Lack of narrow therapeutic index awareness leading to increased risk of acute phenytoin toxicity in a child with traumatic brain injury

Phenytoin is a commonly prescribed antiepileptic medication in the pediatric age group for multiple indications. It has a very narrow therapeutic range with well known side-effects. A careful dose dispensing is of utmost importance while administering medications with narrow therapeutic index especially in pediatric age groups with variable weight bands. Multiple dosage formulations like tablets/syrups of varying strength ranging from 30-300mg are available in the market just with a small difference of color coding on the labels making it prone to iatrogenic errors leading to toxicity.