What is the treatment for a pediatric patient who has ingested a naphthalene ball?

Management of Pediatric Naphthalene Ball Ingestion

Do not induce emesis or perform gastric lavage in children who have ingested naphthalene balls, as these interventions are contraindicated due to aspiration risk and lack of proven benefit. 1

Immediate Assessment and Stabilization

Airway and Vital Signs

• Establish and maintain airway patency as the first priority, providing bag-mask ventilation if respiratory depression develops 2
• Monitor vital signs continuously, with particular attention to oxygen saturation, heart rate, blood pressure, and respiratory status 2
• Contact your regional poison control center immediately for expert guidance 2

Initial Laboratory Evaluation

• Obtain complete blood count with reticulocyte count to assess for hemolysis 3, 4
• Check serum creatinine, blood urea nitrogen, and urinalysis for acute kidney injury and hemoglobinuria 3, 1
• Measure total and indirect bilirubin, lactate dehydrogenase, and haptoglobin levels 4
• Obtain methemoglobin level, though significant methemoglobinemia is uncommon (typically <10%) 5
• Screen for glucose-6-phosphate dehydrogenase (G6PD) deficiency, as these patients are at markedly higher risk for severe hemolysis 4, 5

Gastrointestinal Decontamination

Activated charcoal is contraindicated in naphthalene ingestion because naphthalene is poorly absorbed from the gastrointestinal tract and the risk of aspiration outweighs any theoretical benefit 1. Emesis and gastric lavage are similarly contraindicated 1.

Supportive Treatment Protocol

Fluid Management

• Initiate aggressive intravenous hydration with isotonic crystalloids (20 mL/kg boluses) to maintain adequate urine output and prevent pigment nephropathy 3, 1
• Target urine output of at least 1-2 mL/kg/hour 1
• Consider urinary alkalinization if hemoglobinuria is present to prevent acute tubular necrosis 1

Management of Hemolysis

• Transfuse packed red blood cells if hemoglobin drops below 7 g/dL or if the child shows signs of hemodynamic instability or severe anemia 3, 4
• Monitor hemoglobin levels every 4-6 hours initially, as hemolysis can progress over 24-72 hours after ingestion 3, 5
• Hemolysis typically begins within hours to 3 days post-ingestion and is the primary life-threatening complication 3, 4, 5

Methemoglobinemia Treatment

• Methylene blue (1-2 mg/kg IV) is indicated only if methemoglobin levels exceed 20% with symptoms or exceed 30% regardless of symptoms 6
• Do not exceed a cumulative dose of 7 mg/kg to avoid methylene blue-induced hemolysis 6
• Note that significant methemoglobinemia is uncommon with naphthalene ingestion (typically mild at 6% or less) 5

Alternative Antioxidant Therapy

• Consider empiric administration of ascorbic acid and N-acetylcysteine, which have been used successfully in case reports, though evidence is limited to case series 5

Renal Replacement Therapy

Initiate hemodialysis if acute kidney injury develops with oliguria, severe electrolyte disturbances, or fluid overload unresponsive to medical management 3. Acute kidney injury occurs secondary to hemoglobinuria and pigment nephropathy 3, 7, 1.

Observation and Disposition

Asymptomatic Patients

• All children with naphthalene ingestion require hospital admission for at least 24 hours of observation, even if initially asymptomatic, because hemolysis can develop in a delayed fashion up to 72 hours post-ingestion 3, 5, 1
• Asymptomatic children should be observed for at least 6 hours with serial laboratory monitoring before considering discharge 1

Symptomatic Patients

• Admit to pediatric intensive care unit if hemolysis, acute kidney injury, or methemoglobinemia develops 3
• Continue monitoring hemoglobin, renal function, and urine output until hemolysis stabilizes and renal function normalizes 3

Critical Pitfalls to Avoid

• Never assume safety based on initial presentation: Hemolysis can be delayed by 2-3 days after ingestion 3, 5
• Do not discharge G6PD-deficient patients early: These children are at highest risk for severe, life-threatening hemolysis requiring transfusion 4, 5
• Avoid nephrotoxic medications during the acute phase when pigment nephropathy risk is elevated 3
• Do not use gastric decontamination methods: These are contraindicated and increase aspiration risk without benefit 1