Curious case of accidental kerosene aspiration in an adolescent girl and blue colored carbonated soft drinks.

Sir,

Accidental aspiration of kerosene continues to remain as a significant public health problem and a major cause of preventable injury in children.(1) Children from developing countries are at maximum risk since kerosene is a commonly used household fuel for cooking stoves.(2) We report a very unusual case of accidental kerosene aspiration in an adolescent girl and the predisposing factors.

A 12-year-old girl presented to emergency room with alleged history of consuming around 20 ml of kerosene 2 hours back. There was history of paroxysms of cough, nausea and one episode of vomiting following intake. She had normal IQ with no developmental delay and was doing well in school. There was no history of any mental illness. She mistook kerosene for soft drink, as it was stored in a ‘used’ plastic soft drink bottle. On admission, she was afebrile and her vitals, oxygen saturation in room air were normal. Chest radiograph taken after 6 hours of admission revealed bilateral non-homogenous infiltrates. She also developed fever within 24 hours (temp 39.4°C), wheezing and scattered crepitations on auscultation.

She was started on intravenous ampicillin (100 mg/kg/day in 4 divided doses), oral paracetomal for fever (15 mg/kg/dose three times daily, and inhaled beta agonist nebulization (0.15 mg/kg mixed in 2 ml normal saline as nebulization every 6th hourly. There was clinical improvement with fever settling within 3 days and she was discharged after 7 days of hospitalization. The girl and her mother underwent pre-discharge counseling regarding prevention of such episodes in future. The girl was followed up 2 weeks post-discharge in our outpatient department, was found to be normal.

Kerosene is commonly used fuel for cooking and lighting in developing countries including India. Kerosene is dispensed via a Public distribution system at a subsidized rate since it is the major cooking fuel used by economically weaker sections of society in India.(3) Kerosene is colorless fuel but is colored blue to prevent adulteration with petroleum products and for easy identification.(4)

Children less than 5 years are prone to accidental ingestion due to their explorative behavior. A review of 70 cases of kerosene aspiration in Indian children found that affected children were between 3 months to 8 years with a mean of 2 years and with the maximum number of cases presenting between 1-3 years.(1) Accidental kerosene aspiration occurring in a 12-year-old child is extremely rare. Storing of kerosene in soft drink plastic bottle was the main reason for the accidental aspiration of the fuel mistaking it for soft drinks. When our index case was questioned as to why she swallowed after tasting the kerosene, she replied that she was confused with the ‘fizziness’ of carbonated soft drink.

An internet search revealed numerous blue colored carbonated soft drinks and blue colored plastic bottles for carbonated drinks marketed in India from both local as well as reputed international companies. A visual comparison of kerosene stored in soft drink bottle and various blue colored soft drinks marketed in India showing striking resemblance between them [Figure 1].

Figure 1

Kerosene stored in soft drinks bottle (a); Blue colored soft drinks available in the market (b, c & d)

Kerosene oil is commonly stored in soft drink and liquor bottles and remain within the easy reach of curious children.(1) Kerosene stored in non-transparent plastic bottles or transparent with label on it can make the visualization of blue color difficult. Hence, children can mistake them for water and can consume it. Moreover, there are few soft drinks or plastic bottle which is blue in color that can make the identification even more difficult. All these factors play an important role in increasing the chances of kerosene aspiration. Blue colored soft drinks should be restricted and parents should be cautious while storing kerosene at home. These are simple but serious cautions to be taken, which is the underlying cause for most kerosene aspirations in children.

In conclusion, kerosene should be stored in transparent containers. Storing kerosene in soft drinks and liquor bottles should be discouraged. Increased awareness about these trivial but often under recognized factors can decrease the incidence of kerosene aspiration. Manufacturing and marketing of blue colored soft drinks mimicking kerosene should be strictly regulated.