Problem: Even though almost 27,000 accidental childhood acetaminophen overdoses have been reported annually over the last few years, death is rare, according to the American Academy of Pediatrics. But when a child dies, the family’s anguish is palpable and may touch us close to home, especially if we have children of our own.
The Institute for Safe Medication Practices (ISMP) received a report of a 10-year-old who died as a result of an accidental overdose of acetaminophen (Tylenol®, Ortho-McNeil), one of the world’s top-selling pain relievers. The child had been sick earlier in the week with cold-like and flu-like symptoms. He was given Tylenol® for his symptoms over the next few days. The drug built up in his system and caused irreversible liver, kidney, and brain damage.
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While the details of this tragic overdose are unknown, unintentional childhood overdoses can occur in several ways.
The infant’s formula is about three times more potent than the children’s formulation. Parents sometimes confuse the two and may give a child the prescribed volumetric dose using the more concentrated infant’s drops, especially if they are tired after being awake all night with a sick child. If infant drops that have been left over from when their child was younger are used, and if the physician assumes that the children’s formulation will be used, the volumetric dose that the physician prescribes will result in an error. Parents might also purchase the wrong formulation, or they might have both formulations if children of different ages are living in the household.
The risk of confusion is heightened even more by the way in which the drug concentration is listed. Instead of showing children’s acetaminophen as 32 mg/ml and the infant’s drops as 100 mg/ml, both concentrations are shown in the amounts per typical dose (160 mg per 5 ml and 160 mg per two droppersful). The inability to compare the products easily can lead to dosing errors. cialis canadian pharmacy
Even if parents use the correct acetaminophen strength, the measurement of the dose may be incorrect, especially if a household teaspoon is used. The measuring cup markers supplied with Children’s Tylenol® Liquid are inexact: the “one teaspoon” mark measures well over 6 ml.
The term “droppersful” is also misleading and can be misinterpreted to mean a “full dropper.” Yet the maximum fill line (1.6 ml) is only one-half to three-quarters of the way up on the dropper, and the white markings for the 0.8-ml and the 1.6-ml fill lines are poorly visible on the whitish, translucent plastic.
Extra doses are another possibility. A parent might not know that another caregiver has already given the child a dose. Children have also been known to sneak an extra swig of the pleasant-tasting liquid.
Children may consume more than one product containing acetaminophen, especially if the outer carton of a combination product has been discarded and the immediate container does not clearly list the active ingredients and strength (as with Infant’s Tylenol® Cold Concentrated Drops).
Safe Practice Recommendation:
Pharmacists must be alert to the potential for acetaminophen toxicity, which should be included in the differential diagnosis of many childhood illnesses. However, preventing acetaminophen overdoses begins long before a child presents with an illness. When counseling parents and caregivers about acetaminophen, health care practitioners should use the following strategies: