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

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    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
    Issue Date
    2012-02-03T15:06:08Z
    MeSH
    *Child Development
    Humans
    Infant, Newborn
    *Infant, Premature
    *Infusions, Intravenous
    Intubation, Gastrointestinal
    Male
    *Medical Errors
    *Milk, Human
    
    Metadata
    Show full item record
    Citation
    Pediatrics. 2006 Jan;117(1):236-8.
    Journal
    Pediatrics
    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
    ISSN
    1098-4275 (Electronic)
    0031-4005 (Linking)
    ae974a485f413a2113503eed53cd6c53
    10.1542/peds.2005-0898
    Scopus Count
    Collections
    Cork University Hospital

    entitlement

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