Ranitidine-Induced Delirium in a 7-Year-Old Girl: A Case Report

Roberta Esteves Vieira de Castro; Carolina da Cunha Sousa; Maria Clara de Magalhães-Barbosa; Arnaldo Prata-Barbosa; Elie Cheniaux

doi:10.1542/peds.2018-2428

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RE: Author's reply
Roberta Castro, Carolina Cunha, Maria Clara Magalhães-Barbosa, Arnaldo Prata-Barbosa and Elie Cheniaux

Published on: 03 March 2019
RE: Salbutamol dosage discussion
Francesca Cossovel and Egidio Barbi

Published on: 14 February 2019

Published on: (3 March 2019)

RE: Author's reply
Roberta Castro, Pediatric intensivist, Universidade do Estado do Rio de Janeiro and Hospital Vitória, Rio de Janeiro, Brazil
Other Contributors:
Carolina Cunha, Pediatric intensivist

Maria Clara Magalhães-Barbosa, Pediatric intensivist

Arnaldo Prata-Barbosa, Pediatric intensivist

Elie Cheniaux, Psychiatrist
We welcome the opportunity to respond to the comments from Dr. Cossovel and Dr. Barbi about our case report recently published in Pediatrics, on the ranitidine-induced delirium in a seven-year-old girl. We considered the comment quite timely from a didactical perspective and we agree that the dose of Beta-2 agonists should be individualized according to severity and adjust according to the patient’s response, as recommended by the British Guidelines of management of asthma. Two to four puffs of salbutamol 100 mcg via a pMID and a spacer might be sufficient for mild asthma attacks, although up to 10 puffs might be needed for more severe attacks (1). However, when this child arrived in the Pediatric Intensive Care Unit (PICU), she had already received higher doses of Beta-2 agonists in the emergency room (ER) and presented improvement of symptoms, as demonstrated by a Wood-Downes asthma severity score of 4. As our goal was to emphasize that anticholinergic medications may be relevant risk factors for pediatric delirium, we only reported the dose the patient was receiving in the PICU at the time of delirium occurrence, which was adjusted to the patient’s response to the initial management in the ER, according to the British Guidelines. Regarding ranitidine, specifically, we had found no case report of delirium induced by its use previously described in the literature.

Reference
1. British Thoracic Society Scottish Intercollegiate Guidelines Network. British guide...
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We welcome the opportunity to respond to the comments from Dr. Cossovel and Dr. Barbi about our case report recently published in Pediatrics, on the ranitidine-induced delirium in a seven-year-old girl. We considered the comment quite timely from a didactical perspective and we agree that the dose of Beta-2 agonists should be individualized according to severity and adjust according to the patient’s response, as recommended by the British Guidelines of management of asthma. Two to four puffs of salbutamol 100 mcg via a pMID and a spacer might be sufficient for mild asthma attacks, although up to 10 puffs might be needed for more severe attacks (1). However, when this child arrived in the Pediatric Intensive Care Unit (PICU), she had already received higher doses of Beta-2 agonists in the emergency room (ER) and presented improvement of symptoms, as demonstrated by a Wood-Downes asthma severity score of 4. As our goal was to emphasize that anticholinergic medications may be relevant risk factors for pediatric delirium, we only reported the dose the patient was receiving in the PICU at the time of delirium occurrence, which was adjusted to the patient’s response to the initial management in the ER, according to the British Guidelines. Regarding ranitidine, specifically, we had found no case report of delirium induced by its use previously described in the literature.

Reference
1. British Thoracic Society Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. 2016.
Show Less

Competing Interests: None declared.
Published on: (14 February 2019)

RE: Salbutamol dosage discussion
Francesca Cossovel, MD, Department of Medical, Surgical and Health Sciences, University of Trieste, 34137 Trieste, Italy
Other Contributors:
Egidio Barbi, Professor of paediatrics, MD
Dear Sirs,
we read with great interest the case report about a ranitidine induced delirium in a 7 years old girl with acute asthma attack. We take exception to the dosage used for this case which was just 700 mcgs every 3 hours for a 34 kg girl and we believe it can be misleading in a didactical perspective.
In our understanding of the last British Guideline of management of asthma [1], we believe that the description of this asthma attack could be classified as severe asthma attack which indeed required ICU admission and ranitidine. So, we think that it would be more appropriate to administer beta-2-agonist (Salbutamol 10 puffs via space or 5 mg if nebulized) and steroid therapy (oral prednisolone 30-40 mg or hydrocortisone 4 mg/kg iv). Following this guideline we believe that the dose of salbutamol used in this case report would have been more appropriate for a 2-5 years old child. We also think that beta-2-agonist therapy repeated every 3 hours would be more adequate during the maintenance phase, whereas to threat severe asthma acute attack it is recommended to administer salbutamol every 20 minutes for the first 2 hours according to response.

REFERENCES
[1] British Thoracic Society Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. 2016.

Competing Interests: None declared.