Annals of Tropical Paediatrics International Child Health
ISSN: 0272-4936 (Print) 1465-3281 (Online) Journal homepage: http://www.tandfonline.com/loi/ypch19
Management of accidental kerosene ingestion H. Singh, J. C. Chugh, A. H. Shembesh, A. A. Ben-Musa & H. C. Mehta To cite this article: H. Singh, J. C. Chugh, A. H. Shembesh, A. A. Ben-Musa & H. C. Mehta (1992) Management of accidental kerosene ingestion, Annals of Tropical Paediatrics, 12:1, 105-109, DOI: 10.1080/02724936.1992.11747553 To link to this article: http://dx.doi.org/10.1080/02724936.1992.11747553
Published online: 13 Jul 2016.
Submit your article to this journal
View related articles
Citing articles: 6 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ypch19 Download by: [La Trobe University]
Date: 09 May 2017, At: 14:48
Annals of Tropical Paedz"atrics ( 1992) 12, 105-109
Management of accidentai kerosene ingestion H. SINGH, J. C. CHUGH, A. H. SHEMBESH, A. A. BEN-MUSA & H. C. MEHTA Department of Paediatrics, Al Arab Medical University, Benghazi, Libya (Received 23 May 1991)
Summary Accidentai kerosene ingestion is still a common problem in Libya. 1t causes considerable morbidity and occasionally mortality. The role and choice of antibacterial agents in its management remain unsettled. Pulmonary damage has been reported as resulting from aspiration. In aspiration pneumonia, anaerobie organisms may be important pathogens and metronidazole may have a place in therapy. The present randomized trial in 100 children with accidentai kerosene ingestion assesses the role of ampicillin, carbenicillin and metronidazole in its management. The results are not conclusive but chemoprophylaxis appears to decrease morbidity. Of the various regimens used, the ampicillin/ metronidazole combination was found to be slightly better than the others. Further study is recommended.
Introduction Kerosene ingestion remains the commonest accidentai poisoning in pre-school children in Benghazi. lt causes considerable morbidity and can be fatal. Opinions vary on the role and choice of antimicrobial agents in its management. Recommendations in the standard textbooks vary from no antibacterial agents in patients without bacterial infections 1 to penicillin and kanamycin, 2 penicillin alone, 3 carbenicillin,4 and clindamycin. 5 There is strong clinical experimental evidence that pulmonary involvement after hydrocarbon ingestion is the result of aspiration. fr9 Anaerobie infections are common in aspiration pneumonia 10 and covering anaerobes in the antibacterial therapy is important. Metronidazole has emerged as one of the most important anti-infective agents against anaerobes. Our anecdotal experience of successful management of a child with
Reprint requests to: Professer Harjit Singh, P.O. Box 12836, Du bai, United Arab Emirates.
kerosene pneumonia prompted us to investigate the role of metronidazole and other antimicrobials in the management of accidentai kerosene ingestion.
Subjects and methods One hundred children whose ages ranged from 10 months to 12 years and who had been admitted following accidentai kerosene ingestion constituted the subjects. The initial work-up included complete blood count, serum bilirubin, serum transaminases and chest X-ray. In the management, besides supportive measures, the children were randomized into the following groups to receive one of four treatment schedules. Group A: Ampicillin 200 mg/kg/day IV in 6-hourly doses for 2 days and then 100 mg/ kg/day by mouth for the next 5 days, and metronidazole 15 mg/kg IV infusion in 1 h followed by 7.5 mg/kg/dose orally every 8 h for 5 days. Group B: Carbenicillin 200 mg/kg/24 h in divided doses 6-hourly for 7 days.
106
H. Singh et al.
Group C: Ampicillin alone as per dosage schedule in Group A. Group D: Metronidazole alone as per dosage schedule in Group A. Control group: This group received no antibacterial agents during the first 48 h. Children remaining asymptomatic or showing improvement in symptoms over this period were observed without treatment. Children who remained symptomatic or developed symptoms during the observation period received anti-infective therapy, as per schedule A.
Randomization A total of 120 consecutive admissions with accidentai kerosene ingestion were allocated to the four treatment groups and the control group by drawing lots before the start of the study. The first 20 children in each group were taken for final analysis.
