What is the management for Motrin (ibuprofen) overdose in pediatrics?

Management of Ibuprofen (Motrin) Overdose in Pediatrics

For pediatric ibuprofen overdose, immediately provide supportive care with airway management, gastric decontamination using activated charcoal if presenting within 1-2 hours, aggressive fluid resuscitation for shock, benzodiazepines for seizures, and consider naloxone for CNS depression—while monitoring for metabolic acidosis, renal failure, and cardiovascular collapse. 1, 2, 3

Initial Assessment and Risk Stratification

• Doses >100-104 mg/kg are associated with toxicity, while ingestions below this threshold rarely produce symptoms 4
• Most symptomatic patients develop toxicity within 4 hours of ingestion 4
• The FDA reports cases of severe toxicity in children as young as 19 months after ingesting 7-10 tablets (400 mg each), resulting in apnea, cyanosis, and unresponsiveness 1

Clinical Manifestations to Monitor

Gastrointestinal effects:

• Nausea, vomiting, abdominal cramps, and hematemesis 4

Central nervous system toxicity:

• Mild sedation, dizziness, nystagmus 1, 4
• Depressed level of consciousness progressing to coma 2, 5
• Apnea and respiratory failure 1, 2, 4
• Seizures requiring benzodiazepine management 3

Metabolic and cardiovascular complications:

• Severe metabolic acidosis with or without respiratory alkalosis 2, 4
• Shock and hemodynamic compromise 2
• Tachycardia 4

Renal toxicity:

• Oliguric renal failure 4

Immediate Management Algorithm

1. Airway and Breathing

• Intubate and provide mechanical ventilation for apnea, severe CNS depression, or inability to protect airway 2
• Administer oxygen as needed 1

2. Gastric Decontamination

• Administer activated charcoal if patient presents within 1-2 hours of ingestion 1, 2
• The FDA notes that gastric emptying by vomiting or lavage recovers little drug if >1 hour has elapsed 1
• Consider multidose activated charcoal to reduce absorption and reabsorption 1

3. Fluid Resuscitation

• Provide aggressive IV fluid resuscitation with dextrose and normal saline for shock 1, 2
• Parenteral fluids are essential for maintaining hemodynamic stability 1

4. Metabolic Acidosis Management

• Administer sodium bicarbonate for severe metabolic acidosis 1, 2
• Alkalinization of urine theoretically enhances excretion since ibuprofen is acidic 1
• Consider hemodialysis or hemofiltration for refractory acidosis 6

5. CNS Depression Management

• Trial naloxone for depressed mental status, as case reports demonstrate marked improvement in consciousness 5
• Administer benzodiazepines per standard pediatric protocols for seizure management 3

6. Diagnostic Testing

• Obtain comprehensive metabolic panel to evaluate liver and kidney function 7
• Check complete blood count to assess for thrombocytopenia 7
• Monitor serial ibuprofen levels if available (though management is primarily supportive) 1
• The FDA reports a blood level of 102.9 mcg/mL at 8.5 hours post-ingestion in a symptomatic child, and 700 mcg/mL at 90 minutes in another case 1

Monitoring and Disposition

• Admit to intensive care for symptomatic patients or large ingestions (>100-104 mg/kg) 2, 4
• Continuous monitoring for at least 4 hours post-ingestion, as most toxic reactions occur within this timeframe 4
• Serial assessment of renal function is crucial given risk of oliguric renal failure 7, 4
• Most patients recover within 24-48 hours with supportive care 5

Critical Pitfalls to Avoid

• Do not assume benign course: While most ibuprofen overdoses are mild, serious complications including death have occurred in children 2, 4, 6
• Do not delay activated charcoal: Efficacy decreases significantly after 1-2 hours 1
• Do not overlook co-ingestions: Many cold medications contain additional NSAIDs that can contribute to toxicity 8
• Do not miss early shock: Aggressive fluid resuscitation is critical for hemodynamic compromise 2
• The favorable outcome in reported cases is attributed to early and aggressive intervention with intubation, fluid resuscitation, and decontamination 2