Published online January 4, 2006
PEDIATRICS Vol. 117 No. 1 January 2006, pp. 236-238 (doi:10.1542/10.1542/peds.2005-0898)
This Article
Right arrow Full Text
Right arrow Full Text (PDF)
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow E-mail this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Add to My File Cabinet
Right arrow Download to citation manager
Right arrowRequest Permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via CrossRef
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Ryan, C. A.
Right arrow Articles by Murphy, B.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Ryan, C. A.
Right arrow Articles by Murphy, B.
Related Collections
Right arrow Premature & Newborn
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us   Add to Digg   Add to Facebook   Add to Reddit   Add to Technorati   Add to Twitter  
What's this?

EXPERIENCE AND REASON

Normal Neurologic and Developmental Outcome After an Accidental Intravenous Infusion of Expressed Breast Milk in a Neonate

C. Anthony Ryan, MB, FRCPI, FRCPCH, FAAP, Izlan Mohammad, MB, FAAP and Brendan Murphy, MB, FRCPI, MRCPCH

Department of Paediatrics and Child Health, Cork University Hospital, University College, Cork, Ireland

Here we describe a premature male infant who was accidentally given 10 mL of expressed breast milk intravenously over a 3.5-hour period. Having survived this event with supportive care, this boy was attending regular school with no obvious neurologic or learning difficulties at 6 years of age. In 1998, after a query on an e-mail discussion group for health care providers in neonatology (NICU-net), we were informed of 8 similar events that proved fatal in 3 infants. A root-cause analysis revealed that accidental intravenous administration of breast milk or formula can be avoided by the use of color-coded enteral-administration sets with Luer connections that are not compatible with intravenous cannulas. The addition of methylene blue to feeds, or bolus enteral feeds (instead of continuous gastric feedings), may also help prevent such errors. These cases show the value of gathering information about rare but important events through a neonatal network. In addition, they confirm that prevention of medical error should focus on faulty systems rather than faulty people.

Key Words: breast milk • infant nutrition • injection therapy • neonatal morbidity • neurologic examination

Abbreviations: EBM, expressed breast milk

Accepted Jun 24, 2005.


Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us   Add to Digg Digg   Add to Facebook Facebook   Add to Reddit Reddit   Add to Technorati Technorati   Add to Twitter Twitter    What's this?


This article has been cited by other articles:


Home page
 Arch. Dis. Child. Fetal Neonatal Ed.Home page
C Snijders, R A van Lingen, A Molendijk, and W P F Fetter
Incidents and errors in neonatal intensive care: a review of the literature
Arch. Dis. Child. Fetal Neonatal Ed., September 1, 2007; 92(5): F391 - F398.
[Abstract] [Full Text] [PDF]