SPECIFIC SUBSTANCES
Household products
Allister Vale
Abstract
Household products are generally ingested accidentally by children. In
developing countries more toxic agents are available in a domestic
setting, but in the developed world serious toxicity is rare.
Keywords Batteries; bleach; detergents; disinfectants; petroleum
distillates; reed diffusers
Introduction
Household cleaning products account for some 10% of exposures
reported to the UK National Poisons Information Service (NPIS)
and 8% of exposures reported to the American Association of
Poisons Control Centers National Poison Data System, which is
not surprising considering their ubiquitous nature in a home.
In a study reported by the UK NPIS, of 5939 enquiries
regarding exposures to household products,1 exposures were
most common among children <5 years of age (66.5% of ex-
posures). The majority of exposures occurred at home (97.6%)
and most were accidental (93.6%). Liquid laundry detergent
capsules were most commonly involved (n ¼ 647), followed by
bleaches (n ¼ 481), air fresheners (n ¼ 429), multipurpose
cleaners (n ¼ 408), dishwasher products (n ¼ 399) and descalers
(n ¼ 397).
Exposure to household products occurred mainly as a result of
ingestion (75.8%), with eye contact (8.4%), inhalation (6.9%)
and skin contact (3.1%) being less common; 5.1% of enquiries
involved multiple routes of exposure. The most commonly re-
ported features were vomiting (ingestion), pain (eye contact),
dyspnoea (inhalation) and burns (skin contact). The majority of
patients (70.5%) were asymptomatic (World Health Organization/
International Programme on Chemical Safety/European Commis-
sion/European Association of Poisons Centres and Clinical Toxi-
cologists Poisoning Severity Score [PSS] 0), 28.0% developed
minor features (PSS 1), 1.3% developed moderate features (PSS 2)
and 0.15% (nine patients) developed serious features (PSS 3).
Detergents
Liquid laundry detergent capsules (also called single-use deter-
gent sacs, laundry pods) have become an increasingly popular
household product over the last decade. The capsules are a
pouch of concentrated liquid laundry detergent in a water-
soluble polyvinyl alcohol membrane that can be placed directly
in a washing machine. In Europe, these liquid detergents most
commonly contain anionic surfactants (20e35% per capsule),
non-ionic surfactants (10e20%), propylene glycol (8e20%) and
ethanol (2e5%), and have a pH of 7e9.
Allister Vale MD FRCP FRCPE FRCPG FFOM FAACT FBTS FBPhS FEAPCCT is
Director of the National Poisons Information Service (Birmingham
Unit) at City Hospital, Birmingham, and Honorary Professor,
University of Birmingham, UK. Competing interests: none declared.
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These capsules are easy to use, providing the exact unit dose
of detergent per wash and are placed directly into the washing
machine. The capsules are designed to release their contents
when they come into contact with water, and this can happen
prematurely if they come into contact with moisture, for example
in the hands or mouth.
As a result, there have been a substantial number of expo-
sures reported in recent years, predominantly involving children
<5 years of age.2,3e6 While the majority of patients remain
asymptomatic or suffer only minor features (PSS 1), a small
proportion develop features such as central nervous system
(CNS) depression, stridor, pulmonary aspiration and/or airway
burns following ingestion, and conjunctivitis leading to corneal
ulceration from eye exposure.2,3
Bleaches
Bleaches are used to whiten clothes and remove stains (and as
disinfectants e see below). Most household bleaches contain
sodium hypochlorite, but others contain 6% hydrogen peroxide.
Following the ingestion of weak concentrations of sodium
hypochlorite (<5%), symptoms are usually mild. With stronger
bleaches, particularly >10% hypochlorite, features are more
severe. Small amounts cause a sensation of burning. The
oropharynx can look mildly inflamed but burns are unlikely.
Larger doses cause nausea, retching, vomiting, diarrhoea and
rarely haematemesis. In severe cases, a hypernatraemic hyper-
chloraemic acidosis, hypotension, coma, convulsions and
cardiorespiratory arrest can occur.7,8 The gastrointestinal mu-
cosa can become haemorrhagic, ulcerated and perforated.
Chlorine is not released from bleach solutions in appreciable
amounts under normal use conditions. However, the mixing of hy-
pochlorite with acids (e.g. when cleaning the toilet bowl) can result
in a substantial release of chlorine and lung injury. Mixing bleach
with ammonia produces chloramine compounds (mainly mono-
chloramine), which can produce severe chemical pneumonitis.9
Hydrogen peroxide causes toxicity via three main mechanisms:
corrosive damage, oxygen gas formation and lipid peroxidation.10
Ingestion can cause irritation of the gastrointestinal tract with
nausea, vomiting, haematemesis and foaming at the mouth; the
foam can obstruct the respiratory tract or result in pulmonary
aspiration. Painful gastric distension and belching can be caused by
the liberation of large volumes of oxygen in the stomach. Blistering
of the mucosae and oropharyngeal burns are common following
ingestion of more concentrated solutions. Most inhalational expo-
sures cause little more than coughing and transient dyspnoea.
Disinfectants
Disinfectants are antimicrobial agents. Previously, these solu-
tions commonly contained phenol (carbolic acid) or cresol (cre-
sylic acid), but these have largely been replaced by the less toxic
chlorophenol or chloroxylenols (dichlorometaxylenol and para-
chlorometaxylenol). Quarternary ammonium compounds such
as benzalkonium chloride, cetyl trimethylammonium bromide,
cetylpyridinium chloride and benzethonium chloride are also
used as disinfectants. Sodium hypochlorite and hydrogen
peroxide (see above) are also effective disinfectants because they
release chlorine and oxygen, respectively, which oxidizes the cell
membrane of microorganisms.
