Oxycodone Intoxication in an Infant: Accidental or Intentional Exposure?

Abstract

A case is presented of a 10 month old male who went into cardiac arrest at a local store. The infant subsequently expired and was autopsied at the Office of the Chief Medical Examiner, State of Maryland. The only remarkable finding was the detection of oxycodone in the postmortem specimens; the blood and liver oxycodone concentrations were 0.6 mg/L and 1.6 mg/kg, respectively. Oxycodone was identified and quantitated by gas chromatography-nitrogen-phosphorus detection and confirmed by full scan electron ionization gas chromatography-mass spectrometry. The medical examiner ruled that the cause of death was oxycodone intoxication, and the manner of death was homicide. The key toxicologic question in this case was whether or not it was reasonable for the infant to be exposed to oxycodone exclusively through breast milk or through an alternate source. It was concluded that, at best, there were serious concerns about the likelihood of drug exposure through consumption of breast milk.

Maturation of Oxycodone Pharmacokinetics in Neonates and Infants: a Population Pharmacokinetic Model of Three Clinical Trials

“…In adults with laparoscopic cholecystectomy a minimum effective concentration of 20-30 ng/ml has been presented (19). In case reports of oxycodone intoxication in children plasma oxycodone concentrations have been significantly higher, 600-1360 ng/ml (24,25). Thus, the oxycodone plasma concentration of 10-50 ng/ml used in these simulations could be considered appropriate.…”

The Implausibility of Neonatal Opioid Toxicity from Breastfeeding

“…Levine et al 24 10-month-old child who died from a suspected oxycodone overdose. One day before death, the mother took oxycodone 60 mg and carisoprodol 700 mg, and on the day of death took hydrocodone 10 mg.…”

“…Some of these publications explicitly raised the possibility of neonatal opioid exposure via routes other than breastfeeding, 24,25 whereas others, upon closer inspection, are not consistent with opioid toxicity at all. The latter is best exemplified by a report of neonatal bradycardia and central nervous system depression occurring 6 days after maternal use of a single 30 mg codeine tablet 26 .…”

“…Only one other publication describes neonatal death in the setting of maternal opioid use while breastfeeding. In that report, a 10‐month‐old child died of suspected oxycodone toxicity, although the child was also found to have multiple head injuries 24 . The authors of the report were openly skeptical about the possibility of breastmilk as the sole source of oxycodone.…”

The Effects of opioids on female fertility, pregnancy and the breastfeeding mother‐infant dyad: A Review

“…Commonly reported symptoms were drowsiness and lethargy in the infant and poor feeding. Only two reports described neonatal death attributed to maternal opioid use while breastfeeding 60,61 . In the first case, there was doubt regarding the plausibility that the measured concentrations of morphine in the mother's breastmilk could be fatal 62 .…”