What Medical Problems Do Laundry Pods Cause?

Patient Presentation
A 2-year-old female came to clinic for her 2 year health maintenance examination. Her mother said that she was a typical 2-year-old but was more adventurous. She seemed to be more active and would get into more things than her other 2 siblings. Recently her mother had found her trying to get into the laundry detergent. “Luckily I have safety locks on the cabinet but she was still trying to get into the container. I bought some of the new laundry pods because I thought they would be less messy, but I worry that she might have tried to eat them if I hadn’t found her. I’ve already put a second latch on the cabinet, ” her mother said.

The pertinent physical exam showed a healthy female with normal vital signs and growth parameters in the 25-50%. Her examination was normal. The diagnosis of a healthy female was made. “I’m really glad you already had a safety latch on the door and I know you try to keep a close eye on her. Laundry pods have become a bigger problem because the kids want to eat them. We actually recommend that parents of small children use regular liquid or powered detergent instead. So you could give the pods away or throw them out. If you keep them I would put the laundry pod detergent container high up in another cabinet if possible so the kids can’t get into them,” the pediatrician recommended. “I’ll write the poison control center number down for you to keep by your phone too just in case something happens.”

Discussion
Laundry detergent capsules are small, single-use pod, liquidtab or sachets with concentrated cleaning product encased in a water dissolvable membrane. They are brightly colored and promote use by being conveniently single-use. They are used mainly for laundry and dishwashers, and look similar to candy or toys which encourages ingestion by children. They were first used in Europe in 2001, and then were marketed in the U.S. in 2010. Not long afterwards, there was an increase in Poison Control Center calls regarding exposure to the products particularly by small children. An analysis from 2012-2013 found the number of exposures increased 645%. Exposure was approximately equal for both genders, and highest in the 1- and 2-yea- old age groups. Almost all cases were in children < 6 years old.

The pods contain anionic and non-anionic detergents and cationic surfactant. Some products also contact alkaline substances. All products contain irritants. It is not really known at this time why laundry pods have more toxic effects than liquid detergent but it does not appear to be simply a chemical concentration issue. Specific chemicals and alkalinity of the products are possible causes.

A review of common toxidromes can be found here.

Learning Point
Patients have primarily 3 types of health problems because of laundry pod exposure (data is from the 2014 study listed below, and is similar to other studies):

  • Ingestion – most common exposure at ~80%, types of clinical effects include emesis, nausea, oral or throat irritation, diarrhea and abdominal pain
  • Multiple routes ~10%
  • Ocular ~7% effects include pain/irritation, red eye/conjunctivitis, lacrimation, abrasion, burns and photophobia
  • Dermal ~1% effects include erythema, edema, irritation/pain, and rash

The most common clinical problems for all types of laundry pod exposures were emesis (48%), coughing/choking (13.3%), ocular irritation (10.9%), lethargy/drowsiness (7.0%) and red eye/conjunctivitis (6.7%).

Most children exposed to laundry pods were not treated in a health care facility (53.5%), 35.4% were treated and released from a health care facility, 2.4% were admitted to a critical care unit, and 2% were admitted to a non-critical care unit. Most children fortunately had a minor effect (50.3%), 17.6% had no effect, 0.6% had a major effect. Other children were not followed for various reasons (31.5%). Major effects include coma, seizure, pulmonary edema and respiratory arrest. Two children died. Endotracheal intubation was required by 102 children.

Although companies have made changes to their packaging including making containers opaque to be less attractive and being harder to open, it is recommended that households with small children use liquid or powdered cleaning products and not laundry pods. As with any household cleaner and other similar products, keeping them out of reach, in locked cabinets is the best way to decrease unintentional exposure with the products.

Questions for Further Discussion
1. Describe your treatment/management strategy if you had a child with a laundry pod exposure come to your practice?
2. What anticipatory guidance do you routinely provide to 2 year old children?
3. What anticipatory guidance do you routinely provide regarding poisoning?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Poisoning.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

American Association of Poison Control Centers. AAPCS Position Statement on Single-Load Liquid Laundry Packets. Available from the Internet at: https://aapcc.s3.amazonaws.com/files/library/AAPCC_Laundry_Packet_Position_Statement.pdf (cited 10/25/16)

Valdez AL, Casavant MJ, Spiller HA, Chounthirath T, Xiang H, Smith GA. Pediatric exposure to laundry detergent pods. Pediatrics. 2014 Dec;134(6):1127-35.

Fontane E. Ingestion of Concentrated Laundry Detergent Pods. J Emerg Med. 2015 Jul;49(1):e37-8.

Sjogren PP, Skarda DE, Park AH. Upper aerodigestive injuries from detergent ingestion in children. Laryngoscope. 2016 Jul 28.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

What Are Some Criteria For Varicocele Evaluation?

