Fatal pediatric paraquat poisoning following scalp application for head lice treatment: Public health implications for pesticide regulation and emergency care - A case series.

Pesticide-related poisoning remains an important but preventable public health problem in children, particularly in settings with limited regulatory control. Paraquat is a highly toxic herbicide associated with severe systemic organ damage and high mortality following human exposure. Although ingestion is the most common route of poisoning, dermal absorption can result in fatal toxicity, especially with prolonged contact or compromised skin integrity. We report a rare case series of three female siblings aged 4, 6, and 8 years who developed severe paraquat toxicity following scalp application of the chemical as a home remedy for head lice. In this setting, scalp shaving is commonly practiced as part of lice treatment, often resulting in abrasions that may enhance dermal absorption. All three children presented approximately 36 h after exposure with features of systemic toxicity. The youngest child, who had more extensive scalp injury, rapidly developed respiratory distress and died shortly after presentation despite emergency resuscitation. The two older siblings initially remained conscious but subsequently developed progressive acute kidney injury and worsening respiratory failure requiring intensive care admission, haemodialysis, corticosteroid therapy, oxygen supplementation, and supportive management. Laboratory investigations demonstrated rising urea and creatinine levels with transient improvement following dialysis before subsequent deterioration. Despite aggressive supportive care, the 6-year-old child died on the ninth day of admission, while the 8-year-old died on the tenth day due to progressive respiratory failure and multi-organ dysfunction. The variation in clinical progression among the siblings likely reflects differences in the extent of scalp injury, degree of dermal absorption, exposure dose, and individual susceptibility. This case series highlights the extreme toxicity of paraquat, the absence of a specific antidote, and the devastating consequences of inappropriate domestic use of agricultural chemicals. It further emphasizes the urgent need for improved public awareness, stricter regulatory enforcement, and strengthened preventive strategies to reduce pediatric exposure and associated mortality.