Assessment (i) Clinical. Resolution offever, tachypnoea and disappearance of râles in the chest were taken as evidence of clinicat improvement. (ii) X-ray changes were graded as follows: GradeO: normalX-ray. Grade 1: minimal unilateral perihilar infiltration. Grade 2: bilateral infiltration. Grade 3: confluent fluffy shadows on one or both sides. Grade 4: extensive bilateral infiltration with consolidation and/or pleural effusion. Children showing clinical as well as radiological improvement were considered to have a satisfactory response. Children were assessed clinically daily, and radiologically on day 8. Biochemical investigations were repeated on day 8. A third chest X-ray was done in all cases remaining symptomatic after day 8.
TABLE 1. Age and sex distribution of children with kerosene poisoning No. of cases Age (mths)
Male
Female
Total
0-12 13--24 25-36 37-48 49--60 >60 Total
5 28 10 4 3 3 53
3 28 8 2
8 56 18 6 3
6 47
9
100
Results The age and sex distributions of the children are given in Table 1. Most were in the age range 13-36 months; both sexes were equally involved. Most children (87%) presented to hospital within 24 h of kerosene ingestion. The clinicat profile of the children is summarized in Table II. Fever and respiratory distress were the most common presenting symptoms. On auscultation, in 58 children, there was diminished air entry in 51 and crepitations were recorded in 32. Seventeen children had slight hepatomegaly: none had jaundice. Radiological abnormalities were recorded in all but two cases. Changes included pneumonie infiltration in 82, consolidation in 14, pleural effusion in four and collapseconsolidation in one case. Changes were generally more severe on the right side. Thirty-two children with no abnormal physical signs in the chest had a radiological abnormality. Seven children had slightly elevated serum transaminases on admission; these had returned to normal on reassessment on day 8. The total white cell and polymorphonuclear cell counts were raised in all cases. Response to therapy The therapeutic response to the various treatment schedules is summarized in Table III.
Accidentai kerosene ingestion
107
TABLE 11. elinical profile of children on admission GroupA
GroupB
Groupe
GroupD
eontrois
19 3 15 14 20
17 4 14 15 20
18 8 16 9 19
18 11 15 14 20
12 8 10 8 19
GroupA
GroupB
Groupe
GroupD
A eJinical (mean (SD) days) 5.1 (2.26) Fever 4.6 (1.42) Respiration 5.5 (3.44) ehestsigns
5.2 (1.78) 5.5 (1.93) 6.0 (2.85)
6.0 (1.87) 6.3 (1.8) 6.5 (3.17)
6.0 (2.0) 6.3 (2.27) 7.5 (2. 71)
17 3
17 3
13 7
Feature Fever ehoking Respiratory distress ehestsigns Radiological abnorrnality
TABLE III. Therapeutic response Response
B Radiological (day 8) lmprovedfnorrnal Deteriorated
18 2
Group A. Out of 20 children, 18 showed a satisfactory response. In the whole group, the temperature settled in (mean) 5.1([SD] 2.26) days; tachypnoea ceased in 4.6(1.42) days, and chest signs cleared in 5.5(3.44) days. Radiologicaliy, 18 children showed improvement on day 8. Two deteriorated, one with coliapse-consolidation on the right side and the other pleural effusion on the left side. These two children showed considerable improvement wh en X -rayed on day 15. Group B. Seventeen of 20 children in this group showed a satisfactory response to therapy. The mean(SD) times for the fever, tachypnoea and chest signs to settle in this group were 5.2(1.78), 5.5(1.93) and 6.0(2.85) da ys, respectively. Radiologically, 17 children bad improved by day 8. In two, pneumonie infiltration bad increased and another child had developed collapse-consolidation on the right side. One child out of these three developed pneumatoceles on day 15.
Statistical significance (t-test) Group A vs B, e, D significant Group A vs B, e, D significant Group A vs B, e, D significant (x 2 test) No significant difference (p>0.05)
Group C. In this group also, 17 children improved. In thewhole group, the fever settled in 6.0(1.87) days and the respiratory rate in 6.3(1.8) days. The physical signs in the chest became normal in 6.5(3.17) days. Radiologically, 16 children showed improvement on day8. Group D. In this group, 13 children improved clinicaliy after 1 week of therapy. Fever settled in 6.0(2.0) days, respiration returned to normal in 6.3(2.27) days, and chest signs cleared in 7.5(2.71) days. Seven children showed clinical and radiological deterioration. Ali these seven bad improved radiologically by day 15. Control group. N ine of the 20 children in this group were symptomatic when assessed at 48 h. These children received antibiotics as per schedule A. Ali the nine remained symptomatic on day 8. Radiologicaliy, seven of these showed deterioration and in two the X-ray appearances remained unchanged.
