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Phenergan Supp given to toddler; child dies



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No. 20
Old Oct 22, 2004, 10:09 PM

First off... The issue with medicine not being equally distributed. Our pharmacy tells us that this is an old school thought and not true at all. They say that it IS evenly distributed... well, according to our pharmacy.
Second... we almost NEVER give phenergan to little ones under 3-- we almost always give TIGAN instead. Less side effects.
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No. 21
Old Apr 12, 2007, 02:47 PM

Default Re: Phenergan Supp given to toddler; child dies
My condolences to you and your friend for the loss of a child. I had a somewhat similar experience. My toddler who was 2 1/2 was vomitting in the morning on and off for weeks and we were told by the pediatrician that it was most likely Motrin induced gastritis. I had been giving him motrin and tylenol on and off because he had been cutting molars and kept complaining that his "mouth hurts." After a few more weeks of vomiting we went back to the pediatrician and he gave my son a phenergan injection for the vomiting. He told me it would make him very drowsy for several hours. My son indeed was very drowsy all afternoon and barely woke up to get into pjs for the night and take little fluids so as not to dehydrate. I fully expected him to wake up in the middle of the night ready to go for the day. He did not. At 6:30am when his twin woke up we could not wake the other toddler. He was completely unresponsive. We called the doctors office and 911 and began CPR as he started to turn blue in our arms. He went into respiratory depression and into a coma. We also found out at the same time that he had a brain tumor as well. He went into multiple cardia arrests and respiratory arrests all day long. We took him off of life support two days after. The pediatrician at the childrens hospital was very upset that the pediatrician had given my son phenergan as she said it was contraindicated for a child that small. I realize my child had a terminal illess that we did not know about, but I do believe the respiratory arrest led to his immediate death.

I understand and can sympathize with loss of a child so unexpectedly. Its been very difficult for our family.

God Bless.
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No. 22
from mamalle
Old Apr 12, 2007, 03:38 PM

Default Re: Phenergan Supp given to toddler; child dies
WOW Im so sorry. I dont think I have ever given my kids more than 6.25mg of rectal phenergan. I hate to use it anyhow due to the sedating effect. our pediatricians office gave it to our daughter when she was 4 since they told me she was vomiting from her bilateral ear infections.(which wasnt true, along with 500mg of rocephin IM) she had the rotovirus but they blew it off. They gave her 12.mg of phenergan IM and she was 28lbs. I was pretty upset that they gave that much. we kept her in our room and constantly aroused her and tried to get her to drink. took her back at 4pm for a recheck and was told I hadnt tried to force fluids that she was too drowsy from the phenergan. they gave her water and she vomited all the way home. the next day I took her to my ER and had the pedi ER look at her and she got a IV line with fluids immediately and labwork sent off. did fine with IV fluids- her glucose level was 59 so they gave her some dextrose and she perked right up. started taking fluid challanges. Of course the office called in a panic monday morning and said her stool came back positive with the rotovirus. I said oh really? they called for 3 days straight after that to check on her...
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No. 23
from bjr3645
Old Apr 12, 2007, 04:58 PM

Default Re: Phenergan Supp given to toddler; child dies
phenergan drops blood pressure, no?

And all my condolences
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No. 24
from tencat
Old Apr 12, 2007, 05:23 PM

Default Re: Phenergan Supp given to toddler; child dies
I see this is an old thread, but really a good one. I learned something about kids and phenergan. That drug makes me nervous with adults, too. I also didn't realize how serious dehydration can be in kids.

I am so sorry about your loss, twinmom. Thank you for sharing with us.
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No. 25
from TazziRN
Old Apr 12, 2007, 10:52 PM

Default Re: Phenergan Supp given to toddler; child dies
My daughter is one that always starts vomiting when she is ill with anything.....it's one of her symptoms of being sick. When she was small and the Phenergan contraindication came out, the docs tried everything with her and nothing else worked. I finally told the docs I would take the risk, to please give her Phenergan. I kept an eagle eye on her each time she got it and has never suffered anything more than drowsiness, but i was willing to take the risk of resp depression rather than having her get sicker because she couldn't stop puking. My doc told me that if I were not a nurse he never would have agreed to it, but knowing what to look for and what to do helped.
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No. 26
from EmerNurse
Old Apr 13, 2007, 12:53 AM