Patient Presentation
A 16-year-old male came to clinic for his health supervision visit. He was a wrestler who had had a shoulder strain and an auricular hematoma the previous season that were now resolved. He and his parents had no concerns. The review of systems was negative.

The pertinent physical exam showed a well-developed male with normal vital signs. Weight was in the 25% and length was in the 50%. Both were consistent with previous measurements. His examination was Tanner V for pubic hair and testicular size. His examination was normal except for a 2×2 cm “bag of worms” mass that was palpable in the upper scrotum that decreased when the patient was lying supine and increased when standing and performing a valsalva maneuver. The patient had been unaware of it and denied any pain. The testicles appeared to be the same size and no other masses or abnormalities were noted. The diagnosis of an asymptomatic varicocele was made. The physician discussed the varicocele with the family and originally was going to monitor it along with the family as it did not appear be causing any problems at the time. After reviewing a PUBMED search, the pediatrician talked with the family and referred the patient to a pediatric urologist for a more accurate testicular volume measurement and future monitoring.

Discussion

Varicoceles are caused by high venous back pressure which causes a tortuous dilatation of the testicular veins (pampiniform plexus) of the spermatic cord. They occur more on the left than right because the left renal vein has a higher pressure than the inferior vena cava which drain the left and right gonadal veins respectively. Varicoceles are not very common in young children (3% in < 10 years old) but increase during the adolescent years when the incidence is ~15% which is similar to the adult population. Most varicoceles do not cause problems, but can. The most worrisome problem is male infertility. "It is estimated that 85% of men with varicocele will not encounter male factor infertility." However for those with male factor infertility, varicocele occurs in up to 40% of men. "In contrast, most adolescents who present with varicocele are asymptomatic and their fertility future is unknown." Therefore evaluation and management for adolescent males with asymptomatic varicocele is controversial.

Varicoceles should reduce in size when the patient is supine. If the varicocele does not reduce when supine, a pelvic/abdominal mass should be considered. Varicoceles are graded with the patient standing:

    i. Palpable with valsalva
    ii. Palpable at rest
    iii. Grossly visible

Subclinical varicoceles are those that are found incidentally such as scrotal ultrasound. Subclinical varicoceles do not have an impact on fertility but can progress over time and may require long-term followup.

Learning Point

Some criteria for evaluation include:

  • Scrotal pain or discomfort that is chronic and not improved by support
  • Testicular volume loss or discrepancy – as assessed by orchiometer or ultrasound is important. Ultrasound is the most sensitive but orchiometer is less expensive.
    Testicular volume loss or discrepancy is often the primary determinant of potential treatment.

  • Additional urological problems

Evaluation can include initial and serial testicular volume measurement, semen analysis, and hormonal analysis. Indication for surgery, embolization or sclerotherapy treatment are also controversial with combinations of factors weighting the decision. One author states, “Varicocele treatment for infertility is not indicated in patients with either normal semen quality or a subclinical varicocele. Varicocele repair in adolescents should be considered when there is objective evidence of reduced ipsilateral testicular size.” Abnormal semen analysis or hormone levels also are factors in the decision making.

Questions for Further Discussion
1. What is included in the differential diagnosis of scrotal masses?
2. What are causes of testicular pain? A review can be found here.
3. Describe the differences between inguinal and femoral hernias?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Testicular Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Garcia-Roig ML, Kirsch AJ. The dilemma of adolescent varicocele. Pediatr Surg Int. 2015 Jul;31(7):617-25.

Kolon TF. Evaluation and Management of the Adolescent Varicocele. J Urol. 2015 Nov;194(5):1194-201.

Casey JT, Misseri R. Adolescent Varicoceles and Infertility. Endocrinol Metab Clin North Am. 2015 Dec;44(4):835-42.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

What are Potential Health Problems Associated with Polycystic Ovary Syndrome?

Patient Presentation
A new patient, 16-year-old female came to clinic with bilateral knee pain for 2 weeks. She said her knees hurt more as the day went on and with more physical activity. They felt better when she rested or in the morning. She denied any trauma and said that they “just hurt all over” and could not indicate any point tenderness. She denied any joint stiffness, other joint pain, swelling, redness, rashes, or visual problems. She was obese and had not lost weight. She had gained ~20 pounds per report since her last visit to another physician 9 months previously. The past medical history was remarkable for being diagnosed 14 months ago with polycystic ovary syndrome (PCOS) after an evaluation for hirsutism and oligomenorrhea. The patient was supposed to be taking some medications, but she and her mother said that they really didn’t understand why she was taking the medicines so they just stopped a few months after starting them. They had moved and had not re-established care until presentation for the knee pain. The family history was positive for obesity, diabetes, and heart disease. The mother denied any gynecological problems in the family.

