Acetaminophen administration in pediatric age: an observational prospective cross-sectional study

Assessment of Paracetamol Usage Practices and Perceptions among Caregivers for Children Post-COVID-19 in Saudi Arabia: A Cross-Sectional Analysis

Caregivers often use paracetamol in the management of pediatric illnesses without a clear rationale. This study evaluated the perception and practices of caregivers regarding the use of paracetamol in children in Southwestern Saudi Arabia. This study involved a cross-sectional design involving 373 caregivers of children under twelve. The questionnaire elucidated the reasons, usage frequency, and safe usage practices. Data were analyzed using SPSS, applying Chi-square tests and logistic regression. Most caregivers were in the age range of 31-40 years, and with intermediate education. Paracetamol was mainly used for fever, generalized pain and, diarrhea, with fewer opting for other self-care measures. Caregivers with primary or less education were more likely to perceive paracetamol as safe (AOR = 2.98 (1.3-6.73), p = 0.009) and less inclined to check warning labels (AOR: 0.11 (0.05-0.25), p < 0.001) and expiry dates (AOR: 0.063 (0.027-0.14), p < 0.001). The caregiver's education level significantly influenced the determination of treatment duration (χ2 = 21.58 (4), p < 0.001), dosage (χ2 = 30.70 (4), p < 0.001), and frequency of administration (χ2 = 17.77 (4), p = 0.001). In conclusion, inadequate health literacy can result in a lack of attention towards crucial safety information about pediatric paracetamol use. Hence, counselling initiatives should be undertaken to ensure the safe and effective use of paracetamol in children.

The Dangers of Acetaminophen for Neurodevelopment Outweigh Scant Evidence for Long-Term Benefits

Based on available data that include approximately 20 lines of evidence from studies in laboratory animal models, observations in humans, correlations in time, and pharmacological/toxicological considerations, it has been concluded without reasonable doubt and with no evidence to the contrary that exposure of susceptible babies and children to acetaminophen (paracetamol) induces many, if not most, cases of autism spectrum disorder (ASD). However, the relative number of cases of ASD that might be induced by acetaminophen has not yet been estimated. Here, we examine a variety of evidence, including the acetaminophen-induced reduction of social awareness in adults, the prevalence of ASD through time, and crude estimates of the relative number of ASD cases induced by acetaminophen during various periods of neurodevelopment. We conclude that the very early postpartum period poses the greatest risk for acetaminophen-induced ASD, and that nearly ubiquitous use of acetaminophen during early development could conceivably be responsible for the induction in the vast majority, perhaps 90% or more, of all cases of ASD. Despite over a decade of accumulating evidence that acetaminophen is harmful for neurodevelopment, numerous studies demonstrate that acetaminophen is frequently administered to children in excess of currently approved amounts and under conditions in which it provides no benefit. Further, studies have failed to demonstrate long-term benefits of acetaminophen for the pediatric population, leaving no valid rationale for continued use of the drug in that population given its risks to neurodevelopment.

Evaluation of age-banded dosing of oral paracetamol in hospitalised children: a retrospective analysis using clinical data in a tertiary paediatric hospital

OBJECTIVE

To evaluate age-banded dosing in paediatric inpatients by determining the proportion of patients whose dose would fall outside the therapeutic range (by weight).

DESIGN

A retrospective observational study. Weight and height measurements and details of hospital admissions were matched from the electronic patient record of a single, tertiary paediatric hospital. Dosage which would be given according to age-banded dosing was then compared with their weight.

PARTICIPANTS

All children admitted to a single tertiary children's hospital aged 3 months to 16 years over a 5-year period. Data were cleaned to remove values likely to be erroneous and filtered to reduce bias due to patients who were admitted on multiple occasions.

OUTCOMES

The main outcome was the proportion of patients who would receive a subtherapeutic or supratherapeutic paracetamol dose if given a dose based on their age. Secondary outcomes were to examine this in children of different ages and to examine the impact of alternative size-based dosing strategies.

RESULTS

100 047 admissions (in 68 310 patients) had a weight documented. If age-banded dosing had been used, a subtherapeutic dose (less than 10 mg/kg) would be given during 19 829 (20%) of the admissions and a supratherapeutic dose (over 18.75 mg/kg, 75 mg/kg/day in four doses) in 4289 (4.3%). The highest risk of a subtherapeutic dose occurred in infants just prior to reaching 6 months of age (83%) and in children just prior to reaching 8 years (66%). The highest risk of a supratherapeutic dose was at 12 years of age (35%).

CONCLUSION

Age-banded dosing is not suitable for an inpatient paediatric population as approximately a quarter of patients receive a dose outside the recommended range of 10.0-18.75 mg/kg.

The safety of pediatric use of paracetamol (acetaminophen): a narrative review of direct and indirect evidence

Paracetamol (acetaminophen) use during pregnancy and early childhood was accepted as safe in the 1970s, but is now a subject of considerable concern. Careful analysis shows that initial acceptance of the drug was based on the false assumption that drug interactions in babies and adults are the same, and on a complete absence of knowledge regarding the impact of the drug on brain development. At least fourteen epidemiological studies now indicate that prenatal exposure to paracetamol is associated with neurodevelopmental problems. Based on these studies, it can be concluded that prenatal exposure to paracetamol causes statistically significant risks of developmental delays, attention deficit hyperactivity disorder, and a subtype of autism spectrum disorder (ASD) associated with hyperkinetic behavior. In contrast, data regarding postnatal exposure to paracetamol are limited, and several factors impede a classic multivariate analysis of epidemiologic data to resolve the issue. However, circumstantial evidence regarding postnatal exposure to the drug is abundant, and includes at least three otherwise unexplained temporal relationships, data from laboratory animal studies, several miscellaneous and otherwise unexplained correlations, and a lack of alternative suspects that fit the evidence-derived profile. Based on this evidence, it can be concluded without any reasonable doubt that oxidative stress puts some babies and children at risk of paracetamol-induced neurodevelopmental injury, and that postnatal exposure to paracetamol in those susceptible babies and children is responsible for many if not most cases of ASD.

Systematic review of methodology and reporting quality of global guidelines on fever in children

OBJECTIVE

This study aimed to evaluate the global clinical practice guidelines on fever in children. We also aimed to select a guideline with good methodology and reporting quality to provide scientific reference for diagnosis and treatment of fever in children.

METHODS

The Chinese and English databases Embase, PubMed, Cochrane library, China National Knowledge Infrastructure, Wanfang database, clinical guides, and the website of the Department of Public Health Administration were retrieved up to January 2020. The clinical practice guidelines on fever in children were included. The AGREE II instrument and Reporting Items for Practice Guidelines in Healthcare statement were used to evaluate the methodology and reporting quality of the guidelines.

RESULTS

Eight clinical guidelines for fever in children were included. Methodological quality assessment showed that the recommendation level of ISP, South Africa, National Institute for Health and Care Excellence, China, and American College of Emergency Physicians were grade B (recommended with modification), while that of American Academy of Pediatrics, New South Wales, and South Australia was grade C recommendation (not recommended). No grade A recommendation guideline was found. The reporting quality from higher to lower was National Institute for Health and Care Excellence, the Chinese guideline, American College of Emergency Physicians, ISP, South Africa, New South Wales, South Australia, and American Academy of Pediatrics. The guideline recommendations were similar in various countries, but they were slightly different in various aspects, including body temperature measurement and the timing of drug administration.

CONCLUSION

There are limitations in the methodology and reporting quality of all eight global guidelines on fever in children. For future development of these guidelines, attention should be paid to improving applicability of the guidelines in terms of methodology. Additionally, the principles and explanations for formation of recommendations should be described, as well as the limitations of the reporting guideline in detail in terms of the reporting quality. Treatments of fever in children are similar in different countries, but there are still differences that require further research.

Multicentre emergency department study found that paracetamol and ibuprofen were inappropriately used in 83% and 63% of paediatric cases

AIM

The Pain Practice in Italian Paediatric Emergency Departments assessed how appropriately analgesic drugs were being used by Italian clinicians, based on national paediatric pain guidelines.

METHODS

This was a retrospective study that involved 17 Italian members of the Pain In Pediatric Emergency Rooms group. It comprised patients up to the age of 14 years who came to hospital emergency departments with pain and were treated with paracetamol, ibuprofen or opioids, such as codeine, tramadol and morphine.

RESULTS

We studied 1471 patients who were given 1593 doses of analgesics. The median time to administration of analgesia was 25 minutes. Opioids were used in 13.5% of the children, and usage increased with age and with more severe clinical conditions, such as trauma: 1.6% of children under two years, 5.9% aged 3-10 and 8.0% aged 11-14. Inappropriate doses of paracetamol, ibuprofen and opioids were used in 83%, 63% and 33% of cases, respectively. The patient's age was a critical determinant of the correct analgesic dosage; for every one-year increase in the patient's age, the probability of appropriate prescriptions rose 14.8%.

CONCLUSION

The appropriate use of paracetamol and ibuprofen for paediatric pain in Italian emergency departments was very poor, but improved with age.

Advances in paediatrics in 2016: current practices and challenges in allergy, autoimmune diseases, cardiology, endocrinology, gastroenterology, infectious diseases, neonatology, nephrology, neurology, nutrition, pulmonology

This review reports main progresses in various pediatric issues published in Italian Journal of Pediatrics and in international journals in 2016. New insights in clinical features or complications of several disorders may be useful for our better understanding. They comprise severe asthma, changing features of lupus erythematosus from birth to adolescence, celiac disease, functional gastrointestinal disorders, Moebius syndrome, recurrent pneumonia. Risk factors for congenital heart defects, Kawasaki disease have been widely investigated. New diagnostic tools are available for ascertaining brucellosis, celiac disease and viral infections. The usefulness of aCGH as first-tier test is confirmed in patients with neurodevelopmental disorders. Novel information have been provided on the safety of milk for infants. Recent advances in the treatment of common disorders, including neonatal respiratory distress syndrome, hypo-glycemia in newborns, atopic dermatitis, constipation, cyclic vomiting syndrome, nephrotic syndrome, diabetes mellitus, regurgitation, short stature, secretions in children with cerebral palsy have been reported. Antipyretics treatment has been updated by national guidelines and studies have excluded side effects (e.g. asthma risk during acetaminophen therapy). Vaccinations are a painful event and several options are reported to prevent this pain. Adverse effects due to metabolic abnormalities are reported for second generation antipsychotic drugs.

