Pain Pills: Watch Child Dosage By Melissa Tennen, HealthAtoZ writer
Your child is sniffling, feeling awful. You naturally want to help make your child feel better. So you dole out the acetaminophen. But watch out: You could cause fatal liver damage. "The issue of overdose is rare but real. It's incredibly safe if taken as directed, but if your child takes too much, the liver can be really damaged," says Philip Walson, M.D., director of clinical pharmacology at the Cincinnati Children's hospital Medical Center, a member of the American Academy of Pediatrics' (AAP) committee on drugs, and chairman of the AAP's section on clinical pharmacology and therapeutics. A recent study found that acetaminophen is now the leading cause of acute liver failure. A study, sponsored by the National Institutes of Health, at the University of Texas Southwestern Medical Center looked at 308 patients with the disease. Acetaminophen and other drug reactions replaced viral hepatitis as the most frequent cause of liver failure. However, the study did not say the drug is dangerous. Eighty-three percent of those who experienced liver failure exceeded the maximum dose. Although the study did not focus on children, it prompted the American Liver Foundation (ALF) to point out the dangers among children. Acetaminophen is a drug that can be given to infants and children to help relieve symptoms such as fever and headache. Given at normal doses, the drug is extremely safe. However, overdosing can be a significant and dangerous error that parents should be aware of, says Rose Ann G. Soloway, R.N., M.S.Ed., D.A.B.A.T., associate director of the American Association of Poison Control Centers. "People think that just because acetaminophen doesn't require a prescription that it's safer," she says. "Medications are medications whether they are over-the-counter or prescription." Make sure that when you give your child acetaminophen, you are not giving it more often than every 4 hours. Even then, if given around the clock for several days, problems could develop. Be sure that you are not giving two different products that both contain acetaminophen, because this could double the recommended dose. How damage happens Overdose of the drug can cause liver injury by producing a toxic metabolite. The body eliminates acetaminophen by changing it into substances, or metabolites, that the body can easily eliminate in the stool or urine. Under certain circumstances, particularly when more acetaminophen is ingested than is recommended on the label, more of the harmful metabolite can be produced than can be eliminated. This can seriously harm the liver. Liver damage is characterized by sudden deterioration of liver function. Symptoms include nausea, fatigue, jaundice (yellowing of the skin), confusion and even coma. The first phase of poisoning, however, may be easy to miss because they are similar to the cold or flu that the child has. A parent mistakenly seeing a lack of appetite, nausea, vomiting as part of the illness itself may dispense even more acetaminophen. In the second phase, more obvious symptoms appear such as right upper abdominal pain or tenderness around the abdomen. Three to five days after the initial poisoning, jaundice, hypoglycemia (too little sugar in the blood), and coagulopathy (abnormal blood clotting) may appear. The last phase can lead to complete liver failure and death. In 2001 Poison Control Centers nationwide received 17,324 from people concerned that a child took too much acetaminophen. No deaths were reported. Caroline Riely, M.D., professor of medicine and pediatrics of liver disease at the University of Tennessee College of Medicine and associate medical director of the American Liver Foundation points out that the manufacturers may not be providing enough information on their products to alert consumers. Riely spoke to the Nonprescription Drug Advisory Committee of the U.S. Food and Drug Administration about ALF's concern that all medications, whether for adults or children, have "package warnings...too small, difficult to read and, thus, appear unimportant to the consumer." ALF says some medications with acetaminophen seem to suggest larger doses lead to faster relief. "Infant" type concentrated Walson notes that some of the problem may lie in misunderstanding about what's in different formulations containing the same drug. Parents may not realize that the concentration of acetaminophen in infant drops is much more than in the syrup formulation administered by teaspoon for older children. Giving teaspoons of the infant drops to a toddler could cause liver damage, he says. But sometimes the problem is hard to avoid. "Either the parent remembered it wrong or the child got medication from someone that the parents didn't know about. The vast majority -- if not all -- cases of liver damage in children are caused by overdoses that were sometimes unrecognized by parents or even treating doctors," Walson says. "Parents should remember that teenagers can also suffer liver damage if they take too much acetaminophen," Soloway says. "Teens might say, 'Two extra-strength pills didn't work; let me try ten or twelve.'" However, accidental overdoses by teens are extremely rare. Most accidental overdoses probably involve taking more than three to four extra strength tablets every several hours for a day or more. If you have the slightest suspicion that your child could have drug poisoning of any kind, call the Poison Control Center immediately at 1-800-222-1222. Here are some tips that Walson offers:
- Read the entire label. Just because medications are over-the-counter doesn't mean they are benign. Working in combination, over-the-counter medications could spell trouble. Some cold and flu formulations, particularly ones that relieve body aches and headaches, already have acetaminophen in them. Parents must read the label to find out. The Food and Drug Administration has said that most overdoses of acetaminophen in general are through accidental use of multiple products that contain acetaminophen.
- Be careful if you get advice, even from your doctor or nurse, over the phone. You may hear the wrong thing or the health care provider may misunderstand you. "You might say 15 pounds but they might hear 50 pounds for example," he says.
- Tell the doctor, nurse or pharmacist about all medications you have given or are giving your child.
Sources: The American Academy of Pediatrics The American Liver Foundation The American Association of Poison Control Centers
This article was reviewed and updated June 2007.
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