|Articles|May 22, 2013

Top 10 Common Medication Errors-Drug #9: Clonidine

After several 5 mg doses of clonidine, this 5 kg boy became extremely lethargic and hypotensive. What went wrong?

A 1-month-old boy (weight, 5 kg) was prescribed clonidine (5 mg [1 mg/kg/dose] PO q8h) for neonatal abstinence syndrome. His parents filled this prescription at a local pharmacy. After taking a few doses of the medication, the boy became extremely lethargic. He was seen at the clinic and was found to be hypotensive and was admitted to a nearby hospital.

What is the problem here?

Click here for the answer and discussion.

Newsletter

Access practical, evidence-based guidance to support better care for our youngest patients. Join our email list for the latest clinical updates.

Subscribe Now!

Related Content

Latest CME

Is TNF-Like Ligand 1A (TL1A) Inhibition the Answer to Improving Disease Remission in Inflammatory Bowel Disease?
In-Person + Virtual Event

Is TNF-Like Ligand 1A (TL1A) Inhibition the Answer to Improving Disease Remission in Inflammatory Bowel Disease?

January 23, 2026

View more
Burst CME: Targeted Therapy for Optimal Psoriasis Management
Video

Burst CME: Targeted Therapy for Optimal Psoriasis Management

Tina Bhutani, MD

View more
Cases and Conversations™: A Horizon View of Continuous Monitoring Systems for Diabetes Management
Video

Cases and Conversations™: A Horizon View of Continuous Monitoring Systems for Diabetes Management

Diana Isaacs, PharmD, BCPS, BC-ADM, BCACP, CDCES, FADCES, FCCP; Anders Carlson, MD; Jennifer B. Green, MD

View more
Progress in Hyperlipidemia Management to Reduce ASCVD Risk: An Illustrated Update
Video

Progress in Hyperlipidemia Management to Reduce ASCVD Risk: An Illustrated Update

Nihar R. Desai, MD, MPH; Martha Gulati, MD, MS, FACC, FAHA, MASPC, FESC, FSCCT (hon), FRCP Edin

View more