OBJECTIVE: To generate national estimates of hydrocarbon-related exposures occurring in children ≤5 years of age who were treated in US emergency departments or called a regional poison control center.
METHODS: This retrospective review compared hydrocarbon-related injuries that occurred from January 1, 2000, through December 31, 2009, that were reported to the National Poison Data System and the National Electronic Injury Surveillance System for children ≤5 years of age.
RESULTS: From 2000 through 2009, the National Poison Data System reported 65 756 actual calls to regional poison centers, and the National Electronic Injury Surveillance System reported an estimated 40 158 emergency department visits for hydrocarbon-related injuries. Individuals involved were predominantly male and 1 to 2 years of age. Ingestion was the most common mechanism of injury, and most injuries did not result in hospitalization. The rate of emergency department visits and calls to poison centers decreased significantly (P < .0001) over the 10-year study period. Exposures to hydrocarbons demonstrated seasonal variation, with more occurrences in the summer months.
CONCLUSIONS: The comparison of the two data sets illustrates a similar trend in hydrocarbon-related injuries in children. Although cases have declined, most likely due to existing prevention efforts, hydrocarbons are still a large source of preventable exposure and injury in children.
- AAPCC —
- American Association of Poison Control Centers
- CI —
- confidence interval
- CPSC —
- Consumer Product Safety Commission
- ED —
- emergency department
- NEISS —
- National Electronic Injury Surveillance System
- NPDS —
- National Poison Database System
- RPC —
- regional poison center
What’s Known on This Subject:
Hydrocarbons are dangerous household products commonly found in homes with young children. Unintentional ingestion continues to be a problem despite existing prevention efforts. Aspiration is often associated with ingestion of hydrocarbons by children.
What This Study Adds:
The National Poison Database System and National Electronic Injury Surveillance System data sets demonstrate similar rates of hydrocarbon-related injuries in children. Rates of hydrocarbon exposure were highest in summer. Gasoline was the product most associated with hydrocarbon injuries.
Unintentional poisoning continues to make up a large percentage of pediatric injuries,1,2 and hydrocarbons are among the top 10 causes of pediatric poisoning deaths in the United States.3–5 Hydrocarbons are ubiquitous in our society, are commonly found in the home, and often result in exposures or injuries to children.6 In 2010, there were over two million poison exposures reported to US regional poison centers (RPCs), half of which were exposures involving children ≤5 years of age.2 Hydrocarbons are substances with high volatility and low viscosity, such as gasoline, kerosene, lighter fluid, lubricating oils, mineral seal oil, and turpentine, and are easily aspirated.7,8 Major morbidity and mortality can occur when a hydrocarbon is aspirated, leading to chemical pneumonitis, acute lung injury, or death from asphyxiation.6,9,10 In 2010, 42 663 hydrocarbon exposures were reported to US RPCs, and one-third of these exposures involved children ≤5 years of age.2 Fatalities are uncommon, but hydrocarbon-related poisonings still represent the third leading cause of poisoning deaths in children ≤5 years of age.2
Previous research largely consists of case reports6,10,11 or has focused on trends in special populations,12,13 has defined triage guidelines,9 or has examined the mechanism of injury14 or medical risks associated with hydrocarbon poisoning.15 To our knowledge, this is the first study to examine hydrocarbon-related injuries in children ≤5 years of age over an extended time period using data from 2 nationally representative surveillance systems. Because parents may either call an RPC or take their child to an emergency department (ED) after an exposure to potentially dangerous hydrocarbons, our objective was to obtain a better understanding of the magnitude of pediatric hydrocarbon-related injuries and to generate national estimates of hydrocarbon-related injuries in children ≤5 years of age. Calls to RPCs and ED visits related to hydrocarbon exposures from 2000 through 2009 were compared. This study describes demographic characteristics of exposed children, the types of injuries resulting from hydrocarbons, and the hydrocarbon substances involved in the exposures.
