How overdose of paracetamol could poison your kids

As paracetamol is widely used to treat pain and fever, there is a common misconception that it is safe and harmless. But know this – although paracetamol is safe when used in therapeutic doses, supra-therapeutic (or excessive) doses can damage the liver and can lead to death from liver failure.Recently, at Kanchi Kamakoti Child’s Trust Hospital (KKCTH), Chennai, we had a case of a three-year-old boy who had fever and cough for three days. His paediatrician prescribed paracetamol to control the fever – 1ml of drops (100milligrams/millilitre or 100mg/ml) every eight hours as needed.However, the fever persisted, and his mother recalled that her other child had been prescribed 2. 5ml of paracetamol syrup (125mg/5ml). So she gave her son 2.5ml of the drops every eight hours, not realising that the drops have much higher concentration than the syrup. After just one day of being administered the drops, the boy became dull and started vomiting blood. He was brought to the emergency room and admitted to the intensive care unit (ICU) with liver failure caused by paracetamol overdose.It is hard to believe that paracetamol can be harmful for children. But around 45 children were admitted at KKCTH with paracetamol poisoning in the last two years. Of them 38 had liver damage. The youngest patient was four months old and the oldest was 17 years old.Eight children required treatment in the ICU. In April, two children were brought in with symptoms of paracetamol overdose – luckily, both recovered. On average, around 20 children a year are treated for the overdose. At least one child dies every year due to liver failure caused by paracetamol overdose. medium nocaption99963713Unintentional poisoningWhile paracetamol poisoning in adults may be intentional, in children it is mostly inadvertent. Often, the overdose is not because children take the medication by accident but because parents have administered doses above the recommended levels. The important reasons for paracetamol poisoning in children are exploratory ingestion; inappropriate therapeutic dosing because of wrong choice of syrup or drops of a higher strength; inadvertent repeated dosing by parents for persistent fever because they do not know the maximum dose that can be given in a day; and accidental overdosing by consuming more than one paracetamol containing product. Intentional poisoning is extremely rare.As paediatricians we see that most parents are worried when their child has a high-grade fever. Fearing seizures or other complications, they tend to give higher doses to their child every two to four hours.Paracetamol is safe only when used at the appropriate dose. The recommended dose for a child is 10-15mg per kilogram of the child’s weight (maximum 650mg to 1,000mg per dose). The dose can be repeated after a minimum gap of four to six hours. Sometimes parents give more than five doses per day, but this ought not to be done. The medication should not exceed a total dose of 60 mg/kg per day (maximum 4,000mg).Exceeding this dose may be harmful and can cause liver failure. If fever persists even after giving the recommended dose of paracetamol, do not blindly give more doses. Instead, use other antipyretics after consulting a doctor.Different strengths of paracetamol syrup and drops are available. In the US, only one strength of paracetamol syrup is available (160mg/5ml), whereas in India at least four different liquid preparations are available, ranging from 125mg/5ml to 750mg/5ml.Parents should remember that paracetamol is dosed as an mg of the drug per kg of the child’s weight and that the recommended volume of the syrup (in ml) varies with the strength chosen. This is clearly outlined in the table below. !function(){"use strict";window.addEventListener("message",(function(a){if(void 0!==a.data["datawrapper-height"]){var e=document.querySelectorAll("iframe");for(var t in a.data["datawrapper-height"])for(var r=0;r For example, if the child is prescribed 6ml per dose of the ‘125mg in 5ml’ preparation but they mistakenly buy and give 6ml of the ‘750mg in 5ml’ preparation, even a few doses will lead to serious liver injury.Caretakers should pay attention to the strength of the syrup or drops every time they buy it. Many preparations available in the market have the appropriate weight-based dose mentioned on the label, for easy reference. In case of any doubt regarding the paracetamol dose, the parents/caretakers should confirm the dose with the child’s doctor.Here's another thing, several parents are unaware of. Paracetamol is often a part of several commonly used cough and cold syrups. When such multiple paracetamol-containing syrups are used simultaneously, it can inadvertently lead to paracetamol overdose. Parents must avoid concurrent administration of multiple paracetamol containing medicines.Exploratory ingestion is not uncommon in young children, especially because the syrups are flavoured and sweet to taste. To prevent such accidents, paracetamol, like any other drug, should be strictly kept out of the reach of children. ShowBlurbsAs doctors, we commonly come across situations where parents don’t seek medical help immediately even after knowing that their child has consumed a supra-therapeutic dose of paracetamol.This is because the parents wrongly presume that paracetamol is non-toxic and most of the children remain asymptomatic soon after consumption. They start developing nonspecific symptoms like vomiting and lethargy only after a few hours, by which time liver injury has already set in.The risk of liver injury can be greatly reduced if a medicine called N-acetyl cysteine, the specific antidote for paracetamol toxicity, is administered within 8-10 hours of ingestion. Therefore, parents should seek medical care immediately after ingestion of a toxic dose and not wait for symptoms to develop.Paracetamol is safe and effective when used correctly. Over dosage can be dangerous and parents should pay close attention to ensure that they give the correct preparation at the correct dose.Untitled Carousel 89088303Dr P Priyatharshini is Fellow, paediatric intensive care, KKCTH, and Dr Bala Ramachandran is head of the department of intensive care and emergency medicine, KKCTH