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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.