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.
