Morphine Overdose in a 6 ½ Week-Old Infant: A Case Report

Case Report

Austin J Pharmacol Ther. 2014; 2 (10).1052

Morphine Overdose in a 6 ½ Week-Old Infant: A Case Report

Eagerton DH1*, Goodbar NH2, Dansby MC3, Abel SN4 and Bell WC5

Department of Pharmaceutical and Administrative Sciences, Presbyterian College School of Pharmacy, USA

Department of Pharmacy Practice, Presbyterian College School of Pharmacy, USA

Walgreen’s Pharmacy, USA

Department of Pharmacy, Madigan Army Medical Center, USA

Forensic Services, South Carolina Law Enforcement Division, USA

*Corresponding author: : Eagerton DH, Department of Pharmaceutical and Administrative Sciences, Presbyterian College School of Pharmacy, 307 N Broad St, Clinton, SC 29325, USA

Received: July 11, 2014; Accepted: October 13, 2014; Published: October 14, 2014


Objective: To report a case of a lethal morphine overdose in a breastfed infant secondary to medication transfer into breast milk.

Case Report: The mother of a 6 ½ week old breastfed infant contacted emergency services secondary to her child being unresponsive. The infant was pronounced dead on arrival of medical personnel to the scene, and the mother reported taking numerous medications including morphine sulfate. Autopsy of the infant revealed lethal levels of morphine in samples of her tissue. The mother was charged with homicide, which is the first case of homicide secondary to medication transfer into breastmilk.

Discussion: Medication transfer into breastmilk is dependent on many factors, including size and molecular weight, lipid solubility, protein binding, and pH. Infant response to the presence of medications in breastmilk is dependent upon age-related pharmacodynamic factors that change weekly in rapidly growing and maturing infants, specifically volume of distribution, growth patterns, organ maturation, and digestive abilities. Infants also have a lower fat concentration, therefore exposure to fat-soluble drugs like morphine have enhanced blood-brain barrier penetration and ultimate accumulation following prolonged exposure.

Conclusion: Enhanced awareness of medication exposure to infants via breastmilk is vital to prevent morbidity and mortality. An understanding of the mechanism of medication transport into breastmilk, as well as differences in infant response to medications based on pharmacodynamics, are crucial in the medical management of a breastfeeding mother. In order to minimize toxicity to the breastfeeding infant, utilizing the lowest effective dose for a minimal amount of time is the cornerstone recommendation.

Keywords: Pharmacodynamics; Lethal morphine; Paracellular; Breastmilk


In recent years the use of opioid analgesics, including morphine has increased among the general population. The CDC reported in 2013 that for every woman that dies of a prescription painkiller overdose, 30 go to the emergency department for painkiller abuse or misuse [1]. Women of childbearing age are the population most likely to abuse or misuse prescription analgesics [1]. Abuse of prescription painkillers by pregnant and lactating women can put infants at risk, including neonatal abstinence syndrome and potential overdose. Between 2000 and 2009 reports of neonatal abstinence syndrome grew almost 300% in the United States [1].

Unfortunately there have not been many studies done on the concentrations of drugs found in the plasma and their relative transfer into the breast milk of a lactating mother. While the pharmacokinetics of morphine are known, there are individual characteristics of the mother and infant that ultimately effect the total concentration of drug. The concentration of morphine that is lethal to an infant has not been well documented and can differ significantly due to age, body weight, fat distribution, and renal and hepatic enzyme development. The mother’s metabolism of the drug is another factor that influences amount transferred into breast milk. The American Academy of Pediatrics (AAP) does consider morphine to be compatible with breastfeeding [2,3]. However, the AAP also states that an infant may have measurable blood concentrations of morphine following long-term repeated exposure [4].

We report a case of a lethal morphine overdose in a breastfed infant whose mother had prescriptions for morphine sulfate, along with numerous other medications. To our knowledge, this is the first case of a mother charged with homicide secondary to medication transfer via breast milk.

Case Report

Emergency services were contacted about a 6 ½ week-old infant girl who was reportedly unresponsive. Dispatcher instructed mother on CPR. Emergency services arrived approximately 12 minutes after 911 were called. Child was pronounced dead on arrival, and the coroner was requested at the scene. Interview with the coroner revealed that the mother went to bed breastfeeding the child around 11 pm the previous night. The father of the infant woke at 5 am the following morning to find the child cold and unresponsive with fixed pupils. The mother stated she last breastfed the child around 2 am. The mother also reported that a few days before, the child was sleeping more than usual and was lethargic with a decreased appetite. Two days prior to the death, parents called the pediatrician regarding congestion and “cold” symptoms. Since the child was not running a fever they did not visit the office but instead were instructed to use a chest rub and vaporizer. The mother also reported that she gave the infant 0.8 mL of 150 mg/5 mL acetaminophen to the child the night before. She said she alternated the acetaminophen with ibuprofen, but the exact dosage of ibuprofen given, if any, was not documented.

During the interview with the coroner the mother was asked about medications she was currently taking, and she reported that she was currently prescribed levetiracetam, baclofen, amlodipine, desvenlafaxine, clonazepam and hydrocodone/ibuprofen. The prescribed dosages, date of last fill, and tablets remaining in the bottles are listed in Table 1. Upon search of the residence, prescription bottles for milancipran, carisoprodol, gabapentin, ropinirole, morphine sulfate extended release, and caffeine tablets were found. Details of these medications can be found in Table 2. All prescription medications found in the residence were prescribed to the mother. The medication most pertinent to this case is the morphine sulfate extended release, which she did not admit to taking upon her interview with the coroner. This medication was originally prescribed to her in 1998 after a serious car accident that left her with a diagnosis of chronic pain. Further investigation revealed that the prescriber of the morphine was unaware that the patient was pregnant and subsequently breastfeeding an infant. Alternatively, the obstetrician and pediatrician were unaware that the mother was taking morphine.