Hydrocarbon-related exposures from January 1, 2000 through December 31, 2009 from the National Electronic Injury Surveillance System (NEISS) and the National Poison Data System (NPDS) were compared for children ≤5 years of age. This study was deemed exempt from review by the Institutional Review Board.
The NEISS provides data on consumer product–related and sports activity–related injuries treated in US EDs.16,17 The NEISS receives data from a network of ∼100 hospitals, which represents a stratified probability sample of 6100 hospitals with ≥6 beds and a 24-hour ED. The network includes urban, suburban, rural, and children’s hospitals. Data collected by the NEISS are weighted by the Consumer Product Safety Commission (CPSC) to yield national estimates for consumer product–related and sports activity–related injuries. At all sampled hospitals, medical charts are viewed by professional NEISS coders, and data regarding each patient’s age and gender, injury diagnosis, body part injured, locale where the injury occurred, product or products involved, and disposition from the ED, as well as a brief narrative describing the incident, are recorded. Data from the US Census Bureau were used to calculate injury rates per 100 000 children ≤5 years of age.18,19
The American Association of Poison Control Centers (AAPCC) maintains the NPDS, a national database of telephone calls made by the public and health care professionals to self-report an actual or suspected exposure to a potentially poisonous substance (eg, an ingestion, inhalation, or topical exposure) or request information and/or educational materials from any of the 61 RPCs.20 Currently, a total of 57 RPCs participate in data reporting to the NPDS and together receive approximately two million human exposure calls annually.2 The NPDS uses a standardized format for recording information from exposure calls, and data are checked for accuracy via standardized protocols for each RPC.2
Case Selection Criteria
Substances involved in the hydrocarbon-related exposures were derived from NEISS product codes and NPDS generic codes (see Appendix) and were combined in the following 8 product categories: gasoline, kerosene, lighter fluid/naphtha, lamp oil, lubricating oil, mineral seal oil (eg, furniture polish), mineral spirits (eg, paint thinner, metal polish), and other hydrocarbons (eg, benzene, automotive products, spot removers, dry cleaning agents, nonhalogenated hydrocarbons, diesel fuel, turpentine, freon and other propellants, methylene chloride, toluene and/or xylene, pine oil cleaner, fabric treatments, auto cleaners, unspecified fuel oil, unspecified solvents, engine fuel, multipurpose fuel, burning and/or lighting fuel, and other).
Case narratives (n = 4605) were reviewed to ensure that each exposure involved a hydrocarbon; ≥1 author reviewed a subset of cases, and discrepancies were resolved through consensus. A total of 3283 actual cases were excluded because the product was determined not to be a hydrocarbon or is not consistently manufactured with hydrocarbons (eg, noncitronella candles, fabric softener, or tire cleaner, etc) (n = 3170), or the case was a duplicate (n = 113). National estimates were based on weighted data for 1322 patients who were ≤5 years of age and were treated for hydrocarbon-related injuries.
All hydrocarbon-related exposure calls involving children ≤5 years old were requested from the NPDS (n = 269 360). Cases were excluded if the product was classified as “unknown hydrocarbon” (n = 3 602), multiple substances were involved in the exposure (n = 12 815), data for age and gender were missing (n = 728), or the exposure resulted in a fatality (n = 13). Cases were also excluded if the hydrocarbon exposure was explicitly coded as not related to the clinical outcome (n = 5 987) or not known to be related due to lack of follow-up (n = 180 459). The final number of cases included in analysis was 65 756.
Injury diagnoses were grouped into four categories: poisoning, chemical burns, dermatitis, and other (including foreign body). Body parts injured were categorized as face (face, eyeball, ear, and neck), all parts of the body (NEISS body part code for poisoning diagnoses), and other. Route of exposure was derived according to injury diagnosis and body part injured. These 3 categories were ingestion (diagnosis = poisoning), ocular (body part = eyeball), and dermal (all others). Locale was grouped into 2 categories, home or public property. Disposition was categorized as hospitalized (eg, admitted or transferred to another hospital) or not hospitalized (eg, treated and released or held for observation).