108
H. Singh et al.
Clinical comparison. Although analysis of variance for means did not show a statisticaliy significant difference between the various treatment groups with respect to the three clinical parameters (p > 0.05 in ali parameters), the children in group A showed a significantly quicker improvement compared with the three other treatment groups in ali the three clinical parameters when analysed by the t-test. Comparing the overall therapeutic responses of the four treatment groups, group D had the maximum number of cases with an unsatisfactory response. However, when the results were analysed using 2 x 5 Chi-square test, there were no significant differences between the various groups. Ali the nine symptomatic patients had an unsatisfactory response to therapy started after 48 h of kerosene ingestion. Discussion Kerosene causes an intense inftammatory reaction and tissue necrosis in the lung parenchyma, the extent of damage corresponding to the amount of the hydrocarbon inhaled. The host defences are compromized, 11 •12 thus setting the stage for opportunistic infections. In the present study, only five of 100 children were symptom-free at the time of initial presentation, and only two had normal chest X-rays; one of these two developed consolidation on day 4. These observations underscore the extent of morbidity caused by kerosene ingestion. The leucocyte response also reftects an intense inftammatory reaction. Clinical improvement was significantly quicker in group A (ampicillin plus metronidazole) compared with group B (carbenicillin), group C (ampiciliin alone) and group D (metronidazole alone). Radiologically, whereas groups A, B and Chad almost similar results, group D showed the highest number of unsatisfactory responses with one-third of cases showing radiological deterioration.
Although in the final analysis the overali therapeutic response in the four groups did not show statisticaliy significant variation, an overview does suggest sorne benefit from the ampicillin-metronidazole combination. The symptomatic children in the control group could not be kept off therapy for a whole week. Therefore, their response to therapy has not been statistically compared with that of the therapy groups. However, prolonged morbidity in the nine symptomatic cases suggests that withholding antibacterial therapy in symptomatic cases may not be in the patient's best interests. The nature of pulmonary pathology caused by hydrocarbon damage facilitates bacterial invasion. The results of the present study, though not conclusive, suggest benefit from chemoprophylaxis against both aerobes and anaerobes. However, further studies are needed to obtain conclusive results.
References
2
3
4
5 6
7
8
9
Tooley WH, Lipow HW. Chemical pneumonitis. In: Rudolph AM, Hotfman JIE, eds. Pediatries. Norwalk, Connecticut: Appleton Century Crofts, 1982; 1446. Stem RC. Hydrocarbon pneumonia. In: Behrman RE, Vaughan VC, eds. Nelson Textbook of Pediatries. Philadelphia: WB Saunders, 1983; 1057. Mitchell RG, Forfar JO. Accidents and poisoning in childhood. ln: Forfar JO, Arneil GC, eds. Textbook of Paediatrics. Edinburgh: Churchill Livingstone, 1984; 1780. Adams WC. Aspiration pneumonia. In: Gellis SS, Kagan BM, eds. Current Pediatrie Therapy 8. Philadelphia: WB Saunders, 1978; 125. Klein BL, Simon JE. Hydrocarbon poisonings. Pediatr Clin North Am 1986; 2:411-19. Gerarde HW. Toxicological studies in hydrocarbon: V. Kerosene. Toxicol Appl Pharmacol 1959; 1: 462-74. Huxtable KA, Bolander RP, Klaus M. Experimental fumiture polish pneumonia in rats. Pediatries 1964; 34:228-35. Giammona ST. Effects of furniture polish on pulmonary surfactant. Am J Dis Child 1967; 113: 658-63. Wolfe BM, Brodeur AE, Shields JB. The role of gastrointestinal absorption of kerosene in producing pneumonitis in dogs. J Pediatr 1970; 76:867-73.
Accidentai kerosene ingestion 10 Bartlett JC. Good antimicrobial prescribing: antianaerobic antibacterial agents. Lancer 1982; ii: 478-81. 11 Yeager H. Tracheobronchial secretions. Am J Med 1971; 50:493-509.
109
12 Burley S, Huber G. The effect of toxic agents commonly ingested by children on antibacterial defences in the Jung. Proc Soc Pediatr Res 1971; 83.
