Normal neurologic and developmental outcome after an accidental intravenous infusion of expressed breast milk in a neonate.

Hdl Handle:
http://hdl.handle.net/10147/208874
Title:
Normal neurologic and developmental outcome after an accidental intravenous infusion of expressed breast milk in a neonate.
Authors:
Ryan, C Anthony; Mohammad, Izlan; Murphy, Brendan
Affiliation:
Department of Paediatrics and Child Health, Cork University Hospital, University , College, Cork, Ireland. ryant01@eircom.net
Citation:
Pediatrics. 2006 Jan;117(1):236-8.
Journal:
Pediatrics
Issue Date:
3-Feb-2012
URI:
http://hdl.handle.net/10147/208874
DOI:
10.1542/peds.2005-0898
PubMed ID:
16396887
Abstract:
Here we describe a premature male infant who was accidentally given 10 mL of expressed breast milk intravenously over a 3.5-hour period. Having survived this event with supportive care, this boy was attending regular school with no obvious neurologic or learning difficulties at 6 years of age. In 1998, after a query on an e-mail discussion group for health care providers in neonatology (NICU-net), we were informed of 8 similar events that proved fatal in 3 infants. A root-cause analysis revealed that accidental intravenous administration of breast milk or formula can be avoided by the use of color-coded enteral-administration sets with Luer connections that are not compatible with intravenous cannulas. The addition of methylene blue to feeds, or bolus enteral feeds (instead of continuous gastric feedings), may also help prevent such errors. These cases show the value of gathering information about rare but important events through a neonatal network. In addition, they confirm that prevention of medical error should focus on faulty systems rather than faulty people.
Language:
eng
MeSH:
*Child Development; Humans; Infant, Newborn; *Infant, Premature; *Infusions, Intravenous; Intubation, Gastrointestinal; Male; *Medical Errors; *Milk, Human
ISSN:
1098-4275 (Electronic); 0031-4005 (Linking)

Full metadata record

DC FieldValue Language
dc.contributor.authorRyan, C Anthonyen_GB
dc.contributor.authorMohammad, Izlanen_GB
dc.contributor.authorMurphy, Brendanen_GB
dc.date.accessioned2012-02-03T15:06:08Z-
dc.date.available2012-02-03T15:06:08Z-
dc.date.issued2012-02-03T15:06:08Z-
dc.identifier.citationPediatrics. 2006 Jan;117(1):236-8.en_GB
dc.identifier.issn1098-4275 (Electronic)en_GB
dc.identifier.issn0031-4005 (Linking)en_GB
dc.identifier.pmid16396887en_GB
dc.identifier.doi10.1542/peds.2005-0898en_GB
dc.identifier.urihttp://hdl.handle.net/10147/208874-
dc.description.abstractHere we describe a premature male infant who was accidentally given 10 mL of expressed breast milk intravenously over a 3.5-hour period. Having survived this event with supportive care, this boy was attending regular school with no obvious neurologic or learning difficulties at 6 years of age. In 1998, after a query on an e-mail discussion group for health care providers in neonatology (NICU-net), we were informed of 8 similar events that proved fatal in 3 infants. A root-cause analysis revealed that accidental intravenous administration of breast milk or formula can be avoided by the use of color-coded enteral-administration sets with Luer connections that are not compatible with intravenous cannulas. The addition of methylene blue to feeds, or bolus enteral feeds (instead of continuous gastric feedings), may also help prevent such errors. These cases show the value of gathering information about rare but important events through a neonatal network. In addition, they confirm that prevention of medical error should focus on faulty systems rather than faulty people.en_GB
dc.language.isoengen_GB
dc.subject.mesh*Child Developmenten_GB
dc.subject.meshHumansen_GB
dc.subject.meshInfant, Newbornen_GB
dc.subject.mesh*Infant, Prematureen_GB
dc.subject.mesh*Infusions, Intravenousen_GB
dc.subject.meshIntubation, Gastrointestinalen_GB
dc.subject.meshMaleen_GB
dc.subject.mesh*Medical Errorsen_GB
dc.subject.mesh*Milk, Humanen_GB
dc.titleNormal neurologic and developmental outcome after an accidental intravenous infusion of expressed breast milk in a neonate.en_GB
dc.contributor.departmentDepartment of Paediatrics and Child Health, Cork University Hospital, University , College, Cork, Ireland. ryant01@eircom.neten_GB
dc.identifier.journalPediatricsen_GB
dc.description.provinceMunster-

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