Mistaken identity of skin cleansing solution leading to extensive chemical burns in an extremely preterm infant

Chemical burns in extremely preterm infants have major implications in terms of morbidity and risk management. We report a case of extensive chemical burn in an extremely low birth weight (ELBW) infant caused by clear, colourless solution of 0.5% chlorhexidine in 70% alcohol mistaken for normal saline for skin cleansing during umbilical catheter insertion. This case reflects the on going problem faced by many neonatal intensive care units of similar coloured solutions with similar packages, but with varying degrees of toxic effects. Conclusion: The case highlights the importance of having a clear policy for skin cleansing in every neonatal unit and measures to avoid errors by vigilant checking of all medications including topical solutions.