Chappell and Newman¹ have asked for urgent initiatives to ensure the manufacture of neonatal targeted products to reduce the risks associated with intravenous drug administration. We endorse their view and report a little recognised problem with the use of adult formulations in neonatal nurseries.

This investigation was conducted after we noticed symptoms of digoxin overdose (bradyarrhythmia) in a neonate. Retrospective review of the case suggested that the overdose received was due to the unaccounted for drug in the dead space of a 1 ml syringe.

The nursing drug dose manual Pediatric drugs and nursing implications² gives the maintenance dose of intravenous digoxin as 2.5 μg/kg/dose. The nursing instruction³ states that the dose must be diluted, with at least four times the volume, using normal saline or 5% dextrose, and the drug must be given over five minutes. In practice, for a 2 …