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A 1000-fold overdose of clonidine caused by a compounding error in a 5-year-old child with
1Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, Texas 79430, USA. pedmjr@ttuhsc.edu
Insights
A child experienced the largest known clonidine ingestion (50 mg) due to a pharmacy error. This case highlights risks associated with pediatric clonidine prescribing and compounding, emphasizing the need for vigilance.
Area of Science:
- Pediatric Toxicology
- Clinical Pharmacy
Background:
- Clonidine is increasingly prescribed for young children.
- Pharmacy compounding of clonidine suspension presents unique challenges.
- Clonidine has a narrow therapeutic index, increasing overdose risk.
Observation:
- A 5-year-old child weighing 17.5 kg ingested 50 mg of clonidine, the largest reported dose per kilogram.
- The child presented with hyperventilation, an atypical symptom of clonidine toxicity.
- The highest reported serum clonidine concentration (64 ng/mL) at 17 hours post-ingestion was documented.
Findings:
- The overdose resulted from a pharmacy compounding error substituting milligrams for micrograms.
- The child recovered fully within 42 hours without sequelae.
- This incident represents a significant case in pediatric clonidine ingestion literature.
Implications:
- Increased clonidine use in pediatrics necessitates heightened awareness of compounding accuracy.
- The potential for severe pediatric ingestions is likely to rise due to compounding and narrow therapeutic index.
- This case underscores the critical importance of meticulous pharmacy practices in pediatric medication safety.
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.