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Indian Pediatr 2016;53: 353 |
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Recurrent Apnea in a Neonate Following
Intranasal Oxymetazoline
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Shridhar Gopalakrishnan and Kirandeep Sodhi
Department of Pediatrics, Command Hospital
(Western Command), Panchkula, Haryana, India.
Email: [email protected]
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Medication errors in the neonatal intensive care unit
(NICU) are an important cause of preventable morbidity [1].
Oxymetazoline nasal drops are commonly available and used for relief of
nasal congestion and stuffiness. Despite their many described adverse
effects and contra-indications for use in children aged below 6 years,
inadvertent use is common, and may result in undesirable and sometimes
life-threatening adverse effects. We report apnea in a late preterm
neonate following the inadvertent use of oxymetazoline nasal drops in
the NICU.
A 34 week, 1600 g, small-for-gestational age male
neonate was born by caesarean section for severe pre-eclampsia to a
primigravida mother. She had an uneventful antenatal course and received
a complete course of antenatal steroids. After a normal transition, the
neonate was shifted to the NICU and fed on expressed breast milk by
paladai. The neonate was euthermic, euglycemic and stable in room
air. Around 60 hours of life, the neonate had an episode of apnea
requiring tactile stimulation. Evaluation for secondary causes was
negative and in view of suspected early-onset sepsis, intravenous
antibiotics were started. There were two more episodes of apnea
requiring tactile stimulation over the next two days. A retrospective
drug chart review revealed the use of oxymetazoline nose drops (for nose
block) by the nurse on night duty, 30 min preceding the apnea, on each
occasion. This was stopped, and there was no recurrence of apnea, and
the neonate remained stable in room air thereafter. Antibiotics were
stopped after three days as the clinical course was not consistent with
sepsis and the blood culture was sterile.
Oxymetazoline is a direct-acting sympathomimetic
which has a vasoconstrictor effect on mucosal blood vessels when applied
topically and in turn reduces edema of the nasal mucosa [2].
Neurological side effects in older children include states of anxiety or
excitement and visual hallucinations [3]. In neonates and infants,
gasping for breath, hypothermia, impaired consciousness, and bradycardia
have been described [4]. These effects are mediated by stimulation of
central a2-adrenoreceptors
in the locus coeruleus and the rostral ventrolateral medulla. Neonates,
whose blood brain barrier is not fully developed, are possibly more
sensitive to the central side effects of the imidazolines.
This case highlights the risks of inadvertent
medication use in the NICU and the need to be vigilant and train all
healthcare providers to avoid medication errors.
References
1. Antonucci R, Porcella A. Preventing medication
errors in neonatology: Is it a dream? World J Clin Pediatr.
2014;3:37-44.
2. Dokuyucu R, Gokce H, Sahan M, Sefil F, Tas ZA,
Tutuk O, et al. Systemic side effects of locally used
oxymetazoline. Int J Clin Exp Med. 2015;8:2674-8.
3. Loewen AHS, Hudon ME, Hill MD. Thunderclap
headache and reversible segmental cerebral vasoconstriction associated
with use of oxymetazoline nasal spray. CMAJ. 2004;171:593-4.
4. Dunn C, Gauthier M, Gaudreault P. Coma in a
neonate following single intranasal dose of xylometazoline. Eur J
Pediatr. 1993;152:541.
5. Söderman P, Sahlberg D, Wiholm BE. CNS reactions to nose drops in
small children. Lancet. 1984;1:573.
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