The Association Between Acetaminophen (PCM / Crocin) and Asthma .... Should Its Pediatric Use Be Banned?

Expert Review of Respiratory Medicine
Expert Rev Resp Med. 2013;7(2):113-122. 
Source

Abstract

During the last few decades, a huge epidemiological effort has been made all over the world in order to cast some light on the origin of asthma (or 'wheezing disorders' as a general term) and its recent increase in prevalence. The focus on genetic factors has failed to show any genetic signal strong enough to be seriously considered, and the tiny genetic signals found have never been appropriately replicated. The focus on environmental factors has provided some variable signals on the role of infections, allergens and bacterial substances, the direction of which have curiously varied from protecting to inducing asthma. The only environmental factor that has launched a large and consistent epidemiological signal, found in almost every epidemiological study addressing the issue, is previous acetaminophen exposure, which consistently increases the prevalence and clinical manifestations of every wheezing disorder under study. Is acetaminophen a real asthma promoter or an innocent bystander?

Conclusion

Too liberal use of acetaminophen in children should no longer be recommended. In the general pediatric population there is a good deal of epidemiological evidence suggesting that acetaminophen exposure increases wheezing disorders prevalence, and while awaiting the results of appropriate randomized clinical trials evaluating this intervention, yet to be designed and carried out, it seems reasonable to limit acetaminophen exposure to clinical settings where no alternatives exist, that is, when ibuprofen is not appropriate. In wheezing children, this recommendation is more strongly evidence based: this intervention (avoiding acetaminophen by using ibuprofen) has proved to decrease wheezing morbidity in this population in a large and well-designed clinical trial.

However, acetaminophen banning in the general pediatric population does not seem appropriate yet, because this intervention has not been properly evaluated to date and there are clinical situations in which children and pediatricians are devoid of an appropriate alternative antipyretic and analgesic drug. Moreover, banning or drug withdrawal is a regulatory issue and only regulatory agencies, with their wide access to safety databases, can accomplish this complex task. The time has come for them to do their part.

We cannot avoid the already classic ending: we are in urgent need for well-designed clinical trials evaluating the effect of avoiding acetaminophen exposure in children on wheezing disorders prevalence and morbidity. Pediatric community: please, move on!

http://www.medscape.com/viewarticle/782029_12

Comment: It is time for pediatricians to at least start using plain Ibuprofen (without PCM) in children who have wheeze.

Infant Botulism case in the USA

Published Date: 2013-04-28 21:21:03
Subject: PRO/EDR> Infant botulism - USA (02): (KS) 
Archive Number: 20130428.1678643

INFANT BOTULISM - USA (02): (KANSAS)
************************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org

Date: Wed 24 Apr 2013
Source: Topeka (KS) Capital-Journal [edited]
http://cjonline.com/news/2013-04-24/diagnosis-treatment-rare-infant-botulism-saves-child


A mother took her 5-month-old son to Stormont-Vail Regional Health Center's breast-feeding clinic 12 Apr 2013 because he wasn't eating well, was unusually fussy and just wasn't acting like himself. Within 24 hours, the infant was in Stormont's pediatric intensive care unit, limp and weak, and finally needing a ventilator to help him breathe. As doctors filed in and out, eliminating possible causes of The rapid deterioration, both parents began to fear the worst.

Although it took more than a week for laboratory tests to confirm the finding, Muthukumar Vellaichamy, a Stormont-Vail pediatric critical care physician, and Daniel Katz, a Cotton O'Neil Clinic pediatric neurologist, were sure enough of their conclusion that they ordered the BabyBIG botulism antitoxin delivered from California to combat infant's illness.

Infant botulism is caused when spores of _Clostridium botulinum_ are ingested by an infant, and germinate in the large intestine into the vegetative bacteria and produce botulin neurotoxin, according to a California Department of Health website. 

The antitoxin had a hefty price tag of $60 000, the mother said. The California Department of Health had to have a guarantee of payment before it could ship, and thankfully, she said, insurance covered $45 000 and the rest was written off. 

Vellaichamy said he saw a case of infant botulism when working in Wichita 2 years ago, and along with Katz, decided that was the most likely cause of the illness.

This case is just the 5th case of infant botulism reported to the Kansas Department of Health and Environment in Kansas since 2002.

Vellaichamy said he expects the infant to have a full recovery, since infant botulism rarely causes long-term effects.

[Byline: Morgan Chilson]

Comment: I am not sure why we in India do not see cases of Infant Botulism, is it being misdiagnosed as sepsis?

Also the price tag of medicines in USA appears to be highly inflated, USD 60,000 for BabyBIG (Infant botulism anti-toxin) translates to more than INR 30 lakh !

A simple two question tool to reliably indicate Post Partum Depression

Postpartum Depression (PPD) (also known as postnatal depression) is a largely overlooked health problem in India, due to lack of awareness and to a stigma of mental illness. In a recent mdCurrent-India survey, 70% of doctors delivering 5 or more babies a week did not always screen for post-partum depression. PPD is a health condition that should not be ignored, as it affects not only the mother, but also the short- and long-term growth and health of the child. Depressed mothers are less able to take care of themselves and provide proper care or nourishment for their infant, which can even lead to increased maternal and infant mortality. The number of deaths and adverse effects on families in India can be reduced by early intervention and prevention by obstetricians and primary care physicians (PCP). The PCP is usually the first doctor to see the mother and infant after birth, and has the advantage of continuity and building a long-term doctor-patient relationship with the patient and family.

PPD diagnostic tools

A well-established screening tool for PPD in India is the Edinburgh Postnatal Depression Scale (EPDS) or a Hindi-translated version of the structured questionnaire. The Kessler-10 item scale is also an established questionnaire for detecting common mental illness in a community setting, and has been used in India and World Mental Health Surveys. The Two-Question Test on depressed mood is a short screening tool with a high sensitivity that may be an effective screening tool for doctors who have time constraints . The following questions are asked in the Two-Question Test:

1. “During the past month, have you often been bothered by feeling down, depressed or hopeless?”
2. “During the past month, have you often been bothered by little interest or pleasure in doing things?”

If the patient answers “no” to both questions, then depression is highly unlikely. If a patient answers “yes” to either question, then other symptoms of depression should be detected before confirming the diagnosis of postpartum depression.

For a formal assessment you can look at these resources...

Physician resources – screening tools:

Edinburgh Postnatal Depression Scale (EPDS) with scoring instructions (ucsf.edu)

Kessler Psychological Distress Scale (K10)
  Self-administered questionnaire (harvard.edu)
  Interviewer-administered questionnaire (harvard.edu)

Source

Comment: Even though I am a pediatrician, I do see many mothers who appear to be having at least some symptoms of PPD. These two questions should help me at do a basic screen to help identify those at risk for this problem which may adversely affect the development of the child too.