting a ‘finger lick’ of detergent (72 per cent) were treated at home with a mouth rinse, and did not attend for medical or hospital treatment. The cost and morbidity described in this study indicates that dishwasher detergent ingestion would be a fruitful subject for poisoning prevention efforts. Three of the 70 children (4.3 per cent) required one or more oesophagoscopies, and one required a gastroscopy, creating an expense to the health care system. At least two children required oesophageal dilation, one of whom required admission to the intensive care unit. This indicates that exposure to detergent caused substantial morbidity. Following this survey, the Victorian Committee on Poisoning Prevention invited detergent and machine suppliers, and representatives of the packaging industry, to a workshop colIectively to seek a solution to this complex poisoning problem. Members of the Committee presented information about poisoning with dishwasher detergents and the antecedents identified in this and other case series, and industry representatives presented. papers on opportunities for prevention by redesigning the chemical, the machine or the package. The workshop made recommendations about pos sible solutions, and industry participants undertook to develop several of these. The most immediate outcome was that suppliers of generic brand products undertook to provide all their products in packs with child-resistant closures within a few weeks of the workshop. The business manager of the largest s u p plier of dishwasher detergents has subsequently formed an industry working group involving the two major Australian dishwashing machine manufacturers to conduct research and redesign or relocate the dispenser. Currently, the major detergent supplier provides leaflets warning about the hazard for inclusion in most new machines. Several machine suppliers have arranged for a warning label to be attached to their machines, and the two local manufacturers are redesigning the machines to relocate the dispenser or alter its design to prevent access by toddlers to detergent. Dispenser redesign is hampered by the fact that almost all of them are obtained from the one source in Europe which supplies the international market. This source would not be likely to forgo economies of scale by producing a modified product for a relatively small market such as Australia. There is more potential to influence redesign or relocation of the dispenser if it could be shown that current dispensers provide access to detergent to large numbers of children in substantially bigger markets such as the United States and the European Economic Community. Many machine suppliers have amended the user’s guide provided with the machine to include a warning about this poisoning hazard. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

Automatic dishwasher detergent poisoning: opportunities for prevention

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Publisher
Wiley
Copyright
Copyright © 1996 Wiley Subscription Services, Inc., A Wiley Company
ISSN
1326-0200
eISSN
1753-6405
DOI
10.1111/j.1467-842X.1996.tb01029.x
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See Article on Publisher Site

Abstract

Barry J. Parsons Pharmacy Department, Rqal Childrens Hospital, Melbourne and Victorian Poisons Infmation Centre, ’ Melbourne Malcolm D. Dobbin Department of Health and Community Seruices, Melbourne Abstraa: We investigated the antecedents of ingestion of dishwashing machine detergent to enable the development of effective countermeasures. Parents who had sought advice from the Victorian Poisons Information Centre about dishwasher detergent poisoning exposures of their children were interviewed by telephone. Almost all the children (94 per cent) were aged between 6 and 29 months. Of the 61 children included in the survey, 53 (87 per cent) gained access to the detergent from the dishwasher. Of these, 50 (94 per cent) took the detergent from the dispenser on the internal surface of the door of the machine, and 38 (76 per cent) of these ingested detergent remaining in the dispenser after operation of the machine. Parents were present in the room on 78 per cent of occasions at the time of ingestion. Most parents (72 per cent) were aware of the toxicity of the detergents. Relocation of the dispenser or redesigning it to prevent access both before and after operation would have prevented most of the exposures to detergent. Altering the detergent to prevent caking or sludging might prevent many of the exposures to detergent remaining in the dispenser after operation of the machine. The level of prior knowledge about toxicity suggests that education or additional warnings are unlikely to contribute Substantially to prevention of poisoning. Telephone call-back to identified cases is a useful method of investigating complex poisoning prob lems and developing effectivecountermeasures. (Aust N ZJPublic Health 1996; 20: 278-83) OISONING continues to be a major paediatric problem.’ It is one of the leading causes of hospital attendance and admissions for injury in children, particularly for the 0 to 4 years age group.