Default Re: Phenergan Supp given to toddler; child dies
Originally Posted by twinmom0704 View Post
My condolences to you and your friend for the loss of a child. I had a somewhat similar experience. My toddler who was 2 1/2 was vomitting in the morning on and off for weeks and we were told by the pediatrician that it was most likely Motrin induced gastritis. I had been giving him motrin and tylenol on and off because he had been cutting molars and kept complaining that his "mouth hurts." After a few more weeks of vomiting we went back to the pediatrician and he gave my son a phenergan injection for the vomiting. He told me it would make him very drowsy for several hours. My son indeed was very drowsy all afternoon and barely woke up to get into pjs for the night and take little fluids so as not to dehydrate. I fully expected him to wake up in the middle of the night ready to go for the day. He did not. At 6:30am when his twin woke up we could not wake the other toddler. He was completely unresponsive. We called the doctors office and 911 and began CPR as he started to turn blue in our arms. He went into respiratory depression and into a coma. We also found out at the same time that he had a brain tumor as well. He went into multiple cardia arrests and respiratory arrests all day long. We took him off of life support two days after. The pediatrician at the childrens hospital was very upset that the pediatrician had given my son phenergan as she said it was contraindicated for a child that small. I realize my child had a terminal illess that we did not know about, but I do believe the respiratory arrest led to his immediate death.

I understand and can sympathize with loss of a child so unexpectedly. Its been very difficult for our family.

God Bless.
My very deepest condolences for your loss. I'll send up a prayer for your little one and your family.
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No. 27
from EmerNurse
Old Apr 13, 2007, 12:54 AM

Default Re: Phenergan Supp given to toddler; child dies
Originally Posted by Mom23 View Post
I WAS an RN in NICU (taking some time off to raise a family). I am unfamiliar with Phenergan. Obviously we did not use it in my area.

I have a very tragic situation....A very good friend of mine brought her toddler to our local ER for vomitting and dehydration from viral Gastroenteritis. The child was under two and small for her age (9.5 kg). After waiting more than two hours with symptoms worsening (vomitting blood), her child was given a Phenergan suppository 12.5. No IV was given. No exam was performed. My friend think it was actually the 50 dose based on the color of the packaging and size of the supp. Later, when her daughter coded, the child was given Epinephrine (excessive dose). I have been able to find out that Epi contraindicates with the Phenergan (Lippincott). Her child died. She had me look over the records and the Phenergan stuck out.

What has been your experience with Phenergan supp in pediatric patients? Thanks for your input.....Mom23
Please give my condolences to your friend. How very sad

We don't really give phenergan to kids in our ER - if they've been vomiting, we give IVF and then a PO trial later. Usually, they do pretty well. If we're in doubt, we'll transfer to a peds facility (we don't have inpatient peds).
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No. 28
from GoldenLove
Old Apr 13, 2007, 01:06 AM

Default Re: Phenergan Supp given to toddler; child dies
In 2005, the FDA actually made a revision to the safety labeling of promethazine (Phenergan) for use in patients under the age of 2 due to the potential for fatal respiratory depression. We ceased use of it all together after the label change for all patients under 2.
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No. 29
from kmoonshine
Old Apr 15, 2007, 02:11 AM

Default Re: Phenergan Supp given to toddler; child dies
Originally Posted by newfloridaRN View Post
First off... The issue with medicine not being equally distributed. Our pharmacy tells us that this is an old school thought and not true at all. They say that it IS evenly distributed... well, according to our pharmacy.
Second... we almost NEVER give phenergan to little ones under 3-- we almost always give TIGAN instead. Less side effects.
Tigan suppositories have been pulled by the FDA as of 04/06/2007:
http://www.fda.gov/medwatch/safety/2...methobenzamide

I've subscribed to the "e-list" from medwatch and I am sent medical alerts as they become available. I suggest every ED RN subscribe to this.
http://www.fda.gov/medwatch/elist.htm
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