A 1000-fold overdose of clonidine caused by a compounding error in a 5-year-old child with attention-deficit/hyperactivity disorder

M. J. Romano, A. Dinh

Research output: Contribution to journalArticle

43 Scopus citations

Abstract

A 5-year-old child who weighed 17.5 kg received 50 mg of clonidine. The amount ingested was confirmed by analysis of the suspension administered (clonidine HCl 9.78 mg/mL). To our knowledge, this represents the largest ingestion in a child and the largest ingestion on a milligram per kilogram basis in the medical literature. The child's initial presentation included hyperventilation, an unusual feature of clonidine toxicity. The child was discharged without sequela 42 hours after admission. A serum concentration of clonidine 17 hours postingestion was 64 ng/mL, the highest reported to date in a pediatric patient. The intoxication was traced to a pharmacy compounding error in which milligrams were substituted for micrograms. Increased prescribing of clonidine in young children coupled with the requirement to compound clonidine in a suspension and the narrow therapeutic index suggests that the frequency of severe ingestions in children will increase in the future.

Original languageEnglish (US)
Pages (from-to)471-473
Number of pages3
JournalPediatrics
Volume108
Issue number2 II
DOIs
StatePublished - Aug 25 2001
Externally publishedYes

Keywords

  • Adrenergic α agonists
  • Antihypertensive agents
  • Attention-deficit/hyperactivity disorder
  • Clonidine
  • Drug compounding
  • Drug ingestion
  • Drug therapy
  • Overdose
  • Poisoning
  • Toxicity

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health

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