title: A 1000-fold overdose of clonidine caused by a compounding error in a 5-year-old child with attention-deficit/hyperactivity disorder.
abstract: 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.
authors.affiliation: Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, Texas 79430, USA. pedmjr@ttuhsc.edu
authors.forename: M J
authors.initials: MJ
authors.lastname: Romano
authors.forename: A
authors.initials: A
authors.lastname: Dinh
mesh_terms: D000316:Adrenergic alpha-Agonists / Q000097:blood / Q000506:poisoning* / Q000627:therapeutic use; D000959:Antihypertensive Agents / Q000097:blood / Q000506:poisoning / Q000627:therapeutic use; D001289:Attention Deficit Disorder with Hyperactivity / Q000097:blood / Q000188:drug therapy*; D002675:Child, Preschool; D003000:Clonidine / Q000097:blood / Q000506:poisoning* / Q000627:therapeutic use; D004339:Drug Compounding / Q000009:adverse effects; D062787:Drug Overdose / Q000097:blood / Q000209:etiology; D006801:Humans; D008508:Medication Errors / Q000009:adverse effects*
chemical_list: D000316:Adrenergic alpha-Agonists; D000959:Antihypertensive Agents; D003000:Clonidine