*4 Childhood poisoning problems are often complex, particularly when opportunities for exposure occur at a number of different stages in the normal use of poisoning agents. This makes the design of countermeasures difficult unless good data about the circumstances of poisoning are available. While substantial progress has been made in the prevention of poisoning, it remains a dynamic area as domestic technologies change, potentially poisonous domestic chemicals are introduced, and others are replaced. In Australia, strongly alkaline dishwashing machine detergents (automatic dishwasher detergents) have emerged as agents responsible for severe corrosive injury in children aged one to three years.5 It is estimated that one in five Australian households possesses a dishwashing machine.6 Most dishwashing machine detergents are formu- Correspondence to Barry J. Parsons, Director of Pharmacy, Pharmacy Department, Royal Children’s Hospital, Flemington Road, Parkville, Vic 3052. Fax (03) 9349 1261. Now at Pharmacy Department, Geelong Hospital, Geelong. lated from a mixture of alkaline salts, and are strongly caustic, with a pH of more than 11.5 in a 1 per cent solution. Caustic substances cause liquefaction necrosis of tissue, and ingestion may result in corrosive injury to the lips, mouth, pharynx and upper aerodigestive tract, with the potential for severe morbidity requiring complex and prolonged surgical management.’” Caustic ingestions are a major public health problem, accounting for an estimated 26 000 ingestions of corrosive agents each year in the United state^.^ Long-term sequelae for injured children include chronic oesophageal stricture and a greatly increased risk of cancer of the oesophagus in adult life.’o-’2It has been estimated that the incidence of oesophageal carcinoma in patients suffering from caustic stricture is at least 1000-foldthat in the general population.” This form of poisoning incurs a considerable cost to the health care system, both in the acute stage when patients require assessment by oesophagoscopy and hospitalisation,I3and in the prolonged and complex management of those who sustain corrosive injury of the upper aerodigestive tract. Characteristics of dishwashing machines make them effective vehicles for delivering this caustic AUSTRALIAN AND N W ZEALAND JOURNAL O WBUC HEALTH 1996 voc. 20 NO. 3 E F DISHWASHER DETERGENT POISONING chemical to toddlers: they are usually located in one of the busiest rooms in the house, where parents may be distracted when the machine is open; the detergent dispenser is usually located on the door, within the visual field and easy reach of crawling children when it is open; and the dispenser snaps open with light finger-tippressure, attracting a curious toddler’s attention. Toddlers are curious about mechanical devices and like to copy their parents. They are curious about the taste and mouth feel of materials like powders and liquids, and have sufficient mobility and motor skills to gain access to these detergents unrestrained by the sense of caution that comes with experience. In 1987 it became evident that dishwashing detergents were poisoning a substantial number of young children. ‘The National Health and Medical Research Council recommended that the states and territories amend their legislation to require liquid and gel forms of these detergents to be supplied in packs fitted with child-resistant closures, and all packs (including those of powdered detergents) to feature prominent warnings on the label indicating the hazard. Victorian Poisons Information Centre data indicate that, apart from the major agents which are the subject of poisoning inquiries (paracetamol, cough and cold preparations, benzodiazepines, oral contraceptives, cleaning agents, cosmetics), most callers inquire about ingestions of drugs or chemicals accounting for less than 2 per cent of calls. Dishwasher (detergentis in this category, accounting for about 1.3 per cent of calls concerning actual poisoning exposures of children aged 0 to 4 years. Nevertheless, because of the potential for severe morbidity, dishwasher detergent is a worthy subject for investigation. It was also recognised at that time that most exposures resulted from children gaining access to the detergent from the machine (T. Nolan, personal communication),5 so a recommendation for a warning label on dishwashing machines was referred to the National Consumer Products Safety Committee, since this was considered to be outside the area of responsibility of poisons legislation. In 1990 7Jictorian injury prevention personnel recognised that insufficient progress had been made in preventing further poisoning. This occurred despite efforts to warn parents of young children with media releases, a leaflet and adhesive warning label, and attempts to persuade authorities responsible for regulating the safety of electrical goods to address the problem. Since this experience was seen to be symptomatic of general liimitations of present systems to prevent poisoning, it was decided to call together injury prevention personnel representing various agencies with an interest in poisoning prevention. At the initial meeting the Victorian Committee on Poisoning Prevention was formed. Its purpose was to develop a collaborative approach to poisoning prevention by collecting data aimed at developing preventive interventions. Since the initial impetus for the formation of the committee was the problem of dishwasher detergent poisoning, it was decided to use methods developed to prevent this poisoning as a model for further activities. Two Australian case series indicated that toddlers were gaining access to the detergent at several stages in its chain of use: directly from the pack; from the dispenser in the machine prior to its operation; and from a sludge remaining in the machine after completion of its ~ p e r a t i o n The design of effective .