The Institute for Safe Medication Practices (ISMP) learned about another child who died after gaining access to a transdermal fentanyl patch. This time it was a 15-month-old boy who had been cuddling with his mother, sleeping on her chest as they both took a nap. The boy's mother had been wearing a fentanyl patch on her chest to treat pain associated with multiple sclerosis. When the mother awoke, she found her son unresponsive. The child was rushed by ambulance to the hospital. Resuscitation efforts continued in a pediatric emergency department without success. The child's mother noticed that the patch on her chest was missing. The baby apparently ingested the patch, although the patch was never found. During intubation, vomitus was visualized in the baby's esophagus and trachea, indicating aspiration, and perhaps the patch was overlooked in the vomitus. A medical examiner confirmed the child's access to the patch, revealing physical findings of pulmonary congestion and edema, and toxicology findings of acute fentanyl intoxication.
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