ISSN: 0272-4936 (Print) 1465-3281 (Online) Journal homepage: http://www.tandfonline.com/loi/ypch19
Management of accidental kerosene ingestion H. Singh, J. C. Chugh, A. H. Shembesh, A. A. Ben-Musa & H. C. Mehta To cite this article: H. Singh, J. C. Chugh, A. H. Shembesh, A. A. Ben-Musa & H. C. Mehta (1992) Management of accidental kerosene ingestion, Annals of Tropical Paediatrics, 12:1, 105-109, DOI: 10.1080/02724936.1992.11747553 To link to this article: http://dx.doi.org/10.1080/02724936.1992.11747553
Published online: 13 Jul 2016.
Submit your article to this journal
View related articles
Citing articles: 6 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ypch19 Download by: [La Trobe University]
Date: 09 May 2017, At: 14:48
Annals of Tropical Paedz"atrics ( 1992) 12, 105-109
Management of accidentai kerosene ingestion H. SINGH, J. C. CHUGH, A. H. SHEMBESH, A. A. BEN-MUSA & H. C. MEHTA Department of Paediatrics, Al Arab Medical University, Benghazi, Libya (Received 23 May 1991)
Summary Accidentai kerosene ingestion is still a common problem in Libya. 1t causes considerable morbidity and occasionally mortality. The role and choice of antibacterial agents in its management remain unsettled. Pulmonary damage has been reported as resulting from aspiration. In aspiration pneumonia, anaerobie organisms may be important pathogens and metronidazole may have a place in therapy. The present randomized trial in 100 children with accidentai kerosene ingestion assesses the role of ampicillin, carbenicillin and metronidazole in its management. The results are not conclusive but chemoprophylaxis appears to decrease morbidity. Of the various regimens used, the ampicillin/ metronidazole combination was found to be slightly better than the others. Further study is recommended.
Introduction Kerosene ingestion remains the commonest accidentai poisoning in pre-school children in Benghazi. lt causes considerable morbidity and can be fatal. Opinions vary on the role and choice of antimicrobial agents in its management. Recommendations in the standard textbooks vary from no antibacterial agents in patients without bacterial infections 1 to penicillin and kanamycin, 2 penicillin alone, 3 carbenicillin,4 and clindamycin. 5 There is strong clinical experimental evidence that pulmonary involvement after hydrocarbon ingestion is the result of aspiration. fr9 Anaerobie infections are common in aspiration pneumonia 10 and covering anaerobes in the antibacterial therapy is important. Metronidazole has emerged as one of the most important anti-infective agents against anaerobes. Our anecdotal experience of successful management of a child with
Reprint requests to: Professer Harjit Singh, P.O. Box 12836, Du bai, United Arab Emirates.
kerosene pneumonia prompted us to investigate the role of metronidazole and other antimicrobials in the management of accidentai kerosene ingestion.
Subjects and methods One hundred children whose ages ranged from 10 months to 12 years and who had been admitted following accidentai kerosene ingestion constituted the subjects. The initial work-up included complete blood count, serum bilirubin, serum transaminases and chest X-ray. In the management, besides supportive measures, the children were randomized into the following groups to receive one of four treatment schedules. Group A: Ampicillin 200 mg/kg/day IV in 6-hourly doses for 2 days and then 100 mg/ kg/day by mouth for the next 5 days, and metronidazole 15 mg/kg IV infusion in 1 h followed by 7.5 mg/kg/dose orally every 8 h for 5 days. Group B: Carbenicillin 200 mg/kg/24 h in divided doses 6-hourly for 7 days.
106
H. Singh et al.
Group C: Ampicillin alone as per dosage schedule in Group A. Group D: Metronidazole alone as per dosage schedule in Group A. Control group: This group received no antibacterial agents during the first 48 h. Children remaining asymptomatic or showing improvement in symptoms over this period were observed without treatment. Children who remained symptomatic or developed symptoms during the observation period received anti-infective therapy, as per schedule A.
Randomization A total of 120 consecutive admissions with accidentai kerosene ingestion were allocated to the four treatment groups and the control group by drawing lots before the start of the study. The first 20 children in each group were taken for final analysis.
