Medication errors are an important cause of morbidity and mortality in children, occurring roughly every 8 minutes for children under 6. Among all medical errors, medication dosing errors are very common. In this context, we present the case of amonozygotic twin girl with severe, persistent asthma, who erroneously received a double dose of nebulized budesonide (2 mg/day) for a period of 23 months. Although the patient’s height and weight tracked along the 50thpercentile before starting budesonide, these growth measures fell to the 5th and 10thpercentile respectively following the initiation of this prescription error, despite having improved asthma control over this period. In contrast, during the same time period, the patient’s twin sister experienced normal growth along the 50th centile. Furthermore, this patient experienced long-term harm: three years after discontinuing the erroneous budesonide dose, growth did not return to the 50th percentile and a DEXA scan documented persistent osteopenia, a known side effect of corticosteroids.
This case highlights key considerations to reduce harm using ICS medications: First, any changes in growth trajectory should prompt a review of inhaled corticosteroid medications being used. Second, corticosteroid medications should be reviewed at any hospital visit. The use of clinical standard work pathways in primary care and the emergency department can help to standardize medical management and reduce the risk of medical errors. Finally, minimal effective doses of corticosteroids (and all medications) should be prescribed.