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A 1000-fold overdose of clonidine caused by a compounding error in a 5-year-old child with

M J Romano1, A Dinh

  • 1Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, Texas 79430, USA. pedmjr@ttuhsc.edu

Pediatrics
|August 3, 2001
PubMed

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.

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