Unintentional poisoning from liquid fuels accounts for approximately 2.5% of all unintentional poisoning exposures among children aged less than 6 years (1). The risk for unintentional poisoning increases when fuel is transferred from its original container, often with required child-resistant packaging, to other containers (e.g., fuel lamps) without special packaging requirements (2,3). This report describes the poisonings of four children who were admitted to a regional referral medical center in Columbus, Ohio, during a 2-week period in August 1997; these children developed serious pulmonary complications after ingesting household lamp oil. CASE REPORTS

Case 1. On August 11, a 13-month-old boy was given ipecac inappropriately by his father after ingesting up to 1/2 cup of lamp oil. The child vomited and became lethargic. On arrival at a community emergency department (ED), he was cyanotic and had nasal flaring. He was intubated because of respiratory insufficiency and was transported to a tertiary-care medical center. His hemoglobin level was 11.9 g/dL (normal: 11.5 g/dL-13.5 g/dL) and was not remeasured. On August 15, he was extubated. His condition improved except for a productive cough, which was treated with antibiotics. On August 18, he was discharged with no further difficulty breathing.

Case 2. On August 14, a 7-month-old girl was taken to a local ED because of episodes of tachypnea, retractions, rhonchi, and coughing. Her first chest radiograph was normal. She was transported to a tertiary-care medical center, where she was intubated because of increasing respiratory distress. Additional chest radiographs showed infiltrates in the right and left lung fields, and pneumonia was presumptively diagnosed. Her hemoglobin level decreased from 12.7 g/dL on August 14 to 9.8 g/dL on August 15. She developed pneumothorax, which was treated with tube thoracostomy. She suffered a cardiac arrest but was resuscitated. After resuscitation, extracorporeal membrane oxygenation (ECMO) was started. She required multiple blood transfusions to maintain adequate oxygenation. Blood and sputum cultures did not identify a bacterial cause for pneumonia. ECMO was continued for 5 days, and conventional mechanical ventilation was continued for an additional 3 days. On August 22, the patient was extubated and had no further difficulty breathing. Although a computerized tomography scan of the head showed cloudiness and loss of grey-white differentiation that was consistent with substantial ischemic damage, a neurodevelopmental assessment showed no deficits. On August 27, she was discharged. On August 16, her mother found a empty oil lamp in the girl's play area at home. Although the mother believed the lamp was empty before the child became ill, she recalled that symptoms developed shortly after the girl began playing with the lamp.

Case 3. On August 19, a 20-month-old boy drank 1/2-1 cup of a commercial lamp oil. He immediately began drooling, coughing, and wheezing, and he became lethargic. On arrival at a local ED, he was unresponsive except to noxious stimuli. On physical examination, he had intercostal and subcostal retractions. He was intubated because of increasing respiratory insufficiency, and a chest radiograph showed bilateral pulmonary infiltrates. His hemoglobin level was 11.8 g/dL and decreased to 9.0 g/dL the next day. On August 22, he was extubated but developed severe respiratory distress and was reintubated. He developed fever of 104 F (40 C) and had seizures. He was administered intravenous phenytoin and antibiotics. On August 23, he was extubated. On August 27, he was discharged, and no further seizures occurred.

Case 4. On August 25, a 10-month-old boy drank 1 cup of kerosene from a household oil lamp. The same day, he was taken to an ED with coughing, grunting, and nasal flaring. On arrival, he was intubated because of respiratory distress. A chest radiograph showed bilateral pulmonary infiltrates. His hemoglobin level was 12 g/dL; the next day, it decreased to 10.4 g/dL. On August 27, he was extubated. The same day, antibiotics were administered because of purulent sputum, which later grew Streptococcus pneumoniae. On August 31, he was discharged and given oral antibiotics and had no difficulty breathing. SUMMARY EVALUATION

All four patients were poisoned from oil from the same type of lamp that has a central oil reservoir in which a wick is placed. The wick is encased in a glass sleeve, which can be used as a "straw" by children. The attractiveness of these lamps, the relatively large volume of lamp oil that they contain, and the "straw" around the wick all increase the risk for ingestion and aspiration. Because of the poisoning of these four children, a series of local radio and television public service announcements was aired in an attempt to prevent further occurrences.