~ countermeasures required more information about the circumstances of exposure. More complete data about the circumstances of poisoning were required to enable the development of specific poisoning prevention interventions. The Victorian Poisons Information Centre undertook to collect more specific data about the circumstances resulting in exposure. This paper reports detailed data collected from a sample of cases identified by the Centre from telephone inquiries about dishwashing machine detergent ingestions. Method The Victorian Poisons Information Centre is located in the Pharmacy Department of the Royal Children’s Hospital in Melbourne. The Centre is staffed by pharmacists and receives about 46 000 telephone calls per year seeking advice about acute and chronic poisoning. It provides information on poisons and the safety and appropriate use of chemicals and drugs. Calls are received from medical staff, allied health professionals and the general public. The Centre supplies a service to Victoria, which has a population of about 4.4 million. Between 1June 1991 and 1 March 1992, a sample of 70 calls of a total of 179 calls received from the general public about acute exposure or poisoning with dishwashing machine detergents were selected for detailed analysis of the circumstances of the incident and the sequelae. Cases were selected in sequence in four time blocks during the nine-month period. Treatment was recommended by the Centre’s pharmacists based on symptoms reported, estimated amount consumed, and on the parent’s own assessment. At the time of receipt of the call, and following poisoning management advice, callers were invited to participate in a follow-up survey using a preformulated questionnaire about the circumstances of the poisoning. Those agreeing were asked for their contact telephone numbers, but not their names, so they remained anonymous. Callers were contacted, usually within six to eight weeks of the initial call. The interviewing pharmacists indicated that they were calling from the Victorian Poisons Information Centre and were conducting a survey of dishwashing machine detergent ingestions. People contacted were informed that the survey was anonymous, that it would take about 10 to 15 minutes to complete, and that their involvement was voluntary. It was explained that the reason for the survey was to prevent poisoning with these products by defining aspects of packaging, product formulaW. AUSTRALIAN AND N W ZEALAND JOURNAL OF PUBLIC HEALTH 1996 E 20 NO.3 CORNISH ET AL. Table 1: Estimated amount of automatic dishwasher detergent consumed and reported source of treatmen! Amount consumed Teaspoonful ‘Finger lick’ n 010 n Oh Exposure to detergent All exposures Treatment Mouth rinse General practitioner Hospital Total,. Note: (0)53 children obtained detergent from the machine and 6 obtained i t from the packet 1 to 11 12to23 24to35 Age in months over35 Table 2: Access to automatic dishwasher detergent dispenser by children: time of access and reported source of treatment Time of access Before cycle Aher cycle n % n % Figure 1 : Percentage of inquiries, by age, for children exposed to automatic dishwasher detergent, and for all poisoning inquiries for children under 15 years Treatment tion and dishwasher design associated with the poisoning. The questions focused on six issues: means of access to detergents; quantity consumed; adult supervision at the time of the incident; knowledge of the dangers of dishwasher detergents by the adults present at the time of the incidenc first-aid measures used; and storage of the detergent. Respondents were also given the opportunity to comment on how such poisoning might be prevented in the future. Mouth rinse General practitioner Hospital Total” Note: (a) For 50 children for whom time of access was known Results Of the 70 callers, 61 were included in the survey. We were unable to contact four callers, and five callers declined to be included in the survey: four of these stated that they did not have enough time and one was not willing to discuss the incident. Information obtained at the time of the initial call to the Centre indicated that the circumstances of these poisonings were similar to those of the remainder of the sample. Data about the callers obtained at the time of the initial call did not otherwise enable comparison between participants and nonparticipants in the study. A greater proportion of exposures (66 per cent) occurred among the age group 12 to 23 months, compared to all poisoning inquiries (34 per cent) (Figure 1). Almost all children exposed to dishwashing machine detergent (94 per cent) were aged between 6 and 29 months, with a peak incidence in the age group 12 to 17 months (46 per cent). Male children accounted for 57 per cent of the exposures. This ratio is consistent with all poisoning inquiries about children received by the Centre. There was little difference in incidence of exposures between days of the week. Most children (86 per cent) exposed to the detergent consumed a ‘finger lick’ quantity (Table 1) and were usually treated at home with a mouth rinse. Of the eight children reported to have consumed larger quantities, six (75 per cent) attended a general practitioner or hospital emergency department for assessment. The proportion of children attending hospital was slightly higher for those children obtaining access to the powder detergent from the dispenser before commencement of the washing cycle, compared to those obtaining access to the detergent sludge remaining after completion of the cycle (Table 2). Of the 61 children included in the survey, 53 (87 per cent) obtained access to the detergent from the machine, six (10 per cent) from the packet, and 2 (3 per cent) in other ways. Of the 53 children who took the detergent from the machine, 50 (94 per cent) took the detergent from the detergent dispenser on the internal surface of the front door. The door to the dishwasher had been opened by an adult on 89 per cent of occasions and by the child on 11 per cent of occasions. Other access to detergent before commencement of the cycle were from the base of the machine (two children) and from detergent spilt on the surface of the door (one child). Information about the formulation of the detergent involved in exposures was collected (Table 3). In 46 out of the 50 cases (92 per cent) for whom information was available, a solid formulation (powder or granules) was involved. A higher proportion of exposures to the solid form (powder and granules) than for the liquid form occurred after completion o dishwasher operation. f 20 NO. 3 AUSTRALIAN AND N W ZEALAND JOURNAL OF WBUC HEALTH 1996 vot. E DISHWASHER DETERGENT POISONING Table 3: Access to automatic dishwasher detergent dispenser by children: time of access and formulation of detergent Time of access Before cycle After cycle n % n % ond child required two oesophagoscopies during a two-day admission. A third child was transferred to the Royal Children’s Hospital intensive care unit, underwent oesophagoscopy, and required follow-up oesophageal dilation. Formulation Liquid Powder Granule Total Nofe: 2 25” (a) Includes one case involving a detergent tablet Of the 50 children for whom information was available, 38 (76 per cent) obtained detergent from the machine after completion of the cycle, as a result of sludge forming in the machine, or failure of the machine to wash detergent from the dispenser. Six children took the detergent from the packet: two children opened the child-resistant closure (one was opened by a one-year-old child), two children opened the container (not a child-resistant packet), and two children chewed through the box. On three occasions the container was in its normal storage place (under the sink), and for the other three incidents, the detergent was in use and left accessible (in two cases on a benchtop). There werle only two other incidents in which the detergent was not taken from either the machine or the packet. In one incident an older sister allowed a five-year-old to fill the detergent dispenser, some detergent was spilt and then accidentally wiped across the child’s mouth. In the other incident, a child consumed liquid detergent from a milk contain’erused for temporary storage and left on the benchtop. This child had severe gastro-oesoplhagealburns requiring extensive treatment and follow-up. For 48 (78 per cent) of the 61 exposures, a parent was present in the room at the time of ingestion: 36 were filling or emptying the dishwasher and 12 were engaged in other activities. Of the remainder, inges tion occurred in eight cases when the child was left alone, in five cases for five minutes or less. The majority (72 per cent) of parents or supervisors were aware of the toxicity of dishwashing machine detergents. Of those who were aware of the toxicity, 90 per cent had stored the detergent out of reach of children in a high cupboard (more than 1.5 metres high) or in a locked cupboard. Of those unaware of the toxicity, only 50 per cent had stored the detergent out of reach. At the time of contact, three of the six patients who attended hospital were reported to have been managed initially in the emergency department and discharged after oral examination and observation. One of these ,returned next day for a gastroscopy. Three children were reported to have required admission to hospital. One was admitted for nine days, and had been unable to swallow. Three oesophagoscopies were performed and the patient discharged for weekly oesophageal dilation. A sec- Discussion The data collected in this study relied on reports of the circumstances of exposure to dishwashing machine detergents by parents or other carers up to eight weeks after the event. Therefore, there is potential for recall bias owing to an interpretation of events that minimises the carer’s responsibility for the child’s exposure. It is also possible that the validity of recall was adversely affected by the delay of several weeks before the informants were contacted. These data indicate that children aged between 6 months and 29 months are most at risk of exposure to caustic dishwasher detergents. This age range is similar to those described in case series of children with corrosive injury of the oesophagus from the ingestion of caustic materialI4 and children attending hospital after ingestion of dishwasher deterg e n t ~This age distribution differs from that of all .~ children who are the subject of calls to the Victorian Poisons Information Centre: 76 per cent of children exposed to dishwasher detergents were aged under 23 months, but only 44 per cent of children the who were the subject of poisoning inquiries to the centre were under 23 months. This difference may reflect the ease of access to these detergents from the open bottom-hinged doors that deliver the loaded dispenser to within a few centimetres of the floor, within the visual range and easy reach of crawling infants or toddlers. The spring-loaded dispenser lid operated with light finger-tip pressure may provide an added attraction to curious toddlers. It may also reflect the more advanced mobility, climbing ability and fine motor skills of older children which allow them access to a wider range of drugs and domestic chemicals stored in packaging such as screw-top bottles and jars. This study confirms the findings of previous reports of case series that the major source of exposure to dishwashing machine detergents is the machine? Almost all of the subjects in this study gained access to the detergent from the machine, both before its operation and after completion of its cycle. Most of the children gaining access from the dispenser in the machine did so after the machine door had been opened by an adult. This suggests that child-resistant catches on the door of dishwashing machines would make a limited contribution to poisoning prevention. Twelve children gained access to detergent from the machine prior to its operation: four out of the nine for whom there was information opened the dispenser themselves. Information about the relative proportions of solid and liquid forms supplied to the