Accidental feeding of a dilute antiseptic solution (chlorhexidine 0.05% with cetrimide 1%) to five babies

Five normal newborn breast fed babies were accidentally fed a dilute antiseptic solution (chlorhexidine 0.05% with cetrimide 1%) in place of sterile water, developing caustic burns of the lips, mouth and tongue within minutes; one baby became quite severely ill due to acute pulmonary oedema, but all survived without sequelae.