Paracetamol - too often, too careless?

[enjoy]

Maybe you'd like to have a closer look at this, an article from the Lancet. What do you think?

Association between paracetamol use in infancy and childhood, and risk of asthma, rhinoconjunctivitis, and eczema in children aged 6?7 years: analysis from Phase Three of the ISAAC programme

Prof Richard Beasley DSc a , Tadd Clayton MSc b, Prof Julian Crane MBBS c, Prof Erika von Mutius MD d, Prof Christopher KW Lai DM e, Prof Stephen Montefort PhD f, Alistair Stewart BSc g, for the ISAAC Phase Three Study Group?

Summary

Background

Exposure to paracetamol during intrauterine life, childhood, and adult life may increase the risk of developing asthma. We studied 6?7-year-old children from Phase Three of the International Study of Asthma and Allergies in Childhood (ISAAC) programme to investigate the association between paracetamol consumption and asthma.

Methods

As part of Phase Three of ISAAC, parents or guardians of children aged 6?7 years completed written questionnaires about symptoms of asthma, rhinoconjunctivitis, and eczema, and several risk factors, including the use of paracetamol for fever in the child's first year of life and the frequency of paracetamol use in the past 12 months. The primary outcome variable was the odds ratio (OR) of asthma symptoms in these children associated with the use of paracetamol for fever in the first year of life, as calculated by logistic regression.

Findings

205 487 children aged 6?7 years from 73 centres in 31 countries were included in the analysis. In the multivariate analyses, use of paracetamol for fever in the first year of life was associated with an increased risk of asthma symptoms when aged 6?7 years (OR 1?46 [95% CI 1?36?1?56]). Current use of paracetamol was associated with a dose-dependent increased risk of asthma symptoms (1?61 [1?46?1?77] and 3?23 [2?91?3?60] for medium and high use vs no use, respectively). Use of paracetamol was similarly associated with the risk of severe asthma symptoms, with population-attributable risks between 22% and 38%. Paracetamol use, both in the first year of life and in children aged 6?7 years, was also associated with an increased risk of symptoms of rhinoconjunctivitis and eczema.

Interpretation

Use of paracetamol in the first year of life and in later childhood, is associated with risk of asthma, rhinoconjunctivitis, and eczema at age 6 to 7 years. We suggest that exposure to paracetamol might be a risk factor for the development of asthma in childhood.

Funding

The BUPA Foundation, the Health Research Council of New Zealand, the Asthma and Respiratory Foundation of New Zealand, the Hawke's Bay Medical Research Foundation, the Waikato Medical Research Foundation, Glaxo Wellcome New Zealand, the New Zealand Lottery Board, Astra Zeneca New Zealand, and Glaxo Wellcome International Medical Affairs.

[Moos]

Enjoy, thank you for sharing the article.

What do you mean by "too often, too careless"? I was looking at the article for an indication of what would be too much, or too often but it seems to imply that using paracetomol per se creates a risk.

[EDmummy]

Looks a little stab in the dark really.

[enjoy]

Hi,

I just wonder if we are taking/giving too easily.

Yesterday the GP described my daughter paracetamol. She has a chest infection and a raised temperature but nothing to worry about. "Give her paracetamol, she will feel much better then"

But Paracetamol is not a comforter, I give it when she is seriously poorly.

And it can be toxic if you take an overdose (I mean a real overdose).

I think we should still treat it as a proper drug.

[Yak]

But it's only a possible risk factor, though, isn't it? For instance, children who are likely to suffer more from colds (and therefore be given paracetamol to relieve symptoms) may suffer from chest infection induced asthma. Correlation doesn't equal causation. The authors point that out by stressing that one may be a risk factor for the other. So while I think it's interesting, I won't be altering how I use calpol etc, at least in the short term. My GP said to me just today she thought people underestimated the usefulness of calpol & that it should be issued at birth!

[Saffron]

"Association of risk" means there is a correlation between paracetamol and the given diseases/syndromes. It's important to understand that correlation does not equal causation. We don't know how these children would have fared without paracetamol, with another drug, or with no drugs. I'm not downplaying their results. Their conclusion is indeed a serious one. However, one must not read into the statical analysis something that isn't actually there, i.e. their research does not appear to address causation. This is a very difficult thing to do in this type of research.

