Mind the Decimal Point: A Case of Diazoxide Overdose-Induced Ileus

Area of Science:

• Neonatal Medicine
• Pediatric Pharmacology
• Gastroenterology

Background:

• Diazoxide is the sole FDA-approved treatment for hyperinsulinism-induced hypoglycemia.
• Infant medication errors, particularly 10-fold overdoses, are a significant concern.

Observation:

• A four-week-old male infant experienced a 10-fold diazoxide overdose, leading to feeding intolerance and abdominal distension.
• Clinical presentation included tachycardia, tachypnea, and a distended abdomen.
• Abdominal X-rays revealed generalized ileus, a rare complication of diazoxide overdose.

Findings:

• The infant was treated with nasogastric tube placement, intravenous dextrose, and gradual enteral feeding resumption.
• Serial X-rays demonstrated improvement, and the ileus resolved.
• The patient was discharged after a period of observation in the neonatal intensive care unit.

Implications:

• This case highlights the infrequent but serious complication of ileus from diazoxide overdose in neonates.
• Decimal point errors are a common source of 10-fold medication overdoses in infants.
• Using appropriately sized syringes can mitigate medication dosing errors in pediatric patients.