Pediatric Update
A 9-month-old with bradycardia and
periodic apnea
Author: Mary Ellen Kraft, RN, CEN, Vacaville, Calif
Section Editors: Deborah Parkman Henderson, RN, PhD, and Donna
Ojanen Thomas, RN, MSN, CEN
A 9-month-old girl with a decreased level of con-
sciousness was brought to our emergency de-
partment by her parents at 8:15 AM. She cried with
stimulation but then would fall asleep. Her parents
said she had not vomited or had diarrhea. The baby
continued to produce tears and wet diapers. On initial
assessment, we noted that her vital signs were as fol-
lows: temperature, 97.2° (rectal); pulse, 120; and res-
pirations, crying. Pulse oximetry was 100% when she
was crying.
The child’s medical history indicated that she
was a normal, healthy 9-month-old girl. The night be-
fore admission, the parents had left the patient with a
babysitter at 10:00 PM so they could go bowling. When
they returned to the babysitter’s house, the baby was
sleeping and they took her home. In the early morning
the mother had difficulty arousing the baby, who also
would not eat and was irritable with an unusual cry.
The parents brought their child to the emergency de-
partment after a few hours of continued decreased
responsiveness.
On arrival at the emergency department, the
baby was irritable, cried strongly, and was moving all
her extremities. Her pupils were small but reactive.
Her mouth was moist, and her lungs were clear to
auscultation. The heart monitor showed normal sinus
rhythm at 120. Her abdomen was soft, and no signs of
trauma were present.
Immediately after triage, the baby was brought
into the emergency department, where she was con-
nected to a cardiac monitor. Her vital signs were as
follows: blood pressure, 141/94; pulse, 104; and respi-
rations, 24. An intravenous line of dextrose 5% and 1⁄2
normal saline solution (D5 1⁄2 NS) was started at a
keep-vein-open rate. The patient was not opening her
Mary Ellen Kraft is Emergency Nurse, Kaiser Permanente, Vallejo,
Calif.
J Emerg Nurs 1998;24:457-9.
Copyright © 1998 by the Emergency Nurses Association.
0099-1767/98 $5.00 + 0 18/9/93083
eyes and became apneic for short periods, although
pulse oximetry continued to be within acceptable
limits. Her skin was warm and dry. Results of an EKG
appeared normal, and a urine bag was applied to do a
urine triage. Laboratory tests for complete blood cell
count, blood cultures, chemistries, calcium, ammo-
nia, and serum glutamate oxaloacetate transaminase
were sent. A chest x-ray film and computed tomogra-
phy scan were ordered.
At 10:35 AM, the patient was sent for her com-
puted tomography scan; results were within normal
limits. Her chest x-ray film was also normal. Her vital
signs were now as follows: blood pressure, 141/59;
pulse, 74; and respirations, 24. She was now opening
her eyes occasionally. The accucheck for blood sugar
was 128 mg/dL. Her intravenous line was converted
to a saline lock at this time.
She was having periods
of apnea.
At 11:00 AM, naloxone (Narcan), 0.5 mg, was
given with little change in the baby’s level of con-
sciousness. Her pupils continued to be miotic. Vital
signs were now as follows: blood pressure, 143/72;
pulse, 78; and hiccuping respirations with a pulse
oximetry of 100%. Her skin was warm and dry. The
parents were in and out of the room, both of them vis-
ibly shaken and appropriately concerned—they were
desperate for answers, which we were still unable to
provide. At 11:50 AM, Narcan, 0.5 mg, was again
given, with slight improvement in the baby’s respira-
tory effort.
The baby’s vital signs were becoming borderline
for her age group: Her heart rate of 70 to 74 was slow,
and she was having periods of apnea. However, her
skin continued to be warm and dry, and her pulse
oximetry continued to be from 98% to 100%, with
October 1998 457
JOURNAL OF EMERGENCY NURSING/Kraft
some improvement in her respiratory effort. She con-
tinued to have good capillary refill. Because her symp-
toms were stable and no further progression was
noted, we opted to monitor her closely and not insert
an endotracheal tube at this point.1
On reviewing the situation, we had a very ill-ap-
pearing infant with pinpoint pupils and a decreased
level of consciousness. We were continually investi-
gating a possible cause, but all diagnoses (such as
meningitis or head trauma) had been ruled out. It was
puzzling that earlier that same day, until arrival home
from the babysitter’s house, the baby seemed normal.
The parents denied any drug use or presence of nar-
cotics in the home and even offered to have them-
selves tested.
The results of the urine triage came back nega-
tive, and a narcotic overdose was ruled out. At this
point, concerns regarding medications found at the
babysitter’s house were investigated. The babysitter
was an elderly woman who denied adamantly that
the baby could have gotten into anything. The pedia-
trician consulted with a pediatric neurologist, who
said he had once seen a similar case with a clonidine
overdose in a young child. The babysitter was imme-
diately called regarding this medication. It happened
that she wore a clonidine patch for hypertension but
denied any possibility that the baby had come in con-
tact with it. The baby had been in her playpen or was
held all night long. Nevertheless, a test to determine
the baby’s clonidine level was ordered.
Earlier that same day, until
arrival home from the
babysitter’s house, the baby
seemed normal.