Reported by: M Casavant, MD, P Walson, MD, W Wolowich, PharmD, M Kelley, MD, Pediatric Pharmacology Research Unit, Children's Hospital, Columbus, Ohio. Health Studies Br, Div of Environmental Hazards and Health Effects, National Center for Environmental Health, CDC.

Editorial Note

Editorial Note: The U.S. Consumer Product Safety Commission (CPSC) estimates that approximately 2300 children aged less than 5 years are treated in hospital EDs each year because of poisoning by petroleum distillates that are not required to be in child-resistant packaging (1). Petroleum distillates, a group of hydrocarbon-based chemicals refined from crude oil, include gasoline, kerosene, mineral spirits, and paraffin. Lamp oil consists of a combination of petroleum distillates that differ by manufacturer. Some preparations of lamp oil contain aromatic hydrocarbons, or various scents and dyes, including aniline dyes that can contribute to additional toxicities (3). In 1996, the regional poison-control center in Columbus, Ohio, reported 95 lamp oil ingestions. In 1996 in the United States, the American Association of Poison Control Centers (AAPCC) Toxic Exposure Surveillance System (TESS) reported 2879 lamp oil ingestions (AAPCC, TESS, unpublished data, 1998).

Ingestion is the most common route of exposure to hydrocarbons, including lamp oil. The viscosity of the oil is an important property because it relates directly to the risk for pulmonary aspiration. Compounds with low viscosity and high volatility (e.g., gasoline, kerosene, and lighter fluid), can spread over mucosal surfaces easily and rapidly (4). When ingested, hydrocarbons produce toxic effects in several organs and organ systems including the pulmonary and central nervous systems, the gastrointestinal and cardiovascular systems, and the hematopoietic system; some hydrocarbons cause acute intravascular hemolysis (3). Among these, the most serious damage occurs to the pulmonary system. Chemical pneumonitis is the greatest cause of death and injury (2-4).

Under the Poison Prevention Packaging Act, the CPSC enforces the requirement that any prepackaged, low-viscosity, liquid-kindling or illuminating fuels that contain at least 10% petroleum distillates must be supplied with child-resistant packaging (5). However, lamp oil is usually sold in separate prepackaged containers with child-resistant packaging, and the oil is later transferred to fuel lamps. The CPSC regulates products in their original containers and has not promulgated child-resistant packaging requirements for fuel lamps unless the lamp is sold containing the fuel. The CPSC is exploring additional measures to help avoid these ingestions.

Pediatricians, poison-control centers, public safety groups, and others interested in childhood injury prevention should increase public awareness concerning the risk for poisoning caused by household lamp oil. Parents should be warned to keep lamps out of the reach of children, close prepackaged containers after every use, and ensure child-resistant caps are fastened correctly. Parents should also keep lamp oils in their original containers. If exposure to lamp oil does occur, parents should not induce vomiting and contact the nearest poison-control center (1,6).

References

1. US Consumer Product Safety Commission. Reducing poisonings to children. Consumer Product Safety Review 1997;1:1-2.

2. Burda AM, Leikin JB, Fischbein C, Woods K, McAllister K. Poisoning hazards of glass candle lamps. JAMA 1997;277:885.

3. Litovitz T, Greene AE. Health implications of petroleum distillate ingestion. Occup Med 1988;3:555-68.

4. Victoria MS, Nangia BS. Hydrocarbon poisoning: a review. Pediatr Emerg Care 1987;3:184-6.

5. Consumer Product Safety Commission. Consumer Product Safety Commission: Poison Prevention Packaging Act of 1970 Regulations. Washington, DC: Office of the Federal Register, Archives and Records Administration, 1995:669-84. (16 CFR 1700.1).

6. Food and Drug Administration. Protect your child from poisons in your home. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, Food and Drug Administration, 1996; publication no. (FDA)96-1262.

   
   

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