Pediatric Hydrocarbon Ingestion

Submitted by: Sanjay Mohan, MD, Mary Ann Howland, PharmD, Mark K. Su, MD, MPH (Case Presented during May 2021 NYC PCC Consultants’ Conference)

Case Presentation

History of Present Illness: A 16-month-old, 14kg child with no known significant past medical history presents to the ED for cough, lethargy and decreased appetite. The child was found with a bottle of lamp oil in hand and witnessed by care providers to ingest approximately “one sip” nine hours earlier. The child was initially asymptomatic but approximately five hours after the ingestion, the patient was noted to be warm to touch and symptomatic; they were brought to the ED. 

Past Medical History: Ex-full-term, normal spontaneous vaginal delivery

Medications: None

Social History: None

Vital Signs: BP, 100/82 mmHg; HR, 178 beats/min; RR, 37 breaths/min; T, 102.8 degrees F; O₂ Sat, 97% (RA)

Physical Examination:

General: “Fussy” on examination

HEENT: Normocephalic, atraumatic, pupils equal round and reactive to light

Lungs: Tachypneic to a respiratory rate ~40 breaths/minute, lungs otherwise clear to auscultation bilaterally; no rales, rhonchi or wheezing.

CV: Tachycardic rate and regular rhythm; no murmurs

Abdomen: Soft, non-distended, non-tender; normoactive bowel sounds

Skin: Warm, dry with moist axillae

Neuro: No gross neurologic deficits; appropriate for age and development

Initial Laboratory Testing, Imaging, and Diagnostic Testing:

Test	Time: Upon Admission	Reference Range
WBC Count	20.7 x 103/mcL	4.0 – 10.0 x 103/mcL
Hemoglobin	10.9 g/dL	11.2 – 15.7 g/dL
Hematocrit	32.5 %	34-45%
Platelets	505 x 103/mcL	150 – 450 x 103/mcL
Sodium	133 mmol/L	136 – 145 mmol/L
Potassium	4.7 mmol/L	3.5 – 4.8 mmol/L
Chloride	103 mmol/L	98 – 107 mmol/L
Bicarbonate	21 mmol/L	22- 29 mmol/L
BUN	3 mg/dL	8- 26 mg/dL
Creatinine	0.47 mg/dL	0.7 – 1.3 mg/dL
Glucose	109 mg/dL	70 – 100 mg/dL
Anion Gap	9	6 – 14 mmol/L

Test	Time: Upon Admission	Reference Range
Venous pH	7.38	7.3 – 7.4
PCO2	44 mm Hg	40 – 50 mm Hg
Calculated Bicarbonate	26 mmol/L	21- 28 mmol/L
Lactate	2.6 mmol/L	0 – 1.9 mmol/L

Urinalysis: Normal

COVID: Negative

Respiratory Viral Panel: + Rhino/Enterovirus

Chest Radiograph: Ill-defined bilateral airspace opacities which may be related to chemical pneumonitis given patient’s clinical history versus infectious etiology.

Hospital Course

In the ED, because of the fever and tachypnea, blood cultures were obtained immediately. The patient was given 15 mg/kg of oral acetaminophen, a 20 cc/kg bolus of normal saline, and intravenous ceftriaxone for presumed community-acquired pneumonia. The patient was admitted to the pediatric floor.

While in the hospital, the patient’s initial symptoms and tachypnea improved; oxygen saturation remained above 95% on room air. The patient did not receive any additional doses of antibiotics and no repeat imaging was obtained because of the observed clinical improvement. After an inpatient stay of approximately 24 hours, the patient was discharged home. The child’s parents were counseled on injury prevention and safe storage prior to leaving the hospital.

The patient’s presentation is thought to have been secondary to aspiration pneumonitis and perhaps coincidentally, the patient happened to have a concurrent viral syndrome. Given that the fever began and subsided within 24 hours spontaneously, we believe that the patient’s clinical presentation was primarily the result of hydrocarbon aspiration.¹

Discussion

Kerosene is a hydrocarbon compound derived from petroleum (NB. Lamp oil or liquid paraffin is in the same chemical family as kerosene but lamp oil is purified to make it burn more cleanly.) Hydrocarbons are organic compounds made up primarily of carbon and hydrogen atoms – usually anywhere from 1 to 60 carbons. They are ubiquitous in the modern world and can be derived from plants (pine oil, vegetable oil), animal fats (cod liver oil), natural gas, petroleum, or coal tar. They account for over 28,000 cases reported to U.S. regional poison control centers annually.²

Hydrocarbon ingestion often causes pulmonary injury due to aspiration. Three properties intrinsic to hydrocarbons are the major determinants of the risk of aspiration: viscosity, surface tension, and volatility. Viscosity is the measurement of the ability of a fluid to resist flow. Surface tension is the cohesive force generated by attraction due to the Van der Waals forces between molecules – also known as a liquid’s “ability to creep” along a surface. Volatility is the tendency for a liquid to become a gas. Hydrocarbons with a low viscosity, low surface tension, and high volatility – all increase the risk of aspiration after a hydrocarbon ingestion. The mechanism of pulmonary injury from hydrocarbons is not fully understood but is thought to be secondary to disruption of the lipid surfactant bilayer.³

