G. Randall Bond

Pediatric Fatalities Associated With Over the Counter (Nonprescription) Cough and Cold Medications

STUDY OBJECTIVE The use of nonprescription cough and cold medicines is widespread, but their use has been sporadically associated with severe toxicity and death. We evaluate the role of these medications in pediatric fatalities and identified factors that contributed to the death. METHODS Fatalities that involved a child younger than 12 years and mentioned a cough and cold ingredient were obtained from 5 sources. An independent panel of 8 experts (pediatrics, pediatric critical care, pediatric toxicology, clinical toxicology, forensic toxicology, forensic pathology) used explicit definitions to assess the causal relationship between medication ingestion and death. Contributing factors were identified. RESULTS Of 189 cases included, 118 were judged possibly, likely, or definitely related to a cough and cold ingredient. Of these 118 cases, 103 involved a nonprescription drug, whereas 15 cases involved a prescription medication alone. Of 103 cases associated with nonprescription drugs, the evidence indicated that 88 involved an overdosage. A dosage could not be assessed in the remaining 15 cases. Several contributing factors were identified: age younger than 2 years, use of the medication for sedation, use in a daycare setting, use of 2 medicines with the same ingredient, failure to use a measuring device, product misidentification, and use of a nonprescription product intended for adult use. All cases that occurred in a daycare setting involved a child younger than 2 years. CONCLUSION In our sample, pediatric fatalities caused by nonprescription cough and cold medications were uncommon, involved overdose, and primarily affected children younger than 2 years. The intent of caregivers appears to be therapeutic to relieve symptoms in some cases and nontherapeutic to induce sedation or to facilitate child maltreatment in other cases.

Acetaminophen protein adducts: a review.

Significant controversy surrounds the clinical and legal implications of 3-para cysteinyl acetaminophen, the protein degradation product of acetaminophen protein adducts. Versions of this test have been used for several years in animal research to help understand acetaminophen toxicity. As human research papers have appeared, the allegation has been made that the presence of 3-para cysteinyl acetaminophen in a patient with hepatic injury proves causal association of acetaminophen with the injury. It has also been suggested that quantitative adduct assays can guide the management of acute overdose or repeated supra-therapeutic use of acetaminophen by determining the need for initiating therapy and the timing of the end of therapy. The purpose of this review is to discuss the nature of this molecule and the detection assay, the animal research linking it with injury, and to evaluate the human research - specifically the evidence regarding causality and clinical utility. At the current time there is inadequate evidence for the test alone to prove causal association between acetaminophen and hepatic injury. Also, since quantitative 3-para cysteinyl acetaminophen assays parallel other markers of liver injury, it is not clear that assays alone will guide therapy unless quantitative assay markers can be shown to precede other markers (in elevation or decline) or provide more specificity than the Rumack-Matthew risk categorization nomogram. These advantages have not been demonstrated.

Dyskinesias associated with atomoxetine in combination with other psychoactive drugs

Toxicity experience with atomoxetine, a selective norepinephrine reuptake inhibitor approved for Attention Deficit Hyperactivity Disorder (ADHD), is limited. We report two cases of neurologic complications requiring hospitalization in patients when atomoxetine was added to other psychoactive drugs. A 9-year-old taking clonidine and dextroamphetamine developed psychosis, abnormal involuntary movements, and insomnia. An 18-year-old also initiating venlafaxine developed facial tics, tremors, and speech disturbance. Acute symptoms did not respond to diphenhydramine in either case, but resolved after atomoxetine and other medications were discontinued. Possible explanations include atypical atomoxetine effect, excess atomoxetine or metabolites due to poor metabolizer status (CYP 2D6 polymorphism/deficiency), a drug-drug interaction leading to elevated drug levels or to excess synaptic norepinephrine or dopamine. Serotonin syndrome is a possibility in the second case, but not the first. Clinicians should be aware of emergent dyskinesias when combining atomoxetine with dopaminergic, noradrenergic, or serotonergic medications.

A Clinical Decision Aid for Triage of Children Younger Than 5 Years and With Organophosphate or Carbamate Insecticide Exposure in Developing Countries

STUDY OBJECTIVE Unintentional pediatric exposure to insecticides is common in developing countries. A clinical decision aid could guide early triage decisionmaking. METHODS Study design was prospective observational data collection in a specialty poisoning hospital in Cairo, Egypt. Patients were children 2 months to 59 months of age, without pretreatment, presenting within 2 hours of an exposure to an organophosphate or carbamate insecticide. A resource-requiring course was defined as any occurrence of hypoxia, use of atropine or obidoxime, use of ICU care, or death. The goal of analysis was derivation of a clinical decision aid to predict a resource-requiring course with 100% sensitivity. RESULTS During the 21-month study, 197 children 2 months to 59 months of age exposed to an organophosphate or carbamate insecticide were treated at the center. One hundred two of these children met the study inclusion criteria: 95 had parental consent and completed the study observation period of which 65 used resources (4 died). All patients who ultimately met resource-requiring criteria initially did so at arrival. Pinpoint pupil alone identified 63 of 65 of these patients yet wrongly identified only 5 of 30 minimally ill patients. Pinpoint pupil or diarrhea identified 65 of 65 patients with a resource-requiring course while identifying 7 of 30 patients with a non-resource-requiring course (sensitivity 1.00; 95% confidence interval 0.95 to 1.00; specificity 0.77; 95% confidence interval 0.58 to 0.90). CONCLUSION Using 2 features, pinpoint pupils and diarrhea, we identified at presentation all patients who ultimately had a course using medications or advanced resources. According to this preliminary study, symptoms occur rapidly, so using an early triage aid may be feasible. A validation study is necessary.

