Lignocaine and chlorhexidine toxicity in children resulting from mouth paint ingestion: A bottling problem

Background:  A pharmaceutical product was marketed in Australia for ‘teething’ in an almost identical container to a popular paediatric paracetamol preparation. The product contained lignocaine and chlorhexidine. The similarity of the packaging resulted in large number of therapeutic errors in which the ‘teething’ preparation was given in error for paracetamol. As the exact dose of the erroneously administered mouth paint was known this provided an opportunity for outcome assessment of lignocaine ingestion.

[1]  J. Gunter.  Benefit and Risks of Local Anesthetics in Infants and Children , 2002, Paediatric drugs.

[2]  M. Piedmonte,et al.  Symptoms Associated With Infant Teething: A Prospective Study , 2000, Pediatrics.

[3]  S. Wason,et al.  Lidocaine overdose: another preventable case? , 1994, Pediatric emergency care.

[4]  W. Wolfram,et al.  Toxicity--seizures in an infant caused by (or related to) oral viscous lidocaine use. , 1992, The Journal of emergency medicine.

[5]  L. Garrettson,et al.  Rapid onset of seizures following aspiration of viscous lidocaine. , 1992, Journal of toxicology. Clinical toxicology.

[6]  N. Benowitz,et al.  Poisoning Due to Class 1B Antiarrhythmic Drugs , 1989, Medical toxicology and adverse drug experience.

[7]  M. Quinn,et al.  Bradycardia associated with chlorhexidine spray. , 1989, Archives of disease in childhood.

[8]  E. Mucklow.  Accidental Feeding of a Dilute Antiseptic Solution (Chlorhexidine 0.05% with Cetrimide 1%) to Five Babies , 1988, Human toxicology.

[9]  P. Walson,et al.  Seizures secondary to oral viscous lidocaine. , 1988, Annals of emergency medicine.

[10]  F. Lovejoy,et al.  Death following accidental lidocaine overdose in a child. , 1986, The New England journal of medicine.

[11]  M. Giard,et al.  Seizures induced by oral viscous lidocaine. , 1983, Clinical pharmacy.

[12]  B. Shaywitz,et al.  Prolonged seizures associated with the use of viscous lidocaine. , 1982, The Journal of pediatrics.

[13]  J. Lattin,et al.  Lidocaine ingestion. , 1980, American journal of diseases of children.

[14]  D. Scott,et al.  Oral Lignocaine , 1970, Lancet.