I'm not sure what you mean by a "proper drug"..? Excessive pain is definitely worth treating b/c excessive pain actually prevents other body systems including the immune system from functioning efficiently. One hypothesis about this type of pain is that it strengthens the social bonds between us by helping to draw others near to us in our times of need such as illness. However, the pain itself can become counterproductive to healing.

Btw, ALL drugs are toxic in overdose. Paracetamol just has a smaller therapeutic window than other common analgesics and anti-fever drugs. Paracelsus, known as the father of toxicology, put it thusly, "Everything is a toxin. There is nothing that is not toxic. It it the dose alone that determines toxicity."

I think I do get the gist of what you're saying though, that we should think for ourselves about what drugs we give our children and not carelessly to hand them out if truly unnecessary.

[enjoy]

It's "Paracetamol-Day" at my house. We were discussing it quite a bit, so I can feed you with another article

(I know the Daily Mail is not best source for medical research)

http://www.dailymail.co.uk/health/article-1388498/Painkiller-overdose-fear-1-4-babies-given-paracetamol-GPs-parents.html

[Ruth_Baldock]

I'm with Yak on this! Incidentally, was that the lovely Dr B???

[snowboarder]

Oh dear - there was one point last year amidst constant colds and teeth where calpol was almost part of our bedtime routine. My 2.5 yr old actually thinks it's a treat and asks for some if I ever need to give to the baby. Hmm!

[Yak]

Ruth, it was Dr Roscoe, who is just back from mat leave - a good first reserve if the wonderful Dr B isn't available.

[Oxalis]

Maybe I should get a life but here is a recent BMJ article on the subject

http://www.bmj.com/content/341/bmj.c4616.full

[new mother]

I would be asking for abs if children had a chest infection.

[newcomer]

Ha. Just had this problem. Little Newcomer had a virus yesterday, so high fever and some vomiting. Discussed with the doctor, who immediately prescribed large doses of paracetamol suppositories and gravol without any discussion of when they should be used. When questioned, he admitted that it's best only to give paracetamol when fever gets very high (over 101) and he advised that I definitely should give it if Little Newcomer's fever goes above 104, due to increased risk of febrile convulsions and other complications that go with super high temperatures. For slight fevers, he admitted that it's actually preferable to let the body's immune system to do its job, and not to medicate, as the fever will help to kill the infection and so the child will recover more quickly. I asked also about the gravol (anti-sickness medication) and again he said that, despite prescribing it to us, it's best to avoid it unless the child is getting very distressed or dehydrated by the vomiting. I have been following this advice and have given paracetamol when the temperature started to soar to 103/104 but not when temperature is only 99 or so. I haven't given any Gravol. Little Newcomer seems to have gone from really ill to almost totally recovered within a day, so maybe there's something to this "minimal medication" malarky?

However, note that I only got this extra information on usage because I queried it. No wonder drugs are over-used, if doctors prescribe first and explain later.

My personal belief is that paracetomol is a life-saver in many situations, as high fevers can cause a lot of damage to a small child. However, over-use when it's not really needed means that the child's immune system doesn't get the chance to kick in and so, like any other medicine, it should be used with caution.

[ianr]

Oxalis Wrote:

-------------------------------------------------------

> Maybe I should get a life but here is a recent BMJ

> article on the subject

>

> http://www.bmj.com/content/341/bmj.c4616.full

Thank you. If people only have the time or money to read one paper, I think this 2010 paper is the one to recommend. It also happens to be free. It refers to the Lancet paper (Lancet 2008;372:1039-48; doi:10.1016/S0140-6736(08)61445-2).

[enjoy]

latest update:

Child paracetamol dosages revised:

http://www.bbc.co.uk/news/health-15821256

Paracetamol warning: 'Slightly too much can cause overdose'

http://www.bbc.co.uk/news/health-15837468

[Saffron]

newcomer Wrote:

-------------------------------------------------------

> ...paracetomol is a

> life-saver in many situations, as high fevers can

> cause a lot of damage to a small child. However,

> over-use when it's not really needed means that

> the child's immune system doesn't get the chance

> to kick in and so, like any other medicine, it

> should be used with caution.

