Naphthalene ball consumption treatment in child
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https://www.inchem.org/documents/pims/chemical/pim363.htm
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Naphthalene Ball (Mothball) Ingestion in Children - Clinical Management
Background
Naphthalene is a polycyclic aromatic hydrocarbon derived from coal-tar distillation. It is present in mothballs, toilet/room deodorizers, and insecticides. Accidental ingestion by children is the most common mode of poisoning - children often mistake mothballs for candy.
- Fatal dose: ~2 grams (one mothball weighs approximately 2-5 g - a single ball can be toxic)
- Fatal period: a few hours to 2-3 days
- Special risk: Children under 6 years absorb it more quickly; G6PD-deficient individuals are at highest risk of severe hemolysis
Note: Modern mothballs may contain paradichlorobenzene (less toxic) instead of naphthalene. Identification matters - naphthalene sinks in saturated salt solution and requires >80°C water bath to melt, while paradichlorobenzene floats and melts at 53°C.
Mechanism of Toxicity
- Hemolysis - naphthalene metabolites oxidize red cell membranes, especially in patients with G6PD deficiency (low reduced glutathione = increased susceptibility)
- Renal tubular blockade - precipitated hemoglobin/acid hematin crystals block renal tubules
- Hepatic necrosis - direct toxic effect on liver
- Methemoglobinemia - oxidation of hemoglobin iron from Fe2+ to Fe3+
Clinical Features
On Ingestion
| System | Symptoms |
|---|---|
| GI | Nausea, vomiting, diarrhea, abdominal pain, hepatomegaly |
| Renal | Burning micturition, loin pain, oliguria/anuria, hematuria; dark brown/black urine (hemoglobinuria + albumin + casts) |
| Hematologic | Hemolytic anemia, jaundice, Heinz bodies on blood film |
| CNS | Headache, excitement, delirium, muscular twitchings, staggering gait |
| Cardiovascular | Cyanosis, tachycardia, collapse |
| Late/severe | Coma and death |
Classic Triad to Recognize
Dark brown urine + hemolytic anemia + jaundice in a child with mothball exposure history
Treatment
1. Immediate / First Aid
- Call Poison Control immediately (e.g., 1-800-222-1222 in the US)
- Do NOT induce vomiting (aspiration risk)
- Avoid oily or fatty substances (milk, mineral oil) - these dissolve naphthalene and increase absorption
2. Gastrointestinal Decontamination
- Gastric lavage with warm water/saline (if within 1-2 hours of ingestion and airway is protected)
- Activated charcoal (if the child is alert, no contraindications) - to decrease further GI absorption
- Cathartic: Magnesium sulphate (one ounce of saturated solution) to clear the bowel
3. Supportive / Specific Treatment
| Intervention | Rationale |
|---|---|
| IV fluids (5% dextrose saline) | Maintain urine output; treat anuria |
| Urinary alkalinization - NaHCO3 | 15 g orally every 4 hours OR IV sodium bicarbonate; prevents precipitation of acid hematin in renal tubules, protects against AKI |
| Blood transfusion / Exchange transfusion | For severe hemolytic anemia; exchange transfusion for neurological complications (kernicterus in neonates) |
| Glucocorticoids (Hydrocortisone) | Limit naphthalene-induced hemolysis; administer early |
| Ascorbic acid (Vitamin C) | Antioxidant; used empirically for methemoglobinemia |
| N-Acetylcysteine (NAC) | Antioxidant; helps reduce oxidative hemolysis |
| Methylene blue | For methemoglobinemia >20-25% - BUT contraindicated in G6PD deficiency (can worsen hemolysis) |
| Hemodialysis/Renal replacement therapy | For severe AKI, anuria, or CNS complications (kernicterus) |
| Mannitol (diuretic) | Forced diuresis to protect renal tubules |
4. Monitoring
- CBC, reticulocyte count, peripheral smear (Heinz bodies)
- LFTs, renal function (serum creatinine, BUN)
- Urine output and urinalysis (hemoglobinuria)
- Methemoglobin levels (pulse oximetry is unreliable - co-oximetry needed)
- G6PD assay - should be ordered for all cases (result may take time, treat empirically)
- Serum bilirubin
5. Diet
- High protein, high carbohydrate, high vitamin, low fat diet during recovery
Key Management Pearls
- G6PD deficiency is common (~10% of African-American males, also prevalent in Mediterranean, South Asian populations). A single mothball can be lethal in these children.
- Methylene blue is contraindicated in G6PD deficiency - use ascorbic acid + NAC instead
- Avoid fats/oils - naphthalene is lipophilic and fat dissolves it, increasing absorption
- There is no specific antidote for naphthalene - treatment is supportive
- Neonates are at higher risk of kernicterus (bilirubin encephalopathy) from hemolysis - exchange transfusion may be needed
- Anuria may persist 1-2 weeks with eventual full recovery if managed adequately
- Skin and eye exposure: flush with lukewarm running water for at least 20 minutes
Sources
- Parikh's Textbook of Medical Jurisprudence, Forensic Medicine and Toxicology - Naphthalene section
- P.C. Dikshit Textbook of Forensic Medicine and Toxicology
- Roberts and Hedges' Clinical Procedures in Emergency Medicine
- INCHEM PIM 363 - Naphthalene
- Recent pediatric case reports: Sravanthi et al., Cureus 2024 [PMID 38947700]; Orhan et al., Arch Argent Pediatr 2024 [PMID 37801672]
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