# Mind the Decimal Point: A Case of Diazoxide Overdose-Induced Ileus

## TL;DR

A preterm infant experienced ileus after a 10-fold diazoxide overdose, highlighting the risk of medication errors in infants due to decimal point mistakes.

## Contribution

This case highlights the rare but serious complication of ileus caused by a diazoxide overdose and emphasizes the importance of preventing decimal point medication errors in infants.

## Key findings

- A 10-fold diazoxide overdose in a preterm infant led to generalized ileus and required NICU admission.
- Medication errors in infants are often due to decimal point mistakes, leading zeros, or trailing zeros.
- Using the smallest possible syringe for dosing may help reduce such errors.

## Abstract

Diazoxide is the only medication approved by the United States Food and Drug Administration for the treatment of hyperinsulinism-induced hypoglycemia. Overdose is infrequently reported. This case describes a preterm four-week-old male who was prescribed diazoxide and chlorothiazide for perinatal stress-induced hyperinsulinism. The patient presented to the emergency department with feeding intolerance and abdominal distension following an accidental 10-fold diazoxide overdose. On presentation, vital signs were remarkable for tachycardia and intermittent tachypnea. Physical exam revealed a grossly distended abdomen. Laboratory abnormalities included a glucose of 216 mg/dL, sodium of 132 mmol/L, and chloride of 98 mmol/L. Abdominal X-ray interpretation found moderate gaseous distension suggestive of generalized ileus. The patient was admitted to the neonatal intensive care unit (NICU), and a nasogastric tube was placed. He received intravenous dextrose fluids, and enteral feeds were resumed as serial X-rays showed interval improvement. The patient remained in the NICU for several days to monitor bowel movements and resolution of ileus and he was discharged after improvement. While diazoxide overdose is rarely reported, and ileus due to such is documented even less frequently, 10-fold medication dose errors are common among infants. The source of the 10-fold mistake is often decimal points, leading zeros, or trailing zeros. Utilizing the smallest possible syringe for the prescribed dose may reduce the incidence of medication errors.