Loperamide Overdose in Children: Respiratory Depression and Cardiac Arrhythmias

Loperamide is an anti-diarrhea medicine that slows movement through the intestines. It is available without a prescription in many countries, but it is not automatically safe for children. A child can become seriously ill after taking too much, taking it too often, or swallowing an adult’s medicine. Large overdoses may affect both the brain and the heart.

If you believe a child has taken more loperamide than directed, contact emergency services or a poison center immediately. Do not wait for symptoms to appear. In the United States, Poison Control can be reached at 1-800-222-1222. If the child is difficult to wake, breathing abnormally, has fainted, or has a seizure, call emergency services now.

What makes loperamide overdose dangerous?

At recommended doses, loperamide mainly acts in the intestines. In an overdose, however, it can produce opioid-like effects throughout the body. The two most serious complications are:

• Respiratory depression, meaning breathing becomes unusually slow, shallow, or stops
• Cardiac arrhythmias, meaning the heart beats dangerously fast, irregularly, or inefficiently

Heart rhythm problems may include prolongation of the QT or QRS intervals on an electrocardiogram, ventricular tachycardia, torsades de pointes, cardiac arrest, and sudden death. These effects have been reported after large doses and may occur even when the child initially appears well.

Loperamide can remain in the body for a long time, particularly after an overdose. Symptoms may be delayed or may return after a period of improvement. A child who seems normal after swallowing the medicine still needs prompt professional advice.

Signs of loperamide overdose in child

The signs of loperamide overdose in child can vary depending on the amount taken, the child’s age and size, other medicines involved, and underlying health conditions. Possible warning signs include:

• Extreme sleepiness, unusual drowsiness, or difficulty waking
• Confusion, weakness, dizziness, or loss of coordination
• Slow, shallow, irregular, or noisy breathing
• Long pauses between breaths, gasping, or blue or gray lips and fingertips
• Very small “pinpoint” pupils
• Fainting, collapse, or inability to respond normally
• A fast, pounding, fluttering, or irregular heartbeat
• Chest discomfort or unexplained severe weakness
• Seizures
• Severe constipation, swollen abdomen, nausea, or vomiting
• Pale, cold, or clammy skin

A child may not describe palpitations or chest symptoms clearly. Sudden weakness, fainting, or a child becoming unusually quiet and hard to awaken should be treated as an emergency.

When to call emergency services

Call emergency services immediately if the child:

• Is not breathing normally or cannot be awakened
• Has blue, gray, or purple lips or skin
• Has fainted, collapsed, or had a seizure
• Has a very fast or irregular heartbeat
• Is severely confused or unable to respond
• Has taken an unknown amount, a large amount, or loperamide along with another medicine

Place an unconscious but breathing child on their side while waiting for help. If the child is not breathing normally and you know how to provide CPR, begin CPR and follow the emergency dispatcher’s instructions. Do not leave the child alone.

Why respiratory depression can happen

Loperamide can affect opioid receptors at high concentrations. This may suppress the brain’s signals that control breathing. Respiratory depression can develop gradually, so a child who is merely sleepy may become dangerously difficult to wake later.

Do not assume the child is safe because they are breathing at the moment. Watch for shallow breathing, fewer breaths than usual, snoring-like sounds in an unresponsive child, or pauses between breaths. These are urgent warning signs.

Naloxone, an opioid antidote, may sometimes be used by medical professionals when loperamide causes opioid-type breathing problems. It may not completely reverse the toxicity, and repeated doses or prolonged monitoring may be needed. Caregivers should not delay emergency treatment while trying to obtain or administer medicine at home.

How loperamide can affect the heart

Large amounts of loperamide can interfere with the electrical activity that controls the heartbeat. This may lengthen the time it takes the heart to reset between beats. The result can be an unstable rhythm, including a rhythm that causes fainting, seizures, or cardiac arrest.

Heart rhythm toxicity is especially concerning when the child has:

• Known heart disease or a history of fainting
• An inherited long-QT syndrome or another rhythm disorder
• Low potassium or magnesium levels
• Dehydration from vomiting or diarrhea
• Taken medicines that also affect the heart rhythm
• Swallowed substances such as certain antidepressants, antihistamines, or other opioids

A hospital may perform repeated electrocardiograms, monitor oxygen levels and heart rhythm, and check blood tests. Treatment depends on the child’s symptoms and test results. Hospital care may include intravenous fluids, correction of electrolyte problems, medicines for abnormal rhythms, breathing support, and observation for delayed effects.

What to do after a possible overdose

If a child may have swallowed loperamide:

1. Remove the medicine from the child’s reach.
2. Call Poison Control or emergency services right away.
3. Keep the package, bottle, or blister pack available.
4. Note the product strength, possible amount taken, time of exposure, and the child’s weight.
5. Tell the clinician about all other medicines or substances the child may have taken.
6. Follow the poison specialist’s instructions while waiting for help.

Do not make the child vomit. Do not give food, drink, activated charcoal, or another medicine unless a poison specialist or healthcare professional specifically tells you to do so. Home remedies cannot reliably prevent respiratory depression or heart rhythm problems.

If the child vomits, becomes sleepy, or has trouble swallowing, giving anything by mouth may increase the risk of choking. Take the medicine container to the emergency department if possible, but do not delay care while searching for it.

Can a symptom checker help?

For non-emergency concerns, you might consider a free, online symptom check, using the doctor approved Ubie Symptom Checker. It may help organize symptoms and suggest what type of care to seek. However, a symptom checker cannot diagnose loperamide poisoning, measure a child’s heart rhythm, or monitor breathing. Never use it instead of calling emergency services or Poison Control when an overdose is possible or serious symptoms are present.

Preventing accidental loperamide poisoning

Keep loperamide and all medicines locked or stored out of children’s sight and reach. Child-resistant packaging reduces risk but does not make a medicine child-proof. Avoid describing medicine as candy, and count tablets regularly if several people use medicines in the home.

Children should not be given loperamide unless a doctor or other qualified healthcare professional recommends it. Diarrhea in children can have many causes, and treatment may require fluids rather than an anti-diarrhea medicine. Ask a doctor or pharmacist about the correct treatment and dose for the child’s age and condition.

Any possible overdose deserves prompt advice, even if the child seems well. Speak to a doctor about anything that could be life threatening or serious, including unusual sleepiness, breathing changes, fainting, seizures, or a suspected loperamide overdose.