Exposure site (location where the exposure occurred) and caller site (location where the call originated) were categorized as home (own residence or other residence), public property (eg, workplace, restaurant and/or food service, or public area), health-care facility, or other (eg, school or daycare). Management site (location where the patient was treated or evaluated) was grouped into the following categories: managed on site (eg, home, public place, health-care facility, or other), hospitalized (eg, admitted to critical, noncritical, or psychiatric care), or not hospitalized (eg, treated and released). Route of exposure was grouped into categories of ingestions, inhalations, and/or aspirations (eg, inhalation nasal or aspiration ingestion), ocular, or dermal. Medical outcome was grouped into 4 categories: minor (eg, involving skin and mucous membranes; symptoms usually resolved rapidly); moderate (eg, more pronounced, prolonged, or systemic symptoms than minor); major (eg, life-threatening or resulted in residual disability or disfigurement); or unknown. Moderate and major medical outcomes were combined to represent the severity of cases presenting to EDs for treatment. The 135 clinical effects reported in the NPDS were grouped as pulmonary, gastrointestinal, ocular, dermal, central nervous system, cardiac, hematologic, electrolytes/renal, and other.
Data were analyzed by using SAS 9.2 (SAS Institute, Cary, NC). For the NEISS cases, a sample weight was assigned to each case by the CPSC on the basis of the inverse probability of selection, and weights were used to generate national estimates.16,17 Bivariate comparisons were conducted by using χ² tests, and the strength of association was assessed by using odds ratios and their associated 95% confidence intervals (CIs). Trend significance of the numbers of hydrocarbon-related injuries over time was analyzed by using linear regression. Statistical significance was assessed by using α = .05. All NEISS statistical analyses accounted for the complex sampling frame of the NEISS.16,17 NEISS national estimates were based on weighted data for 1 322 patients ≤5 years of age who were treated for hydrocarbon-related injuries in US EDs. All NEISS data reported in this article are national estimates unless specified as actual unweighted case numbers. Intercensal population estimates were used to calculate NEISS and NPDS injury rates from 2000 through 2009 and were derived from the US Census Bureau.18,19 The NPDS data are represented as actual unweighted cases.
Sample Population Characteristics for NPDS and NEISS
From 2000 through 2009, the NPDS reported 65 756 calls and the NEISS reported an estimated 40 158 hydrocarbon-related injuries (Table 1). Boys accounted for the majority of all cases in both data sets: 65.7% of NPDS and 67.3% of NEISS. Children 1 year of age constituted 34.7% of NPDS cases and 44.2% of NEISS cases. The most common route of exposure was ingestion (NPDS: 54.5% and NEISS: 75.9%), and most exposures occurred at home (NPDS: 95.8% and NEISS: 87.7%). Patients who were hospitalized accounted for 13.2% of all NEISS cases. Most calls placed to RPCs were managed on site (NPDS: 60.1%) or did not result in hospitalization (NPDS: 30.3%) and were made from the child’s home or another residence (71.8%) (Table 1).
Hydrocarbon-Related Injuries Over Time and by Season
The rate of ED visits for hydrocarbon-related injuries decreased significantly over the study period (P < .0001) from 19.5 ED visits per 100 000 in 2000 to 13.8 ED visits per 100 000 in 2009 (Fig 1). The rate of hydrocarbon-related exposure calls with clinical effects related to the exposure that were captured by NPDS decreased significantly (P < .0001) over the study period from 34.0 calls to RPCs per 100 000 in 2000 to 20.7 calls to RPCs per 100 000 in 2009. Overall, hydrocarbon-related ED visits and calls to RPCs differed by season (NPDS and NEISS: P < .0001) with highest incidence occurring in the summer months (NPDS: 31.7% and NEISS: 31.8%) and lowest in winter (NPDS: 17.1% and NEISS: 19.0%) (Fig 2). Despite the overall trend, kerosene exposures were highest in winter (NPDS: 38.7% and NEISS: 33.0%) and lowest in summer (NPDS: 16.4% and NEISS: 16.0%), and the percentages of lamp oil exposures did not vary by season (NPDS: P = .800 and NEISS: P = .202).