Discussion
Clonidine is an alpha-2 agonist that acts centrally as
an antihypertensive agent. Symptoms of overdose
manifest rapidly, and generally little clinical deteriora-
tion occurs after 4 hours. Patients generally do well
with prompt supportive care, and symptoms usually
resolve within 24 hours.1 The triad for clonidine toxic-
ity is central nervous system depression, bradycardia,
and miosis, all of which were present in this case. Hy-
potension, apnea, and hypothermia are also common-
ly associated with clonidine toxicity.2 No consistent
abnormalities are found in serum electrolyte, glucose,
creatinine, or blood urea nitrogen values. The com-
458 Volume 24, Number 5
plete blood cell count is usually normal.3 Clonidine is
available in pills that contain 0.1, 0.2, or 0.3 mg of the
medication or as a 7-day patch with 2.5, 5.0, or 7.5 mg
of the medication. As much as 75% of residual drug
can remain in the patch after 7 days.2
The effects of clonidine on the cardiovascular
system are seen within the first several hours after in-
gestion. The usual manifestation is bradycardia fol-
lowed by hypotension. If the patient becomes hemo-
dynamically compromised, the first line of treatment
is atropine. The response is usually favorable. Hy-
potension may also occur, usually within 2 to 4 hours
of ingestion. Respiratory depression is related to the
central nervous system effects of clonidine on the
medulla. If respiratory depression is of sufficient
severity, the patient may require intubation. Hy-
pothermia may develop but usually resolves within 8
hours of ingestion; it can, however, last up to 48
hours. Treatment, which is rarely needed, consists of
external passive warming.2
The use of naloxone as an antidote is controver-
sial. The half-life of naloxone is 1 hour compared with
7 to 12 hours for clonidine. Therefore, if naloxone
proves beneficial, repetitive doses or continuous infu-
sions are necessary.2
Continuing clinical picture
At noon the baby’s blood pressure was 146/59, her
pulse was 71, and her temperature was 97.1° (rectal).
A spinal tap was done, and the results were negative.
An external warmer was applied at this time. At 1:30
PM her vitals signs were as follows: blood pressure,
158/63; pulse, 76; respirations, 20; and temperature,
97.6° (rectal). She was moving all 4 extremities and
was quiet, with intermittent periods of crying. A ten-
tative diagnosis of clonidine toxicity was made, and
the patient was transferred to the pediatric unit.
In the unit, the baby’s hospital course was non-
eventful. Her breathing pattern remained effective
throughout the hospital stay despite initial concerns
about her respiratory rate, which was only 16 to 20 on
discharge from the emergency department. By 7:30
PM that same evening, her respiratory rate was 34 and
remained above 24 until discharge. Her lungs re-
mained clear without any retractions, nasal flaring, or
cyanosis.
Also of initial concern was her cardiac output and
related blood pressure. On arrival from the emergency
department, the patient’s pulse was 76—on the low
side of normal, with a blood pressure of 101/55. Her
skin was warm and dry. By the time she was dis-
charged, her pulse was in the 120s and her skin con-
tinued to be warm and dry. Intake and output were
within normal limits.
 Kraft/JOURNAL OF EMERGENCY NURSING

Because of her decreased level of consciousness,
the baby’s nutrition was also of concern. On arrival in
the emergency department, her weight was 20 lb.
That evening her intake and output was adequate as
reflected by wet diapers, a capillary refill of less than
2 seconds, and good skin turgor. By the following
morning she was able to start taking a bottle. Her
urine had a specific gravity of 1.015. On discharge,
she weighed 20 lb, 93⁄4 oz.
We came to the conclusion
that the babysitter’s
clonidine patch had
accidentally fallen into the
playpen, where the baby
subsequently sucked on it.
The parents were very concerned and stayed at
the baby’s bedside during her hospitalization. They
were able to provide for most of her daily care. The
mother requested the first bottle and was able to feed
the baby. The baby’s grandmother was also present.
Summary
The patient was discharged approximately 36 hours
after admission to the emergency department. At that
time she was awake and alert and responding appro-
priately to her surroundings. Her vital signs were
within normal limits. It took approximately 2 weeks to
receive the baby’s clonidine level, which was 11.0
ng/mL; the therapeutic level is between 0.5 to 4.5
ng/mL.
We came to the conclusion that the babysitter’s
clonidine patch had accidentally fallen into the
playpen, where the baby subsequently sucked on it.
To this day, the babysitter denies any involvement.
Situations such as this confront emergency nurses
every day, and questions arise regarding intent. In
this case, the physician interviewed the babysitter
and believed that the overdose was unintentional.
Once again we are reminded of the fragility of life, the
importance of capable, cautious caregivers, and just
how easily accidents can happen. What a happy out-
come this turned out to be after what appeared to be
such a grave medical emergency on presentation!
References
1. Henretig FM. Special considerations in the poisoned pe-
diatric patient. Emerg Med Clin North Am 1994;12:549-67.
2. Nichols MH, King WD, James LP. Clonidine poisoning in
Jefferson County, Alabama. Ann Emerg Med 1997;29:511-7.
3. Wiley JF, Wiley CC, Torrey SB, Henretig FM. Clonidine
poisoning in young children, J Pediatr 1990;116:654-6.
Contributions for this column can be sent to
Deborah Parkman Henderson, RN, PhD, 1255
Linda Ridge Rd, Pasadena, CA 91103; phone
(310) 328-0720; E-mail: dhendersn@aol.com or
Donna Ojanen Thomas, RN, MSN, CEN, 2822
E Canyon View Dr, Salt Lake City, UT 84109; phone
(801) 588-2240; E-mail: pcdthoma@ihc.com.

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