What is the treatment for a pediatric ibuprofen (Motrin) overdose?

Pediatric Ibuprofen (Motrin) Overdose Management

Immediate Assessment and Risk Stratification

Most pediatric ibuprofen overdoses are benign, with symptoms developing in only 7% of children, and serious toxicity is rare unless ingestion exceeds 400 mg/kg. 1, 2

Dose-Based Risk Assessment

• Ingestions <100 mg/kg: Symptoms are unlikely to develop; these children can typically be managed at home with observation 2, 3
• Ingestions 100-400 mg/kg: May develop mild to moderate symptoms including nausea, vomiting, abdominal pain, drowsiness, and headache 2, 3
• Ingestions >400 mg/kg: Risk of serious toxicity including CNS depression, seizures, apnea, metabolic acidosis, and renal dysfunction 1, 2, 3

Clinical Presentation Timeline

• All symptoms develop within 4 hours of ingestion; if a child remains asymptomatic at 4 hours post-ingestion, serious toxicity is unlikely 2
• The mean ingestion in symptomatic pediatric patients was 440 mg/kg compared to 114 mg/kg in asymptomatic patients 2

Clinical Manifestations to Monitor

Common Symptoms (Mild-Moderate Toxicity)

• Gastrointestinal effects: nausea, vomiting, abdominal pain 1, 2, 3
• CNS effects: drowsiness, headache, dizziness, blurred vision 2, 3
• Nystagmus may occur 1, 3

Serious Toxicity (Rare, Usually >400 mg/kg)

• CNS depression progressing to coma 1, 2
• Seizures (rare but documented in children) 2, 3
• Apnea and respiratory depression 1, 2
• Metabolic acidosis 3
• Cardiovascular effects: bradycardia, hypotension 2
• Renal dysfunction: abnormal renal function tests, hematuria 2

Treatment Algorithm

For All Presentations

1. Calculate mg/kg dose ingested based on reported amount and child's weight to guide management intensity 2, 3
2. Observe for symptom development with particular attention to the first 4 hours post-ingestion 2

Gastrointestinal Decontamination

Activated charcoal is the preferred decontamination method if the child presents within 1-2 hours of ingestion. 1, 3

• Do NOT induce vomiting with ipecac if ingestion exceeds 400 mg/kg due to risk of CNS depression and aspiration 3
• Gastric lavage followed by activated charcoal may be considered if presentation is very early (<1 hour) and ingestion is massive 1, 3
• Little drug will be recovered if >1 hour has elapsed since ingestion due to rapid absorption 1

Supportive Care Based on Severity

Mild Toxicity (<400 mg/kg, minimal symptoms)

• Oral activated charcoal if within 1-2 hours 1, 3
• Observation for 4 hours post-ingestion 2
• Supportive care for GI symptoms 1, 3

Moderate to Severe Toxicity (>400 mg/kg or symptomatic)

• Airway management: Be prepared for respiratory support; intubation may be required for apnea or severe CNS depression 1
• IV fluid resuscitation: Administer parenteral fluids, particularly if vomiting or signs of dehydration 1
• Alkalinization and diuresis: Administer sodium bicarbonate and induce diuresis to enhance urinary excretion of this acidic drug 1
• Seizure management: Treat with benzodiazepines per standard pediatric protocols 4
• Monitor renal function: Check for abnormal renal function tests and hematuria 2

Enhanced Elimination Strategies

• Urinary alkalinization with sodium bicarbonate is theoretically beneficial because ibuprofen is acidic (pKa 4.4) and excreted in urine 1, 3
• However, alkalinization is unlikely to significantly enhance elimination because ibuprofen is highly protein-bound (>99%) with minimal unchanged renal excretion 3
• Hemodialysis is not effective for drug removal due to high protein binding, but may be required if oliguric renal failure develops 3
• Multiple-dose activated charcoal is not recommended for ibuprofen due to its relatively short half-life (2 hours) 3

Important Clinical Caveats

Pharmacokinetic Considerations

• Ibuprofen has rapid and complete oral absorption with peak levels at 1-2 hours 5
• The short plasma half-life (approximately 2 hours) means most drug is eliminated within 12 hours 6, 5
• No toxic metabolites are formed, unlike acetaminophen, which contributes to ibuprofen's relatively favorable safety profile 6

Documented Severe Cases

• A 19-month-old who ingested 7-10 tablets (400 mg each) presented apneic and cyanotic but recovered fully within 12 hours with supportive care 1
• Blood levels do not guide treatment decisions; management is based on clinical presentation 3
• One pediatric death has been reported in the literature, emphasizing that while rare, fatal outcomes can occur 2

Common Pitfalls to Avoid

• Do not rely on plasma ibuprofen concentrations to guide treatment; they do not impact management decisions 3
• Do not use ipecac for large ingestions (>400 mg/kg) due to risk of rapid CNS depression 3
• Do not assume safety based on dose alone in very young children; rare cases of serious toxicity have occurred with smaller ingestions 2
• Do not discharge before 4 hours observation if any concern for significant ingestion 2

Disposition

• Asymptomatic children with ingestions <100 mg/kg: Can be managed at home with parental observation 2, 3
• Children with ingestions 100-400 mg/kg: Observe in emergency department for 4 hours; discharge if asymptomatic 2
• Children with ingestions >400 mg/kg or any symptoms: Admit for monitoring and supportive care 2, 3
• Children with severe toxicity (seizures, apnea, significant CNS depression): Admit to intensive care 1, 2