The pertinent physical exam showed an obese female who was slow to move around the room. Vital signs were pulse of 94, respiratory of 20, blood pressure of 136/72, weight of 197 lbs with a BMI of 32.1. Her skin examination showed significant acanthosis nigricans and comedomal acne. Her thyroid had no masses. Heart was regular rate and rhythm without murmur. Abdomen was obese with no hepatomegaly. Her joint examinations were normal without edema, erythema and general normal range of motion that was only limited by her weight. Her knees had no specific point tenderness, joint line tenderness and medial and cruciate ligaments were intact.

The diagnosis of deconditioning and joint pain secondary to weight gain was made. As the patient and family did not understand her underlying diagnosis of PCOS the patient was referred to a pediatric endocrinologist for patient education, evaluation and monitoring. The patient also had a well-child examination appointment made as it had been more than a year since her last one. She was also referred to a physical therapist to help with the joint pain and conditioning. The family also agreed to meet with the clinic social worker to help coordinate appointments, transportation, obtaining medical records and also helping the mother to establish medical care for herself and the other children in the family.

Discussion
Polycystic ovary syndrome (PCOS) affects 6-8% of reproductive-age women making it the most common endocrinopathy in this age group. There is no consensus on the specific diagnostic criteria for PCOS in adolescents as many of the characteristics overlap with normal adolescent physiology. However, patients should have evidence of hyperandrogenism, oligo- or amenorrhea, and potentially polycystic ovaries. PCOS has a genetic component although a specific gene has not been identified. Incidence of PCOS is 20-40% for a woman with a family history.

Hyperandrogenism
Androgen levels change during puberty therefore actual measurement and interpretation can make the diagnosis more difficult. Obesity increases androgens. Puberty is associated with a 25-50% decrease in insulin sensitivity. Therefore evidence of hyperandrogenism can be difficult to document.

Acne and hirsutism are common presentations. Hirsutism is the presence of terminal hairs in androgen dependent areas (i.e.male pattern) and is evidence of hyperandrogenism. Hypertrichosis is increase in vellus hair in non-male patterned areas such as forearms and lower legs and needs to be distinguished from hirsutism. Hypertrichosis is not evidence of hyperandrogenism. Patients may also have an increase in muscle mass or voice deepening.

Oligo- or amenorrhea
Anovulatory cycles are normal in pubertal girls so oligomenorrhea ( 2 years or have amenorrhea past the normal menarche should be considered for evaluation. This is especially true if hyperandrogen symptoms are present or if there is a family history of PCOS.

Polycystic ovaries
Multicystic ovaries are part of normal physiology for adolescent girls so diagnosis may overlap with adult criteria. Transvaginal ultrasound is a better imaging modality than transabdominal ultrasound for visualizing the ovaries. But many adolescents require transabdominal ultrasound because they are virginal or will not tolerate the procedure. Obesity also limits the adequacy of the transabdominal study.

The differential diagnosis of PCOS includes:

  • Congenital adrenal hyperplasia, late onset
  • Cushing syndrome
  • Hyperprolactinemia
  • Hypothyroidism
  • Pregnancy
  • Primary ovarian failure
  • Tumors – adrenal or ovary
  • Acromegaly

Treatment includes lifestyle modifications to improve obesity, insulin insensitivity and dyslipidemia. Oral contraceptives, usually combination medications, can improve menstrual irregularities, decrease androgens and improve hirsutism. Androgen receptor blockers such as spironolactone, also have similar effects. Insulin sensitizers such as metformin can improve insulin sensitization, menstrual irregularities and decrease androgens. Cosmetic methods of hair removal, and treatment of acne can also be helpful additional treatment for PCOS patients.


Learning Point

Potential health problems in PCOS include:

  • **Irregular menses
  • Infertility
  • Endometrial cancer
  • Obesity
  • Hyperlipidemia
  • Non-alcoholic fatty liver disease
  • Sleep apnea
  • **Acne
  • **Hirsutism
  • Insulin insensitivity, hyperglycemia
  • Type 2 diabetes
  • Acanthosis nigricans
  • Dyslipidemia
  • Hypertension

  • Emotional/psychiatric problems

** Common presentations of PCOS in adolescents

Questions for Further Discussion
1. What evaluation for PCOS should be considered?
2. What specialists help to manage PCOS?

Related Cases

    Symptom/Presentation: Pain

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Polycystic Ovary Syndrome and Knee Injuries and Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Irizarry KA, Brito V, Freemark M. Screening for metabolic and reproductive complications in obese children and adolescents. Pediatr Ann. 2014 Sep;43(9):e210-7.

Hecht Baldauff N, Arslanian S. Optimal management of polycystic ovary syndrome in adolescence. Arch Dis Child. 2015 Nov;100(11):1076-83.

Rosenfield RL. The Diagnosis of Polycystic Ovary Syndrome in Adolescents. Pediatrics. 2015 Dec;136(6):1154-65.

Morris S, Grover S, Sabin MA. What does a diagnostic label of ‘polycystic ovary syndrome’ really mean in adolescence? A review of current practice recommendations. Clin Obes. 2016 Feb;6(1):1-18.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital