Abstract
Background: During the last few years there has been an increase in the number of reports of liver failure associated with prolonged paracetamol (acetaminophen) administration in children for therapeutic reasons.
Objective: To describe the approach taken by medical directors of poison centres regarding the treatment of repeated supratherapeutic doses of paracetamol in children.
Methods: Questionnaires mailed to the medical directors of 76 poison centres in North America and 48 poison centres in Europe asked respondents to comment on the management of a hypothetical case of a child who had received repeated doses of paracetamol at a daily dose of 90 mg/kg during a febrile illness and who presented to the emergency department with mildly elevated serum transaminase levels.
Results: The response rate was 62% for North American centres and 44% for European centres. There was a wide range of answers regarding the maximal safe daily dose of paracetamol. For the case described, 71% of the respondents suggested measuring paracetamol serum concentration. Fifty-four percent suggested treating the patient with acetylcysteine and 35% suggested not treating the patient.
Conclusions: Our study showed that there is little agreement among medical directors of poison centres on the toxic threshold for chronic exposure to paracetamol in children and on how these cases should be managed.
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References
Kogan MD, Pappas G, Yu SM, et al. Over-the-counter medication use among US preschool-age children. JAMA 1994; 272: 1025–30
Taketomo CK, Hurlburt Hodding J, editors. Acetaminophen: pediatric dosage handbook: 6th ed. Hudson (OH): Lexi-Comp, Inc. (American Pharmaceutical Assoc) 1999-2000: 23–5
Hirshfeld AB, Getachew A, Sessions J. Harriet Lane handbook: a manual for pediatric house officers. In: Siberry GK, Iannone R, editors. Missouri: Mosby Year Book Inc., 2000: 615–7
Blake KV, Bailey D, Zientek GM, et al. Death of a child associated with multiple overdoses of acetaminophen. Clin Pharm 1988; 7: 391–7
Rivera-Penera T, Gugig R, Davis J, et al. Outcome of acetaminophen overdose in pediatric patients and factors contributing to hepatotoxicity. J Pediatr 1997; 130: 300–4
Pershad J, Nichols M, King W. ‘The silent killer’: chronic acetaminophen toxicity in a toddler. Pediatr Emerg Care 1999; 15: 43–6
Morton NS, Arana A. Paracetamol-induced fulminant hepatic failure in a child after 5 days of therapeutic doses. Paediatr Anaesth 1999; 9: 463–5
Heubi JE, Barbacci MB, Zimmerman HJ. Therapeutic misadventures with acetaminophen: hepatoxicity after multiple doses in children. J Pediatr 1998; 132: 22–7
Miles FK, Kamath R, Dorney SF, et al. Accidental paracetamol overdosing and fulminant hepatic failure in children. Med J Aust 1999; 171: 472–5
Eriksson LS, Broome U, Kalin M, et al. Hepatotoxicity due to repeated intake of low doses of paracetamol. J Intern Med 1992; 231: 567–70
Smith DW, Isakson G, Frankel LR, et al. Hepatic failure following ingestion of multiple doses of acetaminophen in a young child. J Pediatr Gastroenterol Nutr 1986; 5: 822–5
Rumack BH, Matthew H. Acetaminophen poisoning and toxicity. Pediatrics 1975; 55: 871–6
Prescott LF, Sutherland GR, Park J, et al. Cysteamine, methionine, and penicillamine in the treatment of paracetamol poisoning. Lancet 1976; 2(7977): 109–13
Cranswick N, Coghlan D. Paracetamol efficacy and safety in children: the first 40 years. Am J Ther 2000; 7: 135–41
Kearns GL, Leeder JS, Wasserman GS. Acetaminophen overdose with therapeutic intent. J Pediatr 1998; 132: 5–8
Smilkstein MJ. Acetaminophen. In: Goldfrank LR, Flomenbaum NE, Lewin NA, editors. Goldfrank’s toxicologic emergencies. Stamford (CT): Appleton & Lange, 1998: 541–64
Kozer E, Koren G. Management of paracetamol overdose: current controversies. Drug Saf 2001; 24: 503–12
Sztajnkrycer MJ, Bond GR. Chronic acetaminophen overdosing in children: risk assessment and management. Curr Opin Pediatr 2001; 13: 177–82
Heubi JE, Bien JP. Acetaminophen use in children: more is not better. J Pediatr 1997; 130: 175–7
Alander SW, Dowd MD, Bratton SL, et al. Pediatric acetaminophen overdose: risk factors associated with hepatocellular injury. Arch Pediatr Adolesc Med 2000; 154: 346–50
Blumenthal I. What parents think of fever. Fam Pract 1998; 15: 513–8
Kai J. What worries parents when their preschool children are acutely ill, and why: a qualitative study. Br Med J 1996; 313: 983–6
Crocetti M, Moghbeli N, Serwint J. Fever phobia revisited: have parental misconceptions about fever changed in 20 years? Pediatrics 2001; 107: 1241–6
Li SF, Lacher B, Crain EF. Acetaminophen and ibuprofen dosing by parents. Pediatr Emerg Care 2000; 16: 394–7
Acknowledgements
The authors wish to thank Dr I. Radda for her comments. This manuscript was prepared with the assistance of Editorial Services, The Hospital for Sick Children, Toronto, Ontario, Canada.
Eran Kozer was a recipient of a fellowship grant from the Research Training Centre, The Hospital for Sick Children. Toronto, Ontario, Canada.
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Division of Pediatric Emergency Medicine, Assaf Harofeh Medical Center, Zerifin 70300, Israel
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Kozer, E., McGuigan, M. Approaches Toward Repeated Supratherapeutic Doses of Paracetamol in Children. Drug-Safety 25, 613–617 (2002). https://doi.org/10.2165/00002018-200225080-00006
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DOI: https://doi.org/10.2165/00002018-200225080-00006