Over the 16-year study period, there were 1,317,970 pediatric exposures to cleaning products reported to the NPDS which met the selection criteria for this study. The majority of exposures occurred in males and those aged ≤ 3 years old. Outcomes exceeding a medical outcome of moderate per AAPCC definition were uncommon, occurring in only 2.6% of all exposure calls. These findings are consistent with previously reported AAPCC data [1, 2]. The overall low risk of household cleaner exposures with the majority of cases being able to be managed safely at home without the need for a higher level of medical care is a continued testament on the importance of the AAPCC and the PCCs they maintain. Critical findings resulting from this project were that a majority of the exposures, 86.9%, required no higher level of care and were managed at home and the alkali category was the third most common exposure to children that resulted in a relatively high rate of medical outcomes exceeding a definition of moderate per AAPCC definition.

A majority of all unintentional poisonings fall on a population where verbal communication and verbal education are absent due to the child’s developmental stage. It is important that effective strategies such as the implementation of engineering and administrative controls to prevent poisoning events are utilized. Emphasizing safe storage and prioritization of access to oven cleaners and drain cleaners during well-child visits may help raise awareness and prevent further significant injury outcomes. Providing free or low-cost locks for lower income families may also be a viable and cost-effective intervention and may be a good focus for a cost/benefit analysis.

There are several limitations of this study. Being cross-sectional in design, with all data coming from an already established data system provided, there is little control over exposure and outcome variables. This can lead to misclassification. When evaluating exposure route, we found “Aspiration” was completely absent for many of the years reported, with an overall prevalence of < 0.1% overall. Whether or not this is true representation of calls or a result of differences in reporting by time, location, individual or re-classification(s) is impossible to determine and one example of how misclassification may exist in this dataset. This study was also unable to account for temporal relationships related to extrinsic and ecological factors outside the data that exist during the time period of the study which may have a confounding effect on relationships presented. NPDS data is representative of the entire population from all national PCCs. This allows evaluation of relationships within this population only. Inference about the true prevalence of unintentional poisoning to household cleaners and their relationships in the United States cannot be made based on this type of study and this data is considered an underestimate of the true prevalence of exposures and likely to have significant misclassification. Data was also self-reported and the majority of cases were unable to be verified.

A particular area of interest not addressed in this study is exposures to cleaning products with child resistant packaging. One of the key agencies involved in regulation of products and child resistant packaging is the U.S. Consumer Product Safety Commission (CPSC). The CPSC was responsible for passing the Poison Prevention Packaging Act (PPPA) in 1970 stating that a household product deemed as hazardous “Must be designed or constructed to be significantly difficult for children under five years of age to open within a reasonable time, and not difficult for normal adults to use properly” [11] Despite this definition, the CPSC stands by a powerful statement that “There is no such thing as child-proof packaging” [11]. There is evidence that child resistant packaging is effective. One analysis of the PPPA found that rates of accidental aspirin ingestion from 1973–1978 decreased 45% following packaging regulations [12]. Alkali based drain cleaners and oven cleaners containing > 10% dry forms of sodium and/or potassium hydroxide or > 2% in other forms, fall under the PPPA. Unfortunately, many household cleaning products are exempt from this act and often the only requirement is a statement of “not child resistant” on the packaging for household products [10].

A final limitation is this study period preceded the COVID-19 pandemic. The pandemic has increased the use of cleaning products, as well as cleaning exposure calls to PCCs5, however this study was unable to address any increase pediatric exposures during this time. Further study on the effect of pandemic related cleaning and pediatric exposures should be investigated.