Article Text

other Versions

Download PDFPDF
Acute liver failure secondary to therapeutic paracetamol dosing in an extremely preterm neonate
  1. Krishna Raghu12,
  2. Mary Judith Berry123
  1. 1 Department of Paediatrics and Child Health, University of Otago, Wellington, New Zealand
  2. 2 Neonatal Intensive Care Unit, Wellington Regional Hospital, Wellington, New Zealand
  3. 3 Centre for Translational Physiology, University of Otago, Wellington, New Zealand
  1. Correspondence to Dr Krishna Raghu; krishna.raghu{at}

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

In conjunction with BMJ Case Reports, DTB will feature occasional drug-related cases that are likely to be of interest to readers. These will include cases that involve recently marketed drugs for which there is limited knowledge of adverse effects and cases that highlight unusual reactions to drugs that have been marketed for several years.


We report the first case of standard therapeutic dose paracetamol for patent ductus arteriosus closure causing acute liver failure in an extremely preterm infant. After 5 days of treatment, he presented with jaundice, acute severe hepatitis and coagulopathy. Treatment with N-acetyl cysteine resulted in full recovery.


Paracetamol is widely regarded a safe drug within the neonatal population with no reported cases of toxicity when used within standard therapeutic dosing schedules. It is increasingly used to promote patent ductus arteriosus closure in symptomatic, preterm neonates. This report highlights the need for vigilance if using repeated doses in extremely preterm neonates.

Case presentation

A male infant was delivered via caesarean section at 25 +3 weeks gestation due to concerns about worsening maternal preeclampsia and poor fetal growth and admitted directly to the neonatal intensive care unit. He was born in good condition (Apgars 51, 95, 910) with a birth weight of 655 g (<5th percentile) and a cord arterial lactate of 4 mmol/L. He was intubated at delivery and remained on low pressure mechanical ventilation (fraction of inspired oxygen <40%, volume targeted ventilation at 4–5.5 mL/kg as per our standard practice) until he transitioned to non-invasive respiratory support (CPAP; continuous positive airway pressure ventilation) on day 7 of life.

Routine echocardiography on the day of birth revealed a haemodynamically significant (non-restrictive ductal pattern with left-right flow through the ductus) patent ductus arteriosus. According to our standard unit practice for early targeted ductal closure, he started …

View Full Text


  • Contributors KR and MJB have made equal contributions to the planning, design and conception of this report. Review of records and acquisition of data was obtained by KR. The analysis and interpretation of data was done jointly by KR and MJB. An initial draft was formulated by KR and reviewed and revised critically by MJB. Final approval of the version to be published was done jointly by KR and MJB. Both authors are in agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • First published Raghu K, Berry MJ. Acute liver failure secondary to therapeutic paracetamol dosing in an extremely preterm neonate. BMJ Case Rep 2022;15:e245406.