Abstract
Within hours of accidental instillation of a popular diaper rash protector spray,
a 23 day old male developed severe chemical pneumonitis, acute respiratory failure
and pneumomediastinum. Despite optimal ventilatory management, the unconventional
use of frequent bronchial saline lavages was necessary to maintain oxygenation and
ventilation. The only listed active ingredient, 10% dimethicone was a non-toxic inhalant,
but the undisclosed inactive ingredients included mineral oil and balsam of peru which
may cause chemical pneumonitis and allergic reactions. This case serves as a warning
on OTC product designs and formulations, and cautions us to search beyond the listed
active ingredients for potential toxicity.
Keywords
Chemical pneumonitis - pneumomediastinum - over the counter products design - unintended
use - toxicity - neonate
