A quick respite to a fever or body aches could be found in paracetamol. But the drug, easily available over the counter has also been a cause of concern when it gets misused or overused.
Overdose of acetaminophen, popularly known as paracetamol, is known to cause paracetamol poisoning (PP) or acetaminophen poisoning.
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In November 2022, for the first time, the Indian Academy of Pediatrics (IAP) came up with standard treatment guidelines for paracetamol poisoning among children. The guidelines say that paracetamol is the most common antipyretic analgesic (medicine to reduce the sensation of fever and pain) in use and is freely available over the counter (OTC).
“In India, self-poisoning is underreported. However, unintentional poisoning is increasing with the availability of several unregulated formulations in the market. PP may be due to accidental ingestion or intentional overdose,” the guideline reads.
Speaking to Happiest Health, Dr Supraja Chandrasekar, co-author of the guidelines published by the IAP, says that the major issue faced by paediatricians is the lack of understanding among parents about paracetamol drops and syrup.
The OTC availability of drugs and lack of awareness regarding the dosage is bothering the medical community.
Dr Arun Baranwal, the lead author of the guidelines and a professor at the department of paediatrics, Post Graduate Institute of Medical Education & Research, Chandigarh, says that the childproof caps of the paracetamol syrup bottles that are currently available can prevent unintentional poisoning.
“Parents must ensure that the drug is not accessible to children and must be kept away. Besides, parents must stick to the prescribed dosage and not exceed it. Paracetamol dose should not be repeated within or before four to five hours,” says Dr Baranwal.
How to notice signs and treat paracetamol overdose
The symptoms of overdose are uneasiness, nausea, vomiting, gastritis-like symptoms, pain in the abdomen and irritability.
“The toxicity symptoms occur much later and they would be nonspecific,” says Dr Supraja Chandrashekar, co-author of the guidelines.
The guideline mentions that N-acetylcysteine (NAC), an ante infusion (effective antidote) is to be used to prevent hepatotoxicity. The aim is to prevent acute liver failure, liver transplantation or death, with minimised side effects.
The guideline says that 18 hours into the NAC infusion (two hours before the completion), a blood sample should be sent for checking blood paracetamol levels. Electrolyte levels should be analysed and liver and renal function tests should also be carried out.
Dr Supraja, paediatric intensivist, Manipal Hospitals, Yeshwantpura, Bengaluru, explains that paracetamol is safe when taken in the right quantities. But doctors also point out that there have been cases where adolescents have misused paracetamol and this needs to be prevented.
Paracetamol drops and syrups are not the same
Drops are more concentrated than syrups, says Dr Supraja. “In paracetamol drops, 1 ml is equal to 100 mg, whereas, in paracetamol syrups, 5 ml is equal to 120 mg or 250 mg, depending on the formulation. Overuse of the drug can damage the liver.”
“A doctor might advise giving paracetamol syrup 3.5 ml four times a day. But there are chances that the parents may end up giving 3.5 ml of paracetamol drops and this leads to overuse,” notes the doctor, adding that there is also a lack of awareness among chemists who sometimes hand out drops instead of syrup.
When a paracetamol dose is more than 150 mg per one kg weight of the child, paracetamol poisoning could happen.
During vaccination visits, Dr Supraja makes sure she counsels the parents regarding the difference between paracetamol drops and syrup. “Drop should never cross 1 ml and avoid drops once a child crosses 8 kgs. If the parents have given more than 1 ml or if there is any confusion [regarding the dosage], the parents must consult with a doctor,” says Supraja.
Paracetamol overuse is a reality among adults too. “People use it on their own even in case of cough and cold leading to its misuse,” says Dr Farah Ingale, director, internal medicine, Fortis Hiranandani hospital, Vashi, Mumbai.
How an infant survived in the nick of time
Dr Supraja recalls a case of a six-month-old girl she treated ten years ago.
“The baby [who weighed nine kilos] had a fever and the parents had given two 5 ml bottles of paracetamol drops in just 36 hours. They consulted a doctor before buying the third bottle and they were told about over use. When the child was brought to the ICU, she had low sugar levels and was very irritable,” says Dr Supraja. The parents had asked why the fever didn’t subside and the child was irritable despite giving the paracetamol drops.
In this case, the baby was not fed when she had a fever and hence there was no oral glucose intake. On top of that, the parents had given her paracetamol in large quantities which affected her liver function.
After intense treatment, the baby survived.
Parents often feel confused and stressed if a child’s fever does not reduce after one dose of paracetamol, says Dr Baranwal. “To reduce the fever, parents must not use multiple medicines within a short duration without a prescription. When in doubt, consult a doctor,” he says.
In the last two years, Dr Supraja has come across four paediatric admissions due to PP; all were cases of self-harm. In one case, an adolescent child had consumed multiple drugs including paracetamol.
The guidelines specify that in case of an intentional overdose in an older child or adolescent, psychiatric consultation may be sought.
Permissible limit in kids
The maximum daily dose of paracetamol among children is 60 mg per kg (all doses put together).
“But in obese children, we cannot go by the weight and we need to consider the ideal body weight. For example, a 10-year-old child should weigh about 35 kg. However, if s/he is 50 kg, we must consider it only as 35 kg,” says Dr Supraja.
What is not an overuse?
In adults, six to eight tablets of 500 mg paracetamol a day is fine if prescribed, (depending on the body weight) and monitored by a qualified doctor, as it translates to three to four grams of the medicine taken in a day, says Dr Ingale.
She adds that if an adult without any liver complications consumes more than four grams of paracetamol a day, it is termed an overdose. “If there are liver function issues, we don’t give paracetamol,” she says.
Dr Ingale recalls the case of a 35-year-old woman from Mumbai who was brought to an emergency unit with a history of attempts to self-harm by consuming paracetamol in abnormally high quantities. She required a liver transplant.
In case of overdose, initially, there may not be any symptoms, but gradually in one or two days, the person may develop nausea, a feeling of being sick, vomiting, pain the right abdomen where the liver is situated, hypertension and sweating, points out Dr Ingale. “It can lead to jaundice. The skin and eyes turn yellow,” he says, adding that PP can potentially damage the liver and kidney apart from causing a dip in the platelet count.
Dr Ingale mentions that caution must be exercised while taking any drug, including paracetamol
- Do not take more than two paracetamols at once without consulting a doctor
- Fever not subsiding despite paracetamol usage? Consult a doctor. Do not overuse the drug
- If you are suffering from liver or renal disorder, consult doctors before taking paracetamol
- Read the labels. Paracetamol formulations are available in 500 mg and 650 mg