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PEDIATRICS Vol. 108 No. 2 August 2001, pp. 471-472

EXPERIENCE AND REASON:
A 1000-Fold Overdose of Clonidine Caused by a Compounding Error in a 5-Year-Old Child With Attention-Deficit/Hyperactivity Disorder

Received Sep 11, 2000; accepted Dec 4, 2000.

Michael J. Romano

Ann Dinh

Department of Pediatrics Texas Tech University Health Sciences Center Lubbock, TX 79430 From the Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, Texas.

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.

 Key words:  clonidine, drug ingestion, toxicity, poisoning, drug compounding, adrenergic alpha  agonists, attention-deficit/hyperactivity disorder, drug therapy, overdose, antihypertensive agents.


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