Abstract
Most injuries from caustics ingestion occur due to parental negligence, but other causes such as psychological tendency or childish jealousy or behaviour may be the major cause for harming. Here, we describe a case of injury in a neonate who ingested a caustic substance, probably induced by his brother, but not as a consequence of the negligence of his parents. The mother said she had fed the child toilet bleach instead of water and was very concerned about the child's condition. However, when the baby's older brother was interviewed he did not show concern and was very confused and provided contradictory responses about his knowledge of the poisoning. Later, it was revealed that the baby's brother had prepared the milk and knew what was in it. In our case, damage by caustics ingestion may have been intentional due to psychological problems in parents causing child abuse or in other children due to childish jealousy.
Introduction
Injuries due to ingestion of caustics are mostly referred to as tissue injuries from chemical agents, including acidic or alkaline substances. 1 A wide spectrum of factors can determine the severity of injury: the duration of contact with caustics, the volume of fluid ingested, the physical form of the substance involved and its properties such as concentration, pH and potential of permeability in the tissue. 2 When deciding on the volume of neutralizing agents for reducing the injuries, these are the factors to take into account. Epidemiologically, although most forms of caustics ingestion remain asymptomatic or cause mild damages, severe injuries needing therapeutic intervention occur in about 10% of cases.3,4
About 80% of the injuries caused by caustics ingestion especially from liquid caustics occur in children under five. These may be very serious and even life-threatening 5 and comprise a large proportion of references to the coroner. Although most such injuries occur accidentally due to parental negligence, there may be other causes such as psychological problems or childish jealousy or behaviour. 6 We describe a case of injuries by caustics ingestion in a neonate probably because of his brother's act, but not due to parental negligence.
Case presentation
A six-day-old male neonate with the history of cyanosis and vomiting due to caustic ingestion was referred to the emergency ward of our hospital. His mother said she had fed the child accidentally with toilet bleach instead of water and was very concerned about the baby's condition. This concern was not evident in the baby's older brother, who when interviewed was very confused and provided contradictory answers about what he knew about the nature of this poisoning. In subsequent assessments, it was revealed that the baby's milk was prepared by his brother who was well aware of the danger of swallowing bleach.
On physical examination, erythema and ulcers were observed on the oral mucus, tongue and palate (Figure 1). The patient’s vital signs were stable. On chest and abdominal imaging, no abnormal changes were revealed. The child had been delivered vaginally at term with a body weight of 3300 g with a normal Apgar score. After birth, the neonate fed immediately from the breast. Pregnancy status of the woman was “G2P2L2Ab0” (gravid 2, Para 2, Living 2, and Abortion 0) with no abnormal physical or psychological disorders. The patient was admitted to NICU and the following were undertaken: setting IV line, fluid therapy, broad-spectrum antibiotics, H2 blockers, suppository acetaminophen, chest X-ray and also endoscopy. At endoscopy, tissue damage (grade IIA–IIB) was observed in the oesophagus accompanied with diffuse erythema in his stomach. On chest X-ray, a consolidation was found in the right lung that completely resolved two days after initiating the treatment. Two days later, the neonate was fed by breastfeeding and the patient was transferred to the neonatal ward. The result of arterial blood gas was normal. During hospitalisation, all laboratory parameters, including full blood count, urine analysis, coagulation tests, biochemistry indices and also liver function tests, were all normal. The patient was discharged in good general condition, with a recommendation for weekly follow-up. (Figure 1).
Injury due to feeding with whitening toilet cleaner.
Comments
Ingested agents that cause gastro-oesophogeal damage include alkaline drain cleaners and acidic toilet bowl cleaners, followed by vehicle battery acid, rust-removal products, cement-cleaning products and products containing ammonia. 7 Because some products look similar to milk, the admitting physician should identify carefully the nature of the agent, the volume ingested, pH and also its concentration. The time, duration of contact and the type of exposure are very important when working out the best managerial approach for patients, especially for children. All clinical symptoms, including dyspnoea, dysphagia, odynophagia, oral or abdominal pain, nausea and vomiting should be carefully assessed. 8 The clinical assessment, pH testing of product and saliva, a complete blood count and electrolytes, liver function tests, blood type and urinalysis should be considered immediately on admission to the emergency ward 9 together with an upright chest radiograph to discover pneumo-mediastinal pleural effusions, aspiration pneumonitis or any reactive changes. Other imaging techniques such as abdominal radiography or computed tomography may be needed. However, the first diagnostic tool to assess abnormal changes and to determine tissue damage grading is endoscopy. 10
Along with physical and imaging assessment, a thorough psychological assessment and even professional consultation is necessary especially when there is suspicion of early childhood poisoning. In this regard, all family members should be interviewed and assessed by a professional psychologist. 11 In other words, this common aspect with forensic medicine is very important, because this damage may be intentional due to psychological problems in the parents culminating in child abuse or in other children due to childish sibling jealousy. 12 In our case, deliberate poisoning induced by the baby's brother was suspected due to his reactions and contradictory responses. He was probably aware of the nature of the agent used to harm the baby and this required further assessment. The suspicion of poisoning by the mother was nearly dropped because of her apparent deep concern. However, in such cases, a conclusive psychological assessment of all the family members is strongly recommended to prevent similar events in the future.
Footnotes
Acknowledgment
The authors wish to thank Rasoul Akram Hospital Clinical Research Development Center, Iran University of Medical sciences and Ms Zahra Torabi Goodarzi (clinical psychologist) for the technical support.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.