Assessment (i) Clinical. Resolution offever, tachypnoea and disappearance of râles in the chest were taken as evidence of clinicat improvement. (ii) X-ray changes were graded as follows: GradeO: normalX-ray. Grade 1: minimal unilateral perihilar infiltration. Grade 2: bilateral infiltration. Grade 3: confluent fluffy shadows on one or both sides. Grade 4: extensive bilateral infiltration with consolidation and/or pleural effusion. Children showing clinical as well as radiological improvement were considered to have a satisfactory response. Children were assessed clinically daily, and radiologically on day 8. Biochemical investigations were repeated on day 8. A third chest X-ray was done in all cases remaining symptomatic after day 8.
TABLE 1. Age and sex distribution of children with kerosene poisoning No. of cases Age (mths)
Male
Female
Total
0-12 13--24 25-36 37-48 49--60 >60 Total
5 28 10 4 3 3 53
3 28 8 2
8 56 18 6 3
6 47
9
100
Results The age and sex distributions of the children are given in Table 1. Most were in the age range 13-36 months; both sexes were equally involved. Most children (87%) presented to hospital within 24 h of kerosene ingestion. The clinicat profile of the children is summarized in Table II. Fever and respiratory distress were the most common presenting symptoms. On auscultation, in 58 children, there was diminished air entry in 51 and crepitations were recorded in 32. Seventeen children had slight hepatomegaly: none had jaundice. Radiological abnormalities were recorded in all but two cases. Changes included pneumonie infiltration in 82, consolidation in 14, pleural effusion in four and collapseconsolidation in one case. Changes were generally more severe on the right side. Thirty-two children with no abnormal physical signs in the chest had a radiological abnormality. Seven children had slightly elevated serum transaminases on admission; these had returned to normal on reassessment on day 8. The total white cell and polymorphonuclear cell counts were raised in all cases. Response to therapy The therapeutic response to the various treatment schedules is summarized in Table III.
Accidentai kerosene ingestion
107
TABLE 11. elinical profile of children on admission GroupA
GroupB
Groupe
GroupD
eontrois
19 3 15 14 20
17 4 14 15 20
18 8 16 9 19
18 11 15 14 20
12 8 10 8 19
GroupA
GroupB
Groupe
GroupD
A eJinical (mean (SD) days) 5.1 (2.26) Fever 4.6 (1.42) Respiration 5.5 (3.44) ehestsigns
5.2 (1.78) 5.5 (1.93) 6.0 (2.85)
6.0 (1.87) 6.3 (1.8) 6.5 (3.17)
6.0 (2.0) 6.3 (2.27) 7.5 (2. 71)
17 3
17 3
13 7
Feature Fever ehoking Respiratory distress ehestsigns Radiological abnorrnality
TABLE III. Therapeutic response Response
B Radiological (day 8) lmprovedfnorrnal Deteriorated
18 2
Group A. Out of 20 children, 18 showed a satisfactory response. In the whole group, the temperature settled in (mean) 5.1([SD] 2.26) days; tachypnoea ceased in 4.6(1.42) days, and chest signs cleared in 5.5(3.44) days. Radiologicaliy, 18 children showed improvement on day 8. Two deteriorated, one with coliapse-consolidation on the right side and the other pleural effusion on the left side. These two children showed considerable improvement wh en X -rayed on day 15. Group B. Seventeen of 20 children in this group showed a satisfactory response to therapy. The mean(SD) times for the fever, tachypnoea and chest signs to settle in this group were 5.2(1.78), 5.5(1.93) and 6.0(2.85) da ys, respectively. Radiologically, 17 children bad improved by day 8. In two, pneumonie infiltration bad increased and another child had developed collapse-consolidation on the right side. One child out of these three developed pneumatoceles on day 15.
Statistical significance (t-test) Group A vs B, e, D significant Group A vs B, e, D significant Group A vs B, e, D significant (x 2 test) No significant difference (p>0.05)
Group C. In this group also, 17 children improved. In thewhole group, the fever settled in 6.0(1.87) days and the respiratory rate in 6.3(1.8) days. The physical signs in the chest became normal in 6.5(3.17) days. Radiologically, 16 children showed improvement on day8. Group D. In this group, 13 children improved clinicaliy after 1 week of therapy. Fever settled in 6.0(2.0) days, respiration returned to normal in 6.3(2.27) days, and chest signs cleared in 7.5(2.71) days. Seven children showed clinical and radiological deterioration. Ali these seven bad improved radiologically by day 15. Control group. N ine of the 20 children in this group were symptomatic when assessed at 48 h. These children received antibiotics as per schedule A. Ali the nine remained symptomatic on day 8. Radiologicaliy, seven of these showed deterioration and in two the X-ray appearances remained unchanged.
