While providing pediatric medical care to an infant patient in the clinic setting, a pediatrician recommended oral dosing with mineral oil as a constipation aid. This intervention was in response to the mother’s report that the infant displayed straining and discomfort during elimination, which did not meet the clinical definition of constipation.
Between the time the baby was nine days through three months old, the mother reported similar ongoing symptoms. The pediatrician failed to document an etiology for the symptoms reported. The pediatrician instead arbitrarily increased the mineral oil dosage from 1 teaspoon to as high as 3 tablespoons per day. Mineral oil is contraindicated in infants under one year old.
The patient was hospitalized at age fifteen weeks for extensive lipoid pneumonia, caused by aspiration of the mineral oil into the lungs. Numerous bronchoscopies were required on an inpatient and outpatient basis in an attempt to clear the oil from the infant’s lungs. The patient was placed at risk for chronic lung disease secondary to a chemical pneumonitis and multi-organ dysfunction due to an inability of the lungs to provide sufficient ventilation over a sustained period of time.
The Commission stipulated the pediatrician reimburse costs to the Commission, have her license be placed on probation for a period of two years, and write and submit a paper of at least 2000 words, with references, on the diagnosis and treatment of constipation and its complications in infants under one year of age.
Date: April 2013
Diagnosis: Drug Overdose, Side Effects, or Withdrawal
Medical Error: Improper medication management
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 4
Link to Original Case File: Download PDF
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