Is Tylenol Safe for Children with
Chickenpox?
by the Stork staff
The most prescribed pharmaceutical for children with varicella-induced
fevers is the popular analgesic, antipyretic pain-killer Tylenol (AKA
Acetaminophen, Paracetamol, Paracip). Aspirin (Bayer, Bufferin, Anacin)
and NSAIDS (Advil, Aleve, Motrin, Nuprin) are counter-indicated for such
purposes due, respectively, to complications of Reye's Syndrome and Group
A Streptococcal infections. However, the prevailing practice of Tylenol
use, too, has its issues.
"For over two decades, pediatricians have been made aware of the
potential risk associated with the acute ingestion of large single and/or
multiple doses of acetaminophen," warn GL Kearns, et al. of the University
of Missouri-Kansas City's Department of Pediatrics. Yet, still, pediatricians
and parents remain oblivious or unconcerned about acetaminophen's dangers.
Know this: if given the wrong dosage, your
child can die taking Tylenol.
In one 1998 survey, twenty-four American children died and three required
liver transplants after being given too much acetaminophen. Six were due
to doses slightly above weight–based recommendations. Dr. James Heubi
of Cincinnati Children's Hospital, who compiled these figures, writes,
"It is not safe for children to take twice the recommended dosage
of acetaminophen over a number of days."
William Lee, director of the Clinical Center for Liver Diseases at the
University of Texas concurs, telling the New York Times: "The window
between therapy and toxicity is much smaller with acetaminophen than with
most other compounds." Furthermore, Lee stipulates, "No other
over-the-counter drug has a narrower range between therapy and toxicity
than acetaminophen."
Researchers from the Departments of Emergency Medicine and Pediatrics,
University of Cincinnati, agree with such concerns, writing: "The
literature is replete with reports of significant morbidity and mortality
after repeated supra-therapeutic dosing." Their suggestions are pragmatic.
"Because so many parents are unaware of the potential risk of inappropriate
dosing, education is the key to preventing future cases."
Liver toxicity (hepatoxicity) is the prevalent risk of acetaminophen overdose.
"Ill children receiving repeated supratherapeutic doses (>60 mg
APAP/kg/d) of acetaminophen may show abnormalities in liver function,"
write researchers from the Department of Pediatric Emergency Medicine,
at Tel-Aviv University.
In fact, drug-induced hepatoxicity contributes to more than half of all
acute liver failure cases. And, acetaminophen is the leading cause of
toxic drug ingestions in America, causing an estimated 100 deaths annually.
Ironically, Tylenol's former ad slogan was "Nothing's safer."
Pharmaceutical manufacturers and physicians continue to promote the notion
that, if dosed properly (which it often isn't), acetaminophen is perfectly
safe for pediatric use. But, both must realize that parents frequently
do not follow prescribed dosages. In a 2000 study of patients admitted
to an urban pediatric emergency department, over half of the caregivers
surveyed gave children inaccurate doses of acetaminophen or ibuprofen.
Dosage is not the only problem.
Another variable to consider is duration. Acetaminophen bioaccumulates,
making risk of toxicity increase over time.
Then there's the issue of the patient. Do all children respond the same
to acetaminophen? No. Obese children might have more hepatoxicity risk.
Children with high-fat diets, might, as well.
And what about immuno-compromised children? In a 1999 case at the Children's
Hospital of Alabama, an 18-month-old toddler died of acetaminophen toxicity,
while receiving less than the standard toxic threshold. The toddler had
been born premature, and it was surmised by doctors that immature liver
biology may have made the child more prone to toxicity.
It stands to reason that impaired liver function would increase liver
toxicity susceptibility. Researchers have proposed liver disease as a
risk factor for hepatoxicity. And herein lies the danger with chickenpox
and acetaminophen use (and abuse).
The chickenpox connection.
After the first week of varicella
infection, once the upper respiratory tract has been invaded and lymph
nodes have become a site for viral replication (primary viremia), viral
replication then takes place in the liver and spleen (secondary viremia),
which leads to the tell-tale vesicular chickenpox rash. Varicella is a
liver-compromising disease. A frequent complication of varicella is mild
hepatitis.
The virus invades and kills liver cells (hepatocytes), leaving lesions.
These lesions were demonstrated graphically by researchers in Zurich,
who revealed with CT scans "multiple, hypodense, nodullar lesions"
in the liver of a 61-year-old woman with varicella.
