Three children were sent to the hospital in Kentucky after taking a medication that local officials say a pharmacy may have unwittingly contaminated.
They include one-year-old Ian Burkett, who was sedated and put on a ventilator in the emergency room, and five-year-old Rayven Winters, who remains unresponsive in the intensive care unit.
Both children had been taking the medication Clonidine Oral Suspension (brand name Onyda XR) for some time and had never had any side effects.
It is a liquid form of a blood pressure medication that is used to treat children who have difficulty swallowing pills and is sometimes also used to treat ADHD.
Rayven has been unresponsive in the ICU since paramedics rushed her to the hospital after taking her usual dose of liquid clonidine.
The 5-year-old had been taking the medication to control her ADHD for about a year and had never had a reaction to it before, said her mother, Tabitha Drew.
One Sunday night, Rayven Winters took medication to treat just that.
Like many other nights last year, since she started taking the medication, the five-year-old sat down to play with her toys.
Within ten minutes, her eyes rolled back in her head and despite her mother’s pleas, the girl was unresponsive.
“I honestly thought my baby was dead,” said Tabitha Drew, Rayven’s mother. He told WHAS11. She quickly called 911.
When paramedics arrived, they were quick to treat Rayven with Narcan, among other things. Authorities have not said why this drug was used, but it is possible that they suspected an opioid had contaminated the medication.
“I handed her the vials, and as soon as she saw the name on the vial, she started taking Narcan immediately,” Drew said.
However, previous case studies have shown that there is room for error when liquid medications like these are mixed in the pharmacy as is routine. When mixing a liquid form of a medication, pharmacists run the risk of over- or under-dosing the bottle.
Whatever the cause, Rayven currently lies unconscious in the intensive care unit at Norton Children’s Hospital.
Ms. Drew got the medication from a local Med Save pharmacy that she had been using for at least a decade.
The pharmacy had called the day before the incident to warn Ms Drew that some batches of clonidine had been contaminated, but did not specify what had happened to them.
This is the same pharmacy where 21-month-old Henry Burkett’s parents got their clonidine. Shortly after taking a dose, Henry became so drowsy that he couldn’t sit up or answer questions.
Emergency responders also administered Narcan to Henry as he headed to the hospital after taking the medication.
Ian Burkett, Henry’s father, he told WDRB‘It was definitely an overdose because he received Narcan on the way to the hospital.’
Once in the emergency room, Henry was sedated and connected to a respirator.
He is now at home recovering. “We want answers, we want people held accountable, you know, so this doesn’t happen again,” Burkett said.
The local police force has said it believes evidence points to the local Med Save pharmacy in Eminence, Kentucky, where the three families obtained their clonidine.
Med Save is a state-owned chain, affiliated with the national company The Medicine Shoppe.
Christopher Harlow, executive director of the Kentucky Board of Pharmacy, told WHAS11, “The allegation is that an error was made at the pharmacy.”
Henry Burkett is a 21-month-old boy who lives in Kentucky with his parents, Ian and Beth. His normal dose of liquid clonidine left him unconscious and he was put on a ventilator at a children’s hospital.
Med Save Pharmacy is local to Kentucky, but is affiliated with the national chain The Medicine Shoppe. Officials say anyone who has purchased liquid clonidine from this store should not give it to their children.
Authorities have not detailed how this batch was affected or what caused the three hospitalizations.
In 2009, a three-year-old boy was sent to the hospital after overdosing on clonidine and failing to respond, a case study of The New Mexico Poison Center detailed.
This, the researchers wrote, is evidence that “special care should be taken with medications that have low therapeutic indices, are extemporaneously prepared, and are prepared as liquids, where medication errors are more likely.”
A similar case occurred in a Massachusetts, 12 years in 2020Overall, these cases are rare and clonidine is still considered safe.
Both police and the pharmacy board warned that the investigation was ongoing and they had not yet concluded who was to blame for the faulty batch.
“It’s our job to find out what happened and take appropriate steps to ensure the safety of the people of Kentucky,” Harlow said.
He Henry County, Kentucky, Emergency health services (EMS) has advised all those who have filled their prescription for clonidine oral suspension in Eminence Med Save not to administer the product to their children.
“We have reason to believe there is a problem with your shipment. DO NOT USE,” the official statement said.
If your child has been given the medicine, the emergency medical service told you to watch for sudden loss of consciousness, crying spells, slow heart rate, slow breathing rate, or constricted pupils. If you have these symptoms, call 911.
