Ethanol Ingestion in Two Infants Under 2 Months Old: A Previously Unreported Cause of ALTE

Department of Emergency Medicine, Los Angeles County and University of Southern California, Los Angeles, California.
PEDIATRICS (Impact Factor: 5.47). 01/2013; 131(2). DOI: 10.1542/peds.2012-1652
Source: PubMed


The differential diagnosis for the infant presenting with an apparent life-threatening event (ALTE) is broad. Toxic ingestions are a relatively uncommon cause of an ALTE, although several over-the-counter, prescription, and illicit drugs have been implicated. We present 2 cases of ethanol intoxication in infants as a previously unreported cause of an ALTE. Additionally, serial ethanol levels for these patients offer novel insight into the pharmacokinetics of ethanol metabolism in infants. Ethanol ingestion may be an underrecognized cause of an ALTE and should be considered if the history or physical examination is suggestive.

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    • "Previously published reports on infant kinetics suggest that infants may follow first-order elimination kinetics or a percent of concentration per unit time [3] [10] [12]. McCormick et al. demonstrated a transition from 1st-order to zeroorder kinetics at a blood ethanol level of approximately 225 mg/dL in the two infants they observed [11]. Our patient appeared to follow a constant elimination rate consistent with zero-order kinetics given the linear trendline with a coefficient of determination (í µí±… "
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    ABSTRACT: Primary ethanol metabolism occurs through alcohol dehydrogenase, but minor metabolic pathways such as the P450 enzymes CYP2E1 and CYP1A2 and the enzyme catalase exist. These enzymes have distinct developmental stages. Elimination kinetics of ethanol in the infant is limited. We report the elimination kinetics of ethanol in a 5-week-old African-American male who had a serum ethanol level of 270 mg/dL on admission. A previously healthy 5-week-old African-American male was brought to the ED with a decreased level of consciousness. His initial blood ethanol level was 270 mg/dL. Serial blood ethanol levels were obtained. The elimination rate of ethanol was calculated to be in a range from 17.1 to 21.2 mg/dL/hr and appeared to follow zero-order elimination kinetics with a R (2) = 0.9787. Elimination kinetics for ethanol in the young infant has been reported in only four previously published reports. After reviewing these reports, there appears to be variability in the elimination rates of ethanol in infants. Very young infants may not eliminate ethanol as quickly as previously described. Given that there are different stages of enzyme development in children, caution should be used when generalizing the elimination kinetics in young infants and children.
    Case Reports in Medicine 12/2013; 2013:250716. DOI:10.1155/2013/250716
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    ABSTRACT: Alcohol ingestion in the pediatric patient can be life threatening. Younger patients consume larger volumes per body weight with accidental ingestions, and children have more serious adverse effects at lower blood alcohol levels. Complications of alcohol poisoning can include hypothermia, hypoglycemia, seizures, coma, and death. We present the course of a 9-month-old female infant who became unresponsive at home and presented to the emergency department comatose. When her blood alcohol level registered 489 mg/dL, it was revealed that she had accidentally been given a bottle of formula mixed with vodka rather than water. The infant required intubation for severely depressed level of consciousness and aggressive fluid resuscitation for hemodynamic instability. She had a peak lactate level of 24 mmol/L and a peak blood alcohol level of 524 mg/dL. Based on the severity of her initial presentation, preparations were made for hemodialysis. The infant responded to supportive measures including mechanical ventilation, fluids, and dextrose, and hemodialysis was not necessary. Her alcohol clearance followed zero-order kinetics at an average rate of 28.6 mg/dL per hour over 15.5 hours from her peak level of 524 mg/dL to the lowest measured value of 80 mg/dL. The kinetics of ethanol clearance at this level of toxicity, which is the highest reported in an infant to date, enhance our knowledge of ethanol metabolism and will assist in management decisions in cases of severe intoxication.
    Pediatric Emergency Care 10/2014; 30(10):739-741. DOI:10.1097/PEC.0000000000000240 · 1.05 Impact Factor
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    ABSTRACT: Introduction Ethanol has been used for years in neonatal and infant liquid medications, yet the pharmacokinetics, pharmacodynamics, and safety of ethanol in this vulnerable population have not been well characterized. The purpose of this review is to raise awareness of ethanol use as an excipient in neonatal and infant medications and to provide insight, based on the available evidence, into clearance rates of ethanol in babies. We also discuss ethanol pharmacokinetics in adults, theoretical pharmacokinetic changes in neonates and infants as it may apply to ethanol disposition, and case reports involving ethanol exposure in neonates and infants. Materials and methods This study was a narrative review in which relevant papers were selected using databases and scientific search engines such as PubMed with the key words ethanol, infant, and newborninfant. Results It remains unclear what ethanol exposure is safe for neonates and infants. The Food and Drug Administration and American Academy of Pediatrics have both taken action, by either setting limits of ethanol content in over-the-counter medications or by recommending restricted exposure to ethanol-containing pediatric formulations. Conclusions Until the short- and long-term health effects of chronic ethanol administration can be further characterized, ethanol-containing medications should be used with caution.
    Current Therapeutic Research 12/2014; 76:90-7. DOI:10.1016/j.curtheres.2014.09.002 · 0.45 Impact Factor
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