La fiebre en el niño: una mirada reflexiva a las prácticas de cuidado

Objetivo: Realizar un análisis crítico-reflexivo de las prácticas rutinarias de los profesionales de enfermería y de los cuidadores familiares en el cuidado del niño con fiebre, a fin de incentivar un cuidado basado en evidencia científica que asegure el bienestar infantil.Síntesis de contenido: Se realizó una revisión bibliográfica de artículos científicos publicados entre los años 2007 y 2017, en las bases de datos ebscohost, ScienceDirect, medline, PubMed, cinahl, Web of Science y cuiden®, para lo cual se utilizaron los descriptores y sus combinaciones en español, portugués e inglés Fiebre; Cuidadores; Niño. Se elaboró un compendio de 45 artículos seleccionados y analizados que contenía las prácticas de cuidado con convergencias, divergencias y complementariedades.Los resultados se agruparon en los siguientes cinco temas: Concepción histórica de la fiebre; La fiebrefobia:una concepción en las actuales prácticas de cuidado; El baño de esponja:una práctica ancestral controvertida; El uso de antipiréticos: una rutina en contravía de la salud y la vidade los niños; La fiebre: en busca de una mirada desde su beneficio.Conclusiones: La concepción de la fiebre infantil centrada en el miedo y en el daño permanece. Las acciones de cuidado más comunes, como el baño de esponja y el uso/abuso de antipiréticos, son cuestionadas desde la evidencia científica, demostrando los efectos deletéreos que producen en la salud del niño. El cuidado del niño, después de una evaluación individualizada, deberá enfocarse en el confort, en un ambiente fresco y tranquilo y en el aumento de la ingesta de líquidos para evitar la deshidratación u otras complicaciones.

Guidelines for the symptomatic management of fever in children: systematic review of the literature and quality appraisal with AGREE II

INTRODUCTION

Several societies have produced and disseminated clinical practice guidelines (CPGs) for the symptomatic management of fever in children. However, to date, the quality of such guidelines has not been appraised.

OBJECTIVE

To identify and evaluate guidelines for the symptomatic management of fever in children.

METHODS

The research was conducted using PubMed, guideline websites, and Google (January 2010 to July 2016). The quality of the CPGs was independently assessed by two assessors using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument, and specific recommendations in guidelines were summarised and evaluated. Domain scores were considered of sufficient quality when >60% and of good quality when >80%.

RESULTS

Seven guidelines were retrieved. The median score for the scope and purpose domain was 85.3% (range 66.6-100%). The median score for the stakeholder involvement domain was 57.5% (range 33.3-83.3%) and four guidelines scored >60%. The median score for the rigour of development domain was 52.0% (range 14.6-98.9%), and only three guidelines scored >60%. The median score for the clarity of presentation domain was 80.9% (range 50.0-94.4%). The median score for the applicability domain was 39.3% (8.3-100%). Only one guideline scored >60%. The median score for the editorial independence domain was 48.84% (0-91.6%); only three guidelines scored >60%.

CONCLUSION

Most guidelines were recommended for use even if with modification, especially in the methodology, the applicability and the editorial independence domains. Our results could help improve reporting of future guidelines, and affect the selection and use of guidelines in clinical practice.

Parental Approach to the Prevention and Management of Fever and Pain Following Childhood Immunizations: A Survey Study

Antipyretic analgesics are commonly used to prevent and treat adverse events following immunizations. Current practice discourages routine use due to possible blunting of vaccine immune responses. We surveyed 150 parents/caregivers of recently vaccinated 6- and 15-month-old children to determine the prevalence of and beliefs regarding antipyretic analgesics use around vaccinations. 11% used them prophylactically, before vaccination. Use in the first 48 hours after vaccination was 64%, primarily to prevent and/or treat fever and pain. Acetaminophen was administered 2.6 times more frequently than ibuprofen. Ibuprofen was used more in the 15-month compared with the 6-month-old children (28% vs 7.4%, respectively, P = .001). The majority of caregivers disagreed with their use for fever (53%) or pain (59%). Antipyretic analgesic use, including prophylaxis, around vaccinations was common in our study population. Effective interventions are needed to target parents/caregivers to eliminate unnecessary antipyretic analgesic use around vaccination time and foster nonmedication alternatives.