Products and Clinical Effects
Gasoline was the product most commonly associated with hydrocarbon-related ED visits (31.9%, 95% CI: 27.0–36.7) as well as telephone calls to the RPCs (27.6%) (Fig 3). NEISS case narratives described a large number of gasoline exposures that occurred while refueling automobiles. The NEISS cases that resulted in hospitalization were most often associated with kerosene (25.0%, 95% CI: 16.0–34.0), lighter fluid and/or naphtha (23.8%, 95% CI: 7.1–26.4), and lamp oil (23.2%, 95% CI: 15.0–31.5) (Table 2). Most NPDS hydrocarbon-related exposures that resulted in a moderate or major clinical effect were associated with lamp oil (29.9%), kerosene (23.8%), or lighter fluid and/or naphtha (19.4%) (Table 2). The most common clinical effects associated with the hydrocarbon-related exposure were pulmonary (n = 15 668), gastrointestinal (n = 12 957), and ocular (n = 11 406). Cardiac (n = 811), hematologic (n = 116), and electrolytes and/or renal (n = 47) were less common but had the highest proportion of moderate and/or major outcomes (Fig 4).
During the 10-year study period, almost 66 000 calls were made to RPCs and over 40 000 ED visits were reported regarding hydrocarbon exposures to children ≤5 years of age. The number of hydrocarbon-related injuries declined significantly over the 10-year study period in both data sources and coincided with regulations placed by the CPSC in 2001 requiring hydrocarbon-containing household products to be sold in child-resistant packages.21 Similarly, a Dutch study showed a decline in hydrocarbon-related injuries following enactment of a policy to change the viscosity of lamp oil, but the trend did not persist and was thought to be related to increased media attention.7 Despite the packaging law, many exposures may occur when these products are not kept in their original containers, and despite current prevention efforts, hydrocarbons still present a high risk for exposure and injury in children.
In the current study, the most common age of exposure was between 1 and 2 years of age. This is a common age group for poison injury, as young children have a natural desire to explore their environment.4,22 Inquisitive children mistakenly identify hydrocarbons as a food item or beverage and attempt to ingest the poison.4 Ingestion of hydrocarbons was found to be the most common route of exposure in both data sources. Due to the high volatility and low viscosity of hydrocarbons, children attempting ingestion often aspirate the product, which leads to pulmonary injury.6,13,14 The tendency of children to mimic adult behaviors, such as siphoning gasoline, and their potential to be attracted to the smell of some hydrocarbon substances may, in part, lead to these injuries.
Hydrocarbon-related injuries were most common in the summer months and least common in the winter. Many activities associated with warm weather, such as mowing lawns, use of Tiki torches, and use of lighter fluid for outdoor cooking may increase risk of exposure to these products in summer months. Similarly, Lifshitz et al13 found similar trends in children admitted to hospitals due to hydrocarbon exposure in the Negev Desert. Kerosene exposures were most common during the winter, most likely due to the use of kerosene heaters during cold weather. Lamp oil exposure did not vary by season, which is expected due to the nonseasonal use of decorative oil lamps inside the home. However, one study found increased exposure to hydrocarbons in Jewish children during the Jewish Sabbath and other Jewish holidays when oil-burning lamps are traditionally used.12 Parents should be aware of the heightened potential for hydrocarbon exposure with changing seasons and should ensure proper storage of hydrocarbons in their original containers.