1 Ó 2016 Published by Elsevier Ltd.
 SPECIFIC SUBSTANCES
Chloroxylenols and chlorophenol
These compounds can cause a burning sensation in the mouth
and throat and vomiting. They can cause coma, hypothermia,
hypotension and respiratory depression.11 If the product contains
ethanol, this can exacerbate the CNS depression. Metabolic
acidosis and bradycardia can occur and aspiration pneumonia
and pulmonary oedema have been reported. These complications
can arise following ingestion of a relatively small quantity.
Ingestion of a large quantity of a phenolic disinfectant can cause
renal impairment,12 which can be exacerbated by hypotension
and fluid loss due to excessive vomiting.13
Quaternary ammonium compounds
Concentrated solutions of these compounds (particularly those
10%) can cause immediate burning pain in the mouth, throat
and abdomen, hypersalivation and ulceration of mucous mem-
branes, followed by vomiting, haematemesis, diarrhoea and
confusion.14 In severe cases, which are uncommon, there can be
hypotension, shock, convulsions, respiratory paralysis and
coma. Metabolic acidosis and increased liver enzyme activities
can occur.15 Dermal burns have been reported with concentrated
cetrimide, including solutions of 12% and 17%. Eye exposures
can cause corneal damage.
Petroleum distillates
Petroleum distillates, which include paraffin (kerosene) and
white spirit, are among the most common exposures with
household products worldwide. Nausea, vomiting and diarrhoea
can follow ingestion. A double gastric fluid level may be visible
on X-ray, the lower being the aqueous and the higher the hy-
drocarbon portion in the stomach. The greatest hazard from
ingestion, however, is the associated risk of pulmonary aspira-
tion, causing choking, coughing, wheeze, breathlessness and
possibly cyanosis, hypoxia, fever and leucocytosis. The chest X-
ray may show shadowing in the mid or lower zones. These
symptoms and signs may progress over 24e48 hours. Rarely,
pleural effusions or pneumatocoeles develop.
After substantial ingestion, systemic uptake can result in the
features typical of the narcotic effects of more volatile hydro-
carbons, with CNS depression, convulsions and cardiac ar-
rhythmias. Prolonged contact with skin leads to defatting and
acute inflammatory changes.
In most cases, petroleum distillate ingestion requires no
treatment. Emesis and lavage are absolutely contraindicated as
they can lead to aspiration. However, if a large volume (probably
more than 1 mL/kg body weight) has been ingested, gastric
aspiration can be considered provided the lungs can be protected
by insertion of a cuffed endotracheal tube. The value of gut
decontamination has not been demonstrated in clinical trials.
Activated charcoal is of no value. Supportive measures may be
required in serious cases, but prophylactic corticosteroids and
antibiotics are of no value. If the presence of secondary infection
is proven, antibiotics should be used.
Batteries
These are mainly alkaline (nickel, lithium, cadmium, manganese
dioxide, zinc, silver); mercuric oxide batteries are now banned in
the European Union. Disc (button) batteries are imprinted with a
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code through which it may be possible to identify the chemical
composition.
There are three potential hazards:
 Obstruction e batteries larger than about 20 millimetres
in diameter can become stuck in the oesophagus, causing
obstruction. A chest X-ray is therefore indicated in every
case.
 Leakage e ingested batteries can break open and release
their contents.
 Corrosive effects e batteries can cause local corrosive
effects on the gut wall, with subsequent perforation. These
effects result from leakage of sodium hydroxide or corro-
sive salts from the cells (particularly alkaline manganese
types) and from local electrical discharges (possible only
with batteries that retain much of their charge when
swallowed).
Disc batteries stuck in the oesophagus must be removed,
preferably by endoscopic techniques with or without the use of
magnets. However, most batteries pass into the stomach without
difficulty and do not cause symptoms. In about 60% of cases,
batteries transit the gut within 48 hours and no treatment is
required. In the remainder, transit can take up to 1 week. This
can be speeded by the aid of a laxative, or whole-bowel irrigation
can be considered. There is controversy over whether batteries
that are slow to clear the gut should be removed surgically, to
eliminate the risk of complications should the battery case
disintegrate. However, batteries whose casings are seen radio-
logically to be disintegrating should be removed.16,17
Reed diffusers
Reed diffusers are popular household air fresheners and
comprise vessels or jars made of glass, containing fragrance
liquid and ‘wicking’ reeds, which act to diffuse the scent of the
liquid. In addition to essential oils, the liquid commonly contains
glycol ethers (propylene glycol monobutyl ether, dipropylene
glycol monomethyl ether, dipropylene glycol n-butyl ether,
dipropylene glycol methyl ether acetate); other ingredients and/
or alternatives are 3-methoxy-3-methyl-1-butanol, petroleum
distillates (see above), ethanol and isopropanol.
Experimentally, dipropylene glycol monomethyl ether causes
CNS, respiratory and cardiac toxicity18,19 and dipropylene glycol
n-butyl ether produces CNS toxicity.20 3-Methoxy-3-methyl-1-
butanol has caused CNS toxicity and oesophageal injury in
children.21,22 The ingestion of ethanol and/or isopropanol can
also induce CNS depression. The features of essential oil inges-
tion include dysaesthesia inside the mouth, nausea, vomiting,
tachycardia, drowsiness and, in severe cases, convulsions and
coma. Hence the chemicals present in reed diffusers are poten-
tially very toxic, especially as they are often present in high
concentrations. Despite the presence of chemicals known to
cause CNS, respiratory, cardiac and ophthalmic toxicity, few
patients with severe symptoms have been reported.23 A
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