Three children have been sent to the hospital in Kentucky for taking a drug that local officials say a pharmacy might’ve unknowingly contaminated.
Among them are one-year-old Ian Burkett, who was sedated and put on a ventilator in the ER, and five year old Rayven Winters, who is still unresponsive in the intensive care unit.
Both children had been taking the drug Clonidine Oral Suspension – brand name Onyda XR – for a while and never had any side effects.
It’s a liquid form of an ADHD drug used to treat kids who have a hard time swallowing pills.
Rayven has been unresponsive in the ICU since EMT’s rushed her to the hospital after taking her regular dose of liquid Clonidine
The five year old had been taking the drug to manage her ADHD for about a year, and had never before had a reaction to it, her mother, Tabitha Drew, said
It’s unclear how many of America’s 7million children living with ADHD take the medication to manage their symptoms. Studies have suggested roughly 30 percent of people with ADHD don’t respond to stimulants, like Adderall.
One Sunday evening, Rayven Winters took her ADHD medication, as she had many other nights in the year since she’d begun the drug.
After, the five-year-old 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 would not respond.
‘I honestly thought my baby was dead,’ Tabitha Drew, Rayven’s mom, told WHAS11. She quickly called 911.
When the EMT’s arrived, they quickly moved to treat Rayven with Narcan, among other things. Authorities have not said why this was used, but it’s possible they suspected that an opioid had tainted the medication.
‘I handed [the EMTs] the bottles, and as soon as she looked at the bottle’s name, she started Narcan immediately,’ Ms Drew said.
Older case studies have shown there is room for error when liquid drugs, like these, get mixed in the pharmacy, as is standard course. When mixing a liquid form of a drug pharmacists run the risk of over or under dosing the bottle.
Whatever the cause, Rayven is currently unresponsive in the intensive care unit at Norton Children’s Hospital.
Ms Drew got the medication from a local Med Save pharmacy she’d been using for at least a decade.
The pharmacy had called the day before the incident to warn Ms Drew that some batches of Clonidine had been contaminated, but they did not specify what had happened to them.
This is the same pharmacy the parents of 21-month-old Henry Burkett got his Clonidine from. Shortly after taking a dose, Henry became so drowsy that he couldn’t sit up or answer questions.
Henry was also administered Narcan by emergency responders while on the way to the hospital after taking the drug.
Ian Burkett, Henry’s father, told WDRB: ‘It was definitely an overdose because he received Narcan on the way to the hospital’.
Once in ER, Henry was sedated and put on a ventilator.
He is now home recuperating. ‘We want answers, we want people to be held accountable, you know, so this doesn’t happen again,’ Mr Burkett said.
The local police force has said they believe the evidence points towards the local Med Save pharmacy in Eminence, Kentucky that all three families got their Clonidine from.
Med Save is a statewide chain, affiliated with the national company The Medicine Shoppe.
Christopher Harlow, the executive director of the Kentucky Board of Pharmacy, told WHAS11: ‘The allegation is that an error was made at the pharmacy’.
Henry Burkett is a 21-month-old living in Kentucky with his parents Ian and Beth. His normal dose of liquid clonidine made him unresponsive, and he was put 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 administer it to their children’s
Authorities have not detailed how this batch was affected – and what caused the three hospitalizations.
In 2009, one three-year-old was sent to the hospital after overdosing on clonidine and becoming unresponsive, a case study from the New Mexico Poison Center detailed.
This, the researchers wrote, is evidence that: ‘particular care should be taken with medications that have low therapeutic indices, that are extemporaneously compounded, and are prepared as liquids, where medication errors are more likely.’
A similar case occurred in a Massachusetts 12 year old in 2020. On the whole, these occurrences are rare, and clonidine is still widely considered safe.
The police and board of pharmacy have both cautioned that the investigation was ongoing, and they had yet to conclude who is at fault for the bad batch.
‘It is our job to find out what happened and take appropriate action to ensure the safety of the people of Kentucky,’ Mr Harlow said.
The Henry County, Kentucky, Emergency Health Services (EMS) have told anyone who has filled their Clonidine Oral Suspension prescription at the Eminence Med Save not to administer the product to their children.
‘We have reason to believe that there is something wrong with their shipment. DO NOT USE,’ the official statement said.
If you have given your child the medication, the EMS said to look out for sudden loss of consciousness, crying fits, slow heart rate, slow breathing rate or pinpoint pupils. If you have these symptoms, call 911.