Technically, paracetamol is not an immunosuppressant. Paracetamol acts on the central nervous system, particularly the brain centres which control temperature regulation (and other areas related to pain). So when given to reduce fever, the immune system is still active, but the body no longer has the benefit of the bacteria-killing activity of a raised temperature. There is also a question of the benefit of rest. When children are ill, if a low fever (eg 99/100 F) is preventing them from sleeping well, then the immune system also potentially loses some benefit by the body not being properly rested. A good compromise is give paracetamol (or ibuprofen) only at night, and always at the correct dose (goes w/out saying really). (Incidentally, this works well for adults too.) xx

[Saffron]

enjoy Wrote:

-------------------------------------------------------

> latest update:

> Child paracetamol dosages revised:

> http://www.bbc.co.uk/news/health-15821256

>

I think many people will (still) find this advise confusing, and I don't understand why dosages aren't given by weight as in other European countries. I think the best dosage advise would include both age and weight as factors on a simple colour-coded diagram.

[buggie]

Agreed Saffron - saw a pack from France once that had kilos marked on the syringe so you just drew the paracetamol up to their weight (so no big mathmatical equation to get through first!).

Although think that could cause problems in children who are carrying more weight than they should (& parents are sometimes in denial about this!). Also, once children are over 1yr or so children aren't weighed as frequently & parents often don't have much idea of how much they weigh.

[Saffron]

All fair points, and part of the difficulty in correctly dosing any medicine in children. Perhaps it should be made NHS policy to always weigh children when prescribing paracetamol, and thereby take such factors into consideration?

[buggie]

In A&E this is always done before prescribing paracetamol/brufen (unless it's an emergency/broken limb so unable to sit/stand on scales).

With GP's I don't think most even have scales in their room most of the time, would've thought it would always be a useful thing to do with any patient (adult or child) whenever their seen.

[esme]

newcomer Wrote:

-------------------------------------------------------

> Ha. Just had this problem. Little Newcomer had a

> virus yesterday, so high fever and some vomiting.

> Discussed with the doctor, who immediately

> prescribed large doses of paracetamol

> suppositories and gravol without any discussion of

> when they should be used. When questioned, he

> admitted that it's best only to give paracetamol

> when fever gets very high (over 101) and he

> advised that I definitely should give it if Little

> Newcomer's fever goes above 104, due to increased

> risk of febrile convulsions and other

> complications that go with super high

> temperatures. For slight fevers, he admitted that

> it's actually preferable to let the body's immune

> system to do its job, and not to medicate, as the

> fever will help to kill the infection and so the

> child will recover more quickly. I asked also

> about the gravol (anti-sickness medication) and

> again he said that, despite prescribing it to us,

> it's best to avoid it unless the child is getting

> very distressed or dehydrated by the vomiting. I

> have been following this advice and have given

> paracetamol when the temperature started to soar

> to 103/104 but not when temperature is only 99 or

> so. I haven't given any Gravol. Little Newcomer

> seems to have gone from really ill to almost

> totally recovered within a day, so maybe there's

> something to this "minimal medication" malarky?

>

> However, note that I only got this extra

> information on usage because I queried it. No

> wonder drugs are over-used, if doctors prescribe

> first and explain later.

>

> My personal belief is that paracetomol is a

> life-saver in many situations, as high fevers can

> cause a lot of damage to a small child. However,

> over-use when it's not really needed means that

> the child's immune system doesn't get the chance

> to kick in and so, like any other medicine, it

> should be used with caution.

Completely agree with this posting

[Otta]

I always tried to limit my daughter to 5ml Calpol at a time. Took her to GP last week, and he told me off and insisted she has 10ml.

Why, when 5 seemed to be doing the job, and making her feel better?

[ratty]

If it works it works. I think doctors try to tempt you into the higher does so it looks like they are doing something.

[Saffron]

Interestingly, I think we've had the opposite problem. My daughter is top 1-3% for height and weight, and I think she might be getting underdosed. We usually start with a small dose, then add another if we think she needs it. It's so hard to know if you're getting it right sometimes. But as one of the linked articles above has reported, it's minimal chronic over-dosing with paracetamol, rather than acute high-dosing, that appears to produce the greater toxicity (research was in adults). So whether you use the low- or high-dose, it may be more important that you don't give it too often over a long period of time.