public is not available, so it is not possible to draw any conclusion about the relative safety of liquid versus solid forms of this product, although it may be that the ,liquid form is less likely to form a sludge and remain in the VOL. AUSTRALIAN AND NEW ZEALAND JOURNAL OF WBUC HEALTH 1996 20 NO. 3 CORNISH ET AL machine after completion of its operation. Most children gaining access to detergent from the machine dispenser ingested sludge remaining after completion of the machine’s washing operation. This suggests the possibility of preventing many of these exposures by addressing the potential of these products to sludge or cake and adhere to the dispenser after operation of the machine. There is potential to decrease the likelihood of caking by changing the formulation of these products: granular forms of solid detergents have a smaller surface area and are less likely to cake; and different alkaline salts are more hygroscopic than others, and consequentially more likely to cake. The predominance of access from the dispenser strongly suggests that interventions focused on redesigning or relocating the dispenser have the most potential to prevent poisoning with this agent. The role of obstruction of water flow to the dispenser or prevention of rotation of spray arms by poorly stacked dishes also requires examination. The limitations of packaging are revealed by the small proportion of children who gained access to the detergent from the pack; two opened a child-resistant closure; two opened a pack without a child-resistant closure; and two chewed through a cardboard pack. These findings suggest that cardboard is not a suitable material for packs of these products. Unsafe storage and use offered the opportunity for exposure on several occasions: three children gained access to the detergent in the pack stored under the kitchen sink; and in three cases the detergent was in use on the benchtop. Most parents of children reported that they were aware of the dangers of these products. This suggests that a campaign to educate parents about the dangers of these products would not be likely to make a substantial contribution to prevention of poisoning with this agent. However, parents who were aware of this product’s toxicity reported that they were more likely to store it safely than the proportion of parents who were unaware. In most cases, a parent was present in the room when poisoning occurred, suggesting that the prob lem is more a matter of access than supervision, and that exposures are likely to continue to occur even if the adults are fully aware of the toxicity of these products. Additional efforts to educate the parents about toxicity may not be effective in preventing poisoning with these agents. Children reported to ingest a greater amount of detergent appeared to require a more intensive level of treatment, Most children ingesting a ‘finger lick’ of detergent (72 per cent) were treated at home with a mouth rinse, and did not attend for medical or hospital treatment. The cost and morbidity described in this study indicates that dishwasher detergent ingestion would be a fruitful subject for poisoning prevention efforts. Three of the 70 children (4.3 per cent) required one or more oesophagoscopies, and one required a gastroscopy, creating an expense to the health care system. At least two children required oesophageal dilation, one of whom required admission to the intensive care unit. This indicates that exposure to detergent caused substantial morbidity. Following this survey, the Victorian Committee on Poisoning Prevention invited detergent and machine suppliers, and representatives of the packaging industry, to a workshop colIectively to seek a solution to this complex poisoning problem. Members of the Committee presented information about poisoning with dishwasher detergents and the antecedents identified in this and other case series, and industry representatives presented. papers on opportunities for prevention by redesigning the chemical, the machine or the package. The workshop made recommendations about pos sible solutions, and industry participants undertook to develop several of these. The most immediate outcome was that suppliers of generic brand products undertook to provide all their products in packs with child-resistant closures within a few weeks of the workshop. The business manager of the largest s u p plier of dishwasher detergents has subsequently formed an industry working group involving the two major Australian dishwashing machine manufacturers to conduct research and redesign or relocate the dispenser. Currently, the major detergent supplier provides leaflets warning about the hazard for inclusion in most new machines. Several machine suppliers have arranged for a warning label to be attached to their machines, and the two local manufacturers are redesigning the machines to relocate the dispenser or alter its design to prevent access by toddlers to detergent. Dispenser redesign is hampered by the fact that almost all of them are obtained from the one source in Europe which supplies the international market. This source would not be likely to forgo economies of scale by producing a modified product for a relatively small market such as Australia. There is more potential to influence redesign or relocation of the dispenser if it could be shown that current dispensers provide access to detergent to large numbers of children in substantially bigger markets such as the United States and the European Economic Community. Many machine suppliers have amended the user’s guide provided with the machine to include a warning about this poisoning hazard.

Journal

Australian and New Zealand Journal of Public HealthWiley

Published: Jun 1, 1996

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