Symptoms of aspiration may include an initial episode of coughing, gagging, or choking. Radiographic evidence of hydrocarbon pneumonitis develops in approximately 40-88% of patients following aspiration.^4-6 Fevers may result but the degree of temperature elevation does not seem to correlate with clinical symptoms.⁷ Of note, chest radiographs obtained immediately on initial presentation may not demonstrate the presence of an infiltrate (i.e., radiographic findings may delayed relative to the onset of symptoms).⁶ However, approximately 90% of patients who develop radiologic evidence of pneumonitis will do so by 4 hours post-ingestion.⁴

Management of hydrocarbon (or petroleum distillate) ingestion begins with decontamination – removing the patient from the exposure or the exposure from the patient. Exposed clothing should be removed and safely discarded as further absorption or inhalation can worsen systemic toxicity. Activated charcoal (AC) has limited ability to decreased gastrointestinal absorption of hydrocarbons – furthermore, AC may distend the stomach and increase the risk of vomiting and aspiration. Given this risk, AC and gastric lavage is contraindicated in hydrocarbon ingestions.¹

Antibiotic administration in patients with mild hydrocarbon pneumonitis appears to be unnecessary. In a randomized controlled trial of pediatric patients with mild respiratory symptoms (history of cough or dyspnea, age-specific tachypnea, wheeze) due to kerosene-induced pneumonitis, prophylactic antibiotics did not demonstrate any benefit in reducing the rate of clinical deterioration or duration of hospitalization.⁸ However, it is important to note that this study did not include patients who were deemed “too ill to withhold antibiotics” (i.e., patients requiring supplemental oxygen, positive pressure ventilation, or fever > 40^oC).⁸ Similarly, corticosteroids do not appear to have a demonstrable benefit in these patients and are not routinely recommended.⁹

Children with suspected ingestion of hydrocarbons should be observed in the ED for a minimum of 6 hours after ingestion. During the observation period, if the child demonstrates adequate oxygenation without supplemental oxygen, does not develop tachypnea, has no abnormal pulmonary findings, and has a normal chest radiograph after six hours, they typically have a good prognosis and can be discharged.⁷ A chest radiograph upon initial presentation is not necessary unless the patient is symptomatic. Even for patients who remain asymptomatic after the 6-hour observation period but develop radiographic evidence of pneumonitis, they can also be safely discharged if the vital signs are normal, are clinically well, and can have close follow-up within 24 hours. For patients with clinical evidence of toxicity and those who present after an intentional, non-exploratory ingestion, hospitalization is recommended 

In patients who do not respond to standard care and clinically decompensate, mechanical ventilation may be necessary. Positive end-expiratory pressure (PEEP) in this setting is beneficial. For children who develop severe ventilation-perfusion mismatch despite PEEP, extracorporeal membranous oxygenation (ECMO) has been successfully used for severe pulmonary toxicity.¹⁰

Conclusion

Hydrocarbons are a diverse group of xenobiotics that cause toxicity most commonly from ingestion and subsequent aspiration pneumonitis. Even small sips have the potential to cause toxicity. Hydrocarbons with a low viscosity, low surface tension, and high volatility demonstrate the greatest risk for this.

Patients who remain asymptomatic and have a normal chest radiograph after 6 hours of observation can be safely discharged. For the subset of patients that develop evidence of pneumonitis on imaging but who remain asymptomatic during observation, they can be safely discharged if they have close follow-up within 24 hours. Routine antibiotics and corticosteroids are not recommended at this time.

Lastly, families with children should be instructed on principles of safe storage with regards to medications and non-medications (ie., kerosene) to prevent dangerous exploratory ingestions.

References

1. Cachia EA, Fenech FF. Kerosene poisoning in children. Arch Dis Child. 1964;39:502-504.
2. Gummin DD, Mowry JB, Beuhler MC, et al. 2019 annual report of the american association of poison control centers’ national poison data system (Npds): 37th annual report. Clin Toxicol (Phila). 2020;58(12):1360-1541.
3. Widner LR, et al. Artificial surfactant for therapy in hydrocarbon-induced lung injury in sheep. Crit Care Med. 1996;24:1524-1529.
4. Blattner RJ, et al. Hydrocarbon pneumonitis. Pediatr Clin North Am. 1957:243-253.
5. Foley JC, et al. Kerosene poisoning in young children. Radiology. 1954;62:817-829.
6. Press E, et al. Cooperative kerosene poisoning study: evaluation of gastric lavage and other factors in the treatment of accidental ingestion of petroleum distillate products. Pediatrics. 1962;29:648-674.
7. Anas N, et al. Criteria for hospitalizing children who have ingested products containing hydrocarbons. JAMA. 1981;246:840-843. 
8. Balme KH, et al. The efficacy of prophylactic antibiotics in the management of children with kerosene-associated pneumonitis: a double-blind randomised controlled trial. Clin Toxicol (Phila). 2015;53:789-796.
9. Marks MI, et al. Adrenocorticosteroid treatment of hydrocarbon pneumonia in children—A cooperative study. J Pediatr. 1972;81:366-369. 
10. Scalzo AJ, Weber TR, Jaeger RW, Connors RH, Thompson MW. Extracorporeal membrane oxygenation for hydrocarbon aspiration. Am J Dis Child. 1990;144(8):867-871.

Sanjay Mohan was born and raised on Long Island, New York. He attended medical school at New York University/Bellevue Hospital and stayed on for residency in emergency medicine where he also served as Chief Resident in his final year of training. He is now a second-year Medical Toxicology Fellow at the New York City Poison Control Center.