Toxic reaction to salicylate in a newborn infant: Similarities to neonatal sepsis

A newborn infant had metabolic acidosis, tachypnea, and hypoglycemia. After the initial diagnosis of neonatal sepsis, she was given antibiotics but failed to respond. Further investigation revealed that her mother had taken aspirin throughout pregnancy. This case illustrates the similarities between symptoms of neonatal sepsis and those of a toxic reaction to salicylate.

Safety Profile of Cough and Cold Medication Use in Pediatrics

The safety of pediatric exposures to CCMs is described by using data from 2009 to 2014 from a multisystem surveillance program. BACKGROUND AND OBJECTIVES: The safety of cough and cold medication (CCM) use in children has been questioned. We describe the safety profile of CCMs in children <12 years of age from a multisystem surveillance program. METHODS: Cases with adverse events (AEs) after ingestion of at least 1 index CCM ingredient (brompheniramine, chlorpheniramine, dextromethorphan, diphenhydramine, doxylamine, guaifenesin, phenylephrine, and pseudoephedrine) in children <12 years of age were collected from 5 data sources. An expert panel determined relatedness, dose, intent, and risk factors. Case characteristics and AEs are described. RESULTS: Of the 4202 cases reviewed, 3251 (77.4%) were determined to be at least potentially related to a CCM, with accidental unsupervised ingestions (67.1%) and medication errors (13.0%) the most common exposure types. Liquid (67.3%), pediatric (75.5%), and single-ingredient (77.5%) formulations were most commonly involved. AEs occurring in >20% of all cases included tachycardia, somnolence, hallucinations, ataxia, mydriasis, and agitation. Twenty cases (0.6%) resulted in death; most were in children <2 years of age (70.0%) and none involved a therapeutic dose. The overall reported AE rate was 0.573 cases per 1 million units (ie, tablets, gelatin capsules, or liquid equivalent) sold (95% confidence interval, 0.553–0.593) or 1 case per 1.75 million units. CONCLUSIONS: The rate of AEs associated with CCMs in children was low. Fatalities occurred even less frequently. No fatality involved a therapeutic dose. Accidental unsupervised ingestions were the most common exposure types and single-ingredient, pediatric liquid formulations were the most commonly reported products. These characteristics present an opportunity for targeted prevention efforts.

Adverse events associated with pediatric exposures to dextromethorphan

Abstract Study objective: Dextromethorphan is the most common over-the-counter (OTC) antitussive medication. We sought to characterize adverse events associated with dextromethorphan in children <12 years old from a surveillance program of OTC cough/cold medication exposures. Methods: This is a retrospective case series of oral exposures to dextromethorphan with ≥1 adverse event from multiple U.S. sources (National Poison Data System, FDA Adverse Event Reporting System, manufacturer safety reports, news/media, medical literature) reported between 2008 and 2014. An expert panel determined the relationship between exposure and adverse events, estimated dose ingested, intent of exposure, and identified contributing factors to exposure. Results: 1716 cases contained ≥1 adverse event deemed at least potentially related to dextromethorphan; 1417 were single product exposures. 773/1417 (55%) involved only one single-ingredient dextromethorphan product (dextromethorphan-only). Among dextromethorphan-only cases, 3% followed ingestion of a therapeutic dose; 78% followed an overdose. 69% involved unsupervised self-administration and 60% occurred in children <4 years old. No deaths or pathologic dysrhythmias occurred. Central nervous system [e.g., ataxia (N = 420)] and autonomic symptoms [e.g., tachycardia (N = 224)] were the most common adverse events. Flushing and/or urticarial rash occurred in 18.1% of patients. Dystonia occurred in 5.4%. Conclusions: No fatalities were identified in this multifaceted surveillance program following a dextromethorphan-only ingestion. Adverse events were predominantly associated with overdose, most commonly affecting the central nervous and autonomic systems.

Is the Oral Acetylcysteine Protocol the Best Treatment for Late-Presenting Acetaminophen Poisoning?

In this issue of Annals, Yarema et al present a comparison of an experience with an intravenous N-acetylcysteine protocol for acetaminophen poisoning and an oral protocol. Their model suggests that the 20-hour intravenous protocol that has been used in Canada and much of the world for 3 decades is better for early-presenting patients and that the 72-hour oral protocol commonly used in the United States until recently is better for late-presenting patients. Should we accept these findings? How should we change practice? Because the comparison varied 4 components of therapy simultaneously—N-acetylcysteine duration, total N-acetylcysteine dose, N-acetylcysteine dose delivery rate, and route of N-acetylcysteine—should we adopt all components of the oral protocol in late-presenting patients simultaneously? The authors went to great lengths to make this comparison valid. The numbers are large and the groups are fairly well matched. The comparative model attempts to adjust for key factors that might differ between the 2 protocol groups: age, sex, time from ingestion to treatment with N-acetylcysteine, acute and chronic ethanol ingestion, and acetaminophen concentration (dose). But there are still important limitations, given the different nature of the studies. Unlike all in the prospective PO study, many patients eligible for the retrospective intravenous study did not have end-of-treatment transaminase assessment. Twenty-five percent (n 2965) of eligible patients were specifically excluded because they did not have transaminase testing or they were not tested enough times to meet the study criteria. This suggests that there was something different about those who did meet that criteria— likely, they had higher initial acetaminophen levels, were more ill, or showed an initial increase in end-of-treatment transaminase level, ie, they had a higher prior probability of adverse outcome at whatever time they finished therapy. If this selection bias results in a difference in the proportion of patients in the late treatment subgroups who had experienced the outcome criteria, hepatotoxicity, before the onset of therapy (negating any potential effect of therapy) or even a difference in severity of injury at the initiation of treatment, intravenous