Abstract
The use of theophylline preparations for treating apnea in premature infants has gained popularity in many neonatal intensive care units.1,2 Toxocity of aminophylline in premature infants is not well studied. We present a case of severe aminophylline intoxication in a premature infant secondary to a pharmacy error. We call attention to the massive overdose tolerated by this infant and relate how the error was made so that other hospitals might avoid such incidents. CASE REPORT Baby girl C.E. was a 1.2 kg 30 weeks gestation, second born twin of a 23-year-old gravida 1, para 0, abortus 0 Rh negative mother.
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