Three children have been taken to a Kentucky hospital after taking a medication that local authorities say was unknowingly contaminated by a pharmacy.
Among them are one-year-old Ian Burkett, who was anesthetized and put on a ventilator in the emergency room, and five-year-old Rayven Winters, who remains unresponsive and in intensive care.
Both children had been using the medication Clonidine Oral Suspension (brand name Onyda XR) for some time and never experienced any side effects.
It is a liquid form of an ADHD medication used to treat children who have difficulty swallowing pills.
Rayven has been unresponsive in intensive care since the ambulance rushed her to hospital after she took her usual dose of liquid clonidine
The 5-year-old girl had been taking the drug for about a year to manage her ADHD and had never had a reaction to it before, said her mother, Tabitha Drew.
It’s unclear how many of the 7 million children in America living with ADHD are taking the medication to manage their symptoms. Studies have suggested about 30 percent of people with ADHD do not respond to stimulants, such as Adderall.
On a Sunday evening, Rayven Winters took her ADHD medication, as she had done many times since she started taking the drugs.
The five-year-old then sat down to play with her toys. Within ten minutes, her eyes had rolled back in her head and despite pleas from her mother, the child did not respond.
“I honestly thought my baby was dead,” said Tabitha Drew, Rayven’s mother, told WHAS11. She quickly called 911.
When first responders arrived, they quickly began treating Rayven with Narcan, among other things. Authorities have not said why this was used, but it is possible they suspected an opioid had contaminated the medication.
I gave [the EMTs] “The bottles, and as soon as she looked at the name of the bottle, she immediately started Narcan,” Ms. Drew said.
Previous case studies have shown that there is room for error when liquid medications, such as this, are mixed in the pharmacy, as is common. When mixing a liquid form of a medication, pharmacists run the risk of over- or under-dosing the bottle.
Whatever the cause, Rayven is currently unconscious in the intensive care unit at Norton Children’s Hospital.
Mrs. Drew obtained the medications from a local Med Save pharmacy, which she had been using for at least ten years.
The pharmacy had called the day before the incident to warn Mrs. Drew that some batches of Clonidine were contaminated, but they did not indicate what had happened to them.
This is the same pharmacy where 21-month-old Henry Burkett’s parents got his Clonidine. Shortly after taking a dose, Henry became so drowsy he couldn’t sit up or answer questions.
Henry was also administered Narcan by emergency workers while en route to the hospital after taking the drug.
Ian Burkett, Henry’s father, told WDRB: ‘It was definitely an overdose because he was given Narcan on the way to the hospital’.
Once in the emergency room, Henry was sedated and put on a ventilator.
He is now recovering at home. “We want answers, we want people to be held accountable, you know, so that this doesn’t happen again,” Mr Burkett said.
Local police believe the evidence points to the local Med Save pharmacy in Eminence, Kentucky, where all three families got their Clonidine.
Med Save is a chain that operates in the state and is affiliated with the national company The Medicine Shoppe.
Christopher Harlow, executive director of the Kentucky Board of Pharmacy, told WHAS11, “The allegation is that there was a mistake 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 made him unresponsive and he was placed 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. Authorities say anyone who has purchased liquid clonidine from this store should not give it to their children
Authorities have not disclosed how this group was affected or what caused the three hospitalizations.
In 2009, a three-year-old child was sent to hospital after taking an overdose of clonidine and became unresponsive, according to a case study by the New Mexico Poison Center detailed.
This, the researchers wrote, is evidence that “particular caution is warranted with drugs with a low therapeutic index, those compounded on site, and those prepared as liquids, which are more likely to result in medication errors.”
A similar case occurred in a Massachusetts 12 years old in 2020In general, these events are rare and clonidine is still generally considered safe.
Police and the Pharmaceutical Council have both warned that investigations are ongoing and that they have not yet determined who is responsible for the bad batch.
“Our job is to investigate what happened and take appropriate action to ensure the safety of the people of Kentucky,” Harlow said.
The County Henry, Kentucky, Emergency services (EMS) have advised anyone who has obtained a prescription for Clonidine Oral Suspension from Eminence Med Save not to give the product to their children.
“We have reason to believe there is something wrong with their shipment. DO NOT USE,” the official statement read.
If you gave your child the medication, the EMS said to watch for sudden loss of consciousness, crying spells, slow heart rate, slow breathing, or pinhead pupils. If you have these symptoms, call 911.