Buprenorphine ingestion in a 23-month-old boy.

Case: A previously healthy 23-month-old 12.6-kg boy presented to an outside community emergency department with vomiting and respiratory depression after a single episode of red-orange emesis that looked and smelled like his mother’s buprenorphine/naloxone tablets (8 mg/2 mg formulation). She reported slowed respirations, small pupils, and somnolence, but she denied witnessing any ingestion; therefore, the amount ingested and the time of ingestion remained unknown. At presentation to the emergency department, the patient’s respiratory rate was 14 per minute, with an oxygen saturation of 93% on room air; pupils were miotic, and the patient was described as lethargic. He was treated with 0.4 mg (0.03 mg/kg) of intravenous naloxone initially, without documented improvement in arousal or respiratory status. A second dose of naloxone 0.4 mg was administered intravenously immediately after the fi rst dose. This second dose of naloxone resulted in arousal with crying and a respiratory rate of 18 per minute. At this time he was given 1 g/kg activated charcoal with sorbitol orally. A third dose of naloxone 0.4 mg was administered 20 minutes after the second dose, and at that time a naloxone infusion was initiated at 0.06 mg/hr. Approximately 15 minutes after initiation of the infusion he experienced recurrence of somnolence and bradypnea, and the naloxone infusion was increased to 0.2 mg/hr (0.015 mg/kg) with improvement. The patient was then transferred to the PICU.