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Clinical Pharmacology "Adverse Drug
Event of the month"
Kerosene (Hydrocarbon) poisoning in Children: Something absolutely preventable Introduction and cases Kerosene is a petroleum distillate hydrocarbon that is a central nervous system depressant in high doses and a gastrointestinal and respiratory tract irritant. During the intensive in-hospital adverse event monitoring in the department of Pediatrics, four cases (three boys, one girl) of alleged accidental ingestion of kerosene were admitted in the hospital during the three-month period of January-March 2004. Their age ranged from 1-4 years. The parents provided the history that these children had ingested 10-30 ml of kerosene. Of the four patients, one presented with cough, another with nausea and third with vomiting. The fourth patient was asymptomatic. None of the patients demonstrated any abnormality in the routine chest radiograph carried out at least 6 hours after the reported time of ingestion. The patients received symptomatic treatment and they were kept under observation for 2 days. They were discharged from the hospital after an uneventful hospital stay of 48 hours. Discussion: Poisoning in children is the twelfth most common cause of admission to the pediatric ward (1). It constitutes 0.23 to 3.3% of total poisoning cases and the case fatality rates with childhood poisoning range from 0.64 to 11.6%(2). Accidental poisoning commonly involves children below 5 years of age and kerosene is the commonest orally- consumed poison in Indian children. (3, 4). A prospective study in 120 subjects with poisonings admitted over a 24 month period by Mehta et al found that 56/120 subjects (46.7%) had ingested kerosene. (4). A 3-year retrospective analysis by Gupta et al of 70 children with kerosene poisoning reported a mortality rate of 4.3%. Their study also indicated that ingestion of more than one ounce of kerosene oil adversely affected the clinical and radiological profile (5). Mortality is also high when the poisoning results in chemical pneumonitis. Symptoms of kerosene poisoning include burning of mouth and throat, cough with subsequent nausea and vomiting. Kerosene may get inhaled or aspirated into the respiratory canal leading to chemical pneumonitis. Kerosene being a low viscosity hydrocarbon spreads rapidly across surfaces and when aspirated, covers large areas of the lung (6). Low doses of kerosene can cause central nervous system excitation . en it is ingested in low doses. Rare symptoms include coma, seizures, and acute hepatic or renal failure. Sudden death can result from myocardial irritability and ventricular fibrillation. The diagnosis is based on history and clinical presentation since hydrocarbon assays are not routinely available. In children with chemical pneumonitits, chest radiographs may show infiltrates, atelectasis, effusion and pneumatocele. Although radiological abnormalities could be detected within 2-3 hours of ingestion of kerosene, their appearance could be delayed up to 8-12 hours. Hence, it is customary to take a routine film at 6-8 hours after ingestion. The treatment is mainly supportive in nature and therapeutic interventions include administration of oxygen, provision of respiratory support, monitoring of hepatic, renal and myocardial functions, correction of metabolic abnormalities and maintenance of hydration and nutrition. Patients with aspiration pneumonitis should be monitored carefully for oxygenation and need for ventilatory support. Children have to be treated for superadded bacterial infections, if present. Among the hydrocarbons, ingestion of aromatic (xylene and toluene) and halogenated hydrocarbons (carbon tetrachloride and trichloroethane) is treated with gastric lavage. Due to its "not-so-good" taste, most children do not consume kerosene in large volumes. Most spit it out after tasting the liquid. Hence, systemic toxicity does not occur very frequently. On the other hand, it is possible that a child may gag or vomit while a naso-gastric tube is being passed. During vomiting, a part of the vomitus may get aspirated into the respiratory tract. Therefore, inducing vomiting by administration of emetics or removal of kerosene by gastric lavage are fraught with danger of causing chemical pneumonitis. Considering the lower possibility of CNS toxicity and the unfortunate prospect of precipitating chemical pneumonitis which is associated with incremental morbidity and mortality; emesis and gastric lavage are not routinely undertaken in children who have ingested kerosene. To put it in plain words, the risk-benefit assessment does not merit undertaking these procedures (6). Gentle gastric lavage with precautions to prevent aspiration may have to be undertaken if the child has ingested large quantities of kerosene and there is a risk of resultant CNS toxicity. Families belonging to lower socioeconomic class use kerosene as a fuel for cooking. These families also stay in tiny, overcrowded dwellings. They store everything on the floor and dangerous chemicals, drugs and equipments are accessible to a child. Children over the age of one year are extremely inquisitive and have also the ability to be mobile by themselves. These abilities help children learn new skills and acquire new knowledge. However, the same faculties expose them to "unforeseen" risks. Besides inquisitive nature, increased mobility, low socio-economic status, lack of parental awareness, other etiological factors for childhood poisoning include unsafe environment and accessibility to dangerous substances (4). No doubt parents need to be informed about these dangers. Accidents and poisoning in children are eminently preventable. However, health care providers should be agile enough to provide this information at the right time. Immunization visits at 9 months, monthly visits for growth monitoring and nutritional advice and unscheduled visits for trivial childhood illnesses offer opportunities for the healthcare providers to inform and educate parents about the dangers lurking in the environment and how they could be prevented. The sight of a child who has had multiple contacts with healthcare providers being brought with kerosene poisoning represents the tragic saga of missed opportunities. Offering correct advice at the appropriate time could help prevent the pain children have to go through, the agony and economic loss that the families have to suffer from and the scarce hospital resources that society at large has to commit for taking care of these totally preventable adverse events. References: 1. Pandey P, Ghai OP. Poisoning and accidents. In: Gupta P, Ghai OP (Eds.) Essential Pediatrics, 5th edition, New Delhi, Interprint 2000, P 511. 2. Datta AK, Seth A, Goyal PK, Aggarwal V, Mittal SK, Sharma R, et al. Poisoning in children: Indian scenario. Indian J Pediatr 1998; 65: 365-70 3. Kumar V. Accidental poisoning in South West Maharashtra. Indian Pediatrics 1991; 28:731 4. Mehta A, Kasla RR, Bavdekar SB, Hathi GS, Joshi SY. Acute Poisonings in Children. JIMA 1996; 219- 21 5. Gupta P, Singh RP, Murli MV, Bhargava SK, Sharma P, et al. Kerosene poisoning-a childhood menace. Indian Pediatrics 1992; 29: 979-84. 6. George C, Matyunas NJ, Jenson HB. Poisoning: Drugs, chemicals, and Plants. In: Behrman RE, Kliegman RM (Eds.) Nelson Textbook of Pediatrics, 17th edition, Philadelphia, AIES Saunders, 2004, Pp 2362-75. 7. Linden CH, & Burns MJ. Illness due to poisons, drug overdosage, and Envenomation. In: Braunwald E et al (Eds) Harrison's Principles of Internal Medicine, 15th edition .USA: McGraw-Hill companies, 2001, Pp 2609 Department of Clinical Pharmacology* Department of Pediatrics** Seth GS Medical College and KEM hospital Parel, Mumbai 400 012, INDIA |