Gasoline was most commonly associated with hydrocarbon-related injury resulting in both calls to RPCs and ED visits. Most gasoline exposures were dermal in nature and were commonly due to the child being exposed during automobile refueling. However, when these exposures were reported to a RPC, most were managed at home without the need to be treated in the ED. This trend has been reported in other studies involving exposures and poison centers, demonstrating the potential cost savings of RPCs.23–28
The NEISS and NPDS demonstrated similar patterns of hydrocarbon-related injuries in children ≤5 years of age. The 2 databases documented similar rates of hospitalization among children exposed to hydrocarbons. Kerosene, lamp oil, and lighter fluids were the products that resulted in the largest proportion of hospitalizations and significant clinical effects. The majority of hydrocarbon exposures occurred in the home or residential setting, demonstrating a greater need for prevention efforts in the home. Both the NPDS and the NEISS can be used to estimate the burden of hydrocarbon-related injuries on a national level and were compared and validated in a study by Setlik et al29 regarding pediatric pharmaceutical ingestions. Both the NEISS and NDPS can be used to identify areas for prevention efforts or to report the nature and pattern of exposures.
It should be noted that neither database is constructed to represent a complete incidence of national exposures. NEISS is designed to estimate national injury incidence by extrapolation, whereas NPDS data are actual reported cases. However, it is estimated that only 20% to 30% of all poisoning cases are reported to RPCs, and therefore NPDS cases most likely represent the minimum number of actual exposures to a chemical or drug.29,30 Also, due to the nature of these separate databases, it is impossible to determine if a case is reported in both datasets. Therefore these cases cannot be aggregated to generate an actual number of cases nationwide. Despite these limitations, the strengths of this study are its large, national sample over a 10-year study period.
Finally, it should be noted that despite current prevention efforts, hydrocarbons continue to be among the top 10 causes of pediatric poisoning deaths in the United States.2 Although fatalities were excluded in the analysis of this study, it is noted that 13 of the children in our datasets died as a result of their exposures to hydrocarbons. Exposures to lamp oil were associated with the highest percentage of deaths. Reviewing the numbers of injuries and deaths due to hydrocarbon exposures in children further emphasizes the need for education and prevention efforts in this area.
Although this study demonstrates a significant decrease in hydrocarbon-related injuries in children over the 10-year study period, it is evident that despite current prevention efforts and packaging regulations, hydrocarbons still present a high risk for exposure and injury in children. Prevention and education efforts for parents and caregivers should focus on storing products properly, keeping products in their original containers, and supervising children when these products are being used in and around the home.
The AAPCC (http://www.aapcc.org) maintains the national database of information logged by the country’s regional poison centers serving all 50 US states, Puerto Rico, and the District of Columbia. Case records in this database are from self-reported calls; they reflect only information provided when members of the public or health-care professionals report an actual or potential exposure to a substance (e.g., an ingestion, inhalation, or topical exposure) or request information/educational materials. Exposures do not necessarily represent a poisoning or overdose. The AAPCC is not able to completely verify the accuracy of every report made to member centers. Additional exposures may go unreported to regional poison centers, and data referenced from the AAPCC should not be construed to represent the complete incidence of national exposures to any substances.
- Accepted February 6, 2013.
- Address correspondence to Heath A. Jolliff, DO, 700 Children’s Drive, MA-347, Columbus, OH 43205-2664. E-mail:
Dr Jolliff conceptualized and designed the study, drafted the initial manuscript, reviewed and revised the manuscript, and approved the final manuscript as submitted; Ms Fletcher and Roberts drafted the initial manuscript, carried out the analyses, reviewed and revised the manuscript, and approved the final manuscript as submitted; Dr Baker conceptualized and designed the study, reviewed and revised the manuscript, and approved the final manuscript as submitted; and Dr McKenzie conceptualized and designed the study, drafted the initial manuscript, reviewed and revised the manuscript, and approved the final manuscript as submitted.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
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- ↵U.S. Census Bureau. National Population Estimates. 2010. Available at: www.census.gov/popest/national/asrh/. Accessed May 20, 2010
- ↵U.S. Census Bureau. Intercensal Estimates of the United States Population by Age and Sex, 1990-2000: All Months. 2008. Available at: www.census.gov/popest/archives/EST90INTERCENSAL/US-EST90INT-datasets.html. Accessed July 1, 2009
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- Copyright © 2013 by the American Academy of Pediatrics