What then might result when acetaminophen is added to the equation? You
do the math. Although acetaminophen differs from aspirin in composition
and effect (the mechanics of acetaminophen-induced heptatoxicity are not
completely understood), its results, when used for chickenpox treatment,
may in some ways be similar to Reye's Syndrome, which, in its later stages,
manifests with hepatic injury. It has been clinically shown that acetaminophen
exacerbates, and is possibly a cause of, Reye's Syndrome.
There are two other factors to consider. Any viral illness increases risks
of hepatoxicity, due to impaired defense mechanisms. And, febrile children
have been shown to metabolize acetaminophen differently. So, standard
doses may not apply for many of acetaminophen's common uses such as fever
mitigation, aches associated with viral illnesses ... and chickenpox.
To make matters worse, acetaminophen depletes glutathione stores. Glutathione
is an essential component of the human immune response, playing a vital
role in antioxidant defense and regulation of cellular events. Glutathione
deficiency contributes to oxidative stress, which makes diseases significantly
more dangerous.
Does Tylenol do more harm than good?
Given these risks and issues, pediatricians should reconsider whether
prescribing Tylenol for pediatric treatment of chickenpox is doing children
more harm than good. A 1989 study from Johns Hopkins' Department of Pediatrics
bore that exact title: "Acetaminophen: more harm than good for chickenpox?"
Researchers found that acetaminophen, in fact, does not alleviate symptoms
in children with varicella and may actually prolong illness, with regard
to itching and scabbing.
A subsequent study at the Slone Epidemiology Unit of Boston University
School of Medicine concurred: "Compared with children who did not
receive an antipyretic, those who received (acetaminophen) were more severely
affected by varicella" – with higher incidence of lesions, chills
and muscle aches, requiring more bed rest. And, children were more often
characterized as "severely ill" by their parents.
Besides, let's be honest. Antipyretic fever therapy in children is typically
prescribed to relieve parental concern, not to treat illness. Fevers create
an unfavorable environment for the growth of viral microorganisms and
are therefore important in the healing process. Intervening in the fever
process is not necessarily beneficial and potentially detrimental. Why
prescribe something that has substantial demonstrated risks and provides
dubious benefit – when it shuts down the proper, natural process
of battling disease?
Chart 1: products containing acetaminophen
Aceta
Actamin
Actifed Plus
Apacet
Aspirin Free Anacin Maximum Strength
Bayer Select Maximum Strength
Benadryl Plus and Plus Nighttime
Dapa
Datril Extra-Strength
Dristan
Excedrin
Feverall
Genapap
Genebs
Liquiprin Children's Elixir and Infants' Drops
Neopap
NyQuil
Oraphen-PD
Pamprin
Panadol
Phenaphen
Redutemp
Sinutab
Snaplets
Sominex
St. Joseph Aspirin-Free Fever Reducer for Children
Suppap
Tapanol Extra Strength
Tempra
TheraFlu
Tylenol
Valorin
Chart 2: FYI
Although acetaminophen may not be advisable for use with chickenpox, it
can be helpful for other ailments. If it is given to children, parents
should be aware of and adhere to proper dosages and dosage durations.
Body weight (not age) should dictate dosage. However, recommended dosages
are disconcertingly variable. For example: Dr. Sears suggests 7mg/lb of
body weight every four hours; but state university health programs suggest
2.25 to 4.5mg/lb. All are below toxic levels. But, this prescriptive variance
of over 300% does call into question what is the correct prescribed dosage
and why (given the risks) there is not a concrete consensus for pediatric
use. According to charts from the National Institute of Health, acetaminophen
dosage averages around 5mg/lb every four hours, no more than five times
a day, for no more than five days.
Dosage Recommendation:
Children's Chewable Acetaminophen (80 milligram tablets)
weight dosage
(every 4 hours, max 5 dosages per day, max 5 days)
24-35 lbs 2 tablets
36-47 lbs 3 tablets
48-59 lbs 4 tablets
60-71 lbs 5 tablets
72-95 lbs 6 tablets
95+ lbs 8
tablets
(Source: National Institute of Health)
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JE Heubi, JP Bien. "Acetaminophen use in children: more is not better,"
J Pediatr 1997 Feb;130(2):175-7.
Denise Grady, "Tylenol Overdoses Linked To Acute Failure of Liver,"
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Thomas Easton, "J&J's dirty little secret," Forbes Magazine,
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http://www.forbes.com/free_forbes/1998/0112/6101042a.html
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