108
H. Singh et al.
Clinical comparison. Although analysis of variance for means did not show a statisticaliy significant difference between the various treatment groups with respect to the three clinical parameters (p > 0.05 in ali parameters), the children in group A showed a significantly quicker improvement compared with the three other treatment groups in ali the three clinical parameters when analysed by the t-test. Comparing the overall therapeutic responses of the four treatment groups, group D had the maximum number of cases with an unsatisfactory response. However, when the results were analysed using 2 x 5 Chi-square test, there were no significant differences between the various groups. Ali the nine symptomatic patients had an unsatisfactory response to therapy started after 48 h of kerosene ingestion. Discussion Kerosene causes an intense inftammatory reaction and tissue necrosis in the lung parenchyma, the extent of damage corresponding to the amount of the hydrocarbon inhaled. The host defences are compromized, 11 •12 thus setting the stage for opportunistic infections. In the present study, only five of 100 children were symptom-free at the time of initial presentation, and only two had normal chest X-rays; one of these two developed consolidation on day 4. These observations underscore the extent of morbidity caused by kerosene ingestion. The leucocyte response also reftects an intense inftammatory reaction. Clinical improvement was significantly quicker in group A (ampicillin plus metronidazole) compared with group B (carbenicillin), group C (ampiciliin alone) and group D (metronidazole alone). Radiologically, whereas groups A, B and Chad almost similar results, group D showed the highest number of unsatisfactory responses with one-third of cases showing radiological deterioration.
Although in the final analysis the overali therapeutic response in the four groups did not show statisticaliy significant variation, an overview does suggest sorne benefit from the ampicillin-metronidazole combination. The symptomatic children in the control group could not be kept off therapy for a whole week. Therefore, their response to therapy has not been statistically compared with that of the therapy groups. However, prolonged morbidity in the nine symptomatic cases suggests that withholding antibacterial therapy in symptomatic cases may not be in the patient's best interests. The nature of pulmonary pathology caused by hydrocarbon damage facilitates bacterial invasion. The results of the present study, though not conclusive, suggest benefit from chemoprophylaxis against both aerobes and anaerobes. However, further studies are needed to obtain conclusive results.
References
2
3
4
5 6
7
8
9
Tooley WH, Lipow HW. Chemical pneumonitis. In: Rudolph AM, Hotfman JIE, eds. Pediatries. Norwalk, Connecticut: Appleton Century Crofts, 1982; 1446. Stem RC. Hydrocarbon pneumonia. In: Behrman RE, Vaughan VC, eds. Nelson Textbook of Pediatries. Philadelphia: WB Saunders, 1983; 1057. Mitchell RG, Forfar JO. Accidents and poisoning in childhood. ln: Forfar JO, Arneil GC, eds. Textbook of Paediatrics. Edinburgh: Churchill Livingstone, 1984; 1780. Adams WC. Aspiration pneumonia. In: Gellis SS, Kagan BM, eds. Current Pediatrie Therapy 8. Philadelphia: WB Saunders, 1978; 125. Klein BL, Simon JE. Hydrocarbon poisonings. Pediatr Clin North Am 1986; 2:411-19. Gerarde HW. Toxicological studies in hydrocarbon: V. Kerosene. Toxicol Appl Pharmacol 1959; 1: 462-74. Huxtable KA, Bolander RP, Klaus M. Experimental fumiture polish pneumonia in rats. Pediatries 1964; 34:228-35. Giammona ST. Effects of furniture polish on pulmonary surfactant. Am J Dis Child 1967; 113: 658-63. Wolfe BM, Brodeur AE, Shields JB. The role of gastrointestinal absorption of kerosene in producing pneumonitis in dogs. J Pediatr 1970; 76:867-73.
Accidentai kerosene ingestion 10 Bartlett JC. Good antimicrobial prescribing: antianaerobic antibacterial agents. Lancer 1982; ii: 478-81. 11 Yeager H. Tracheobronchial secretions. Am J Med 1971; 50:493-509.
109
12 Burley S, Huber G. The effect of toxic agents commonly ingested by children on antibacterial defences in the Jung. Proc Soc Pediatr Res 1971; 83.
