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BLOG: August 2009

Pill-crushing children

Could you guess medication use in U.S. children younger than 12? If you're like me, you'd say: "Once in a while, when they get sick". Not a lot. Welcome to the real world. This young children are already well into the pill crush of the grown-up's world.

A recent random phone survey by Sloan Epidemiology Center in Boston (Vernacchio et al, Pediatrics 8/2009) of 2857 children age 0 to 11 across the 48 contiguous US states inquired about medication use within the previous 7 days. The results are as follows:

56% of the children used one or more medication
15% used 2
7.1% used 3
3.1% used 4 , and
1.9% used 5 or more.

Among them, 20% was taking 1 or more prescription-only medication. The most commonly used over-the-counter medications were

 acetaminophen and ibuprofen

(the study includes multivitamin, but it is hardly appropriate, since food and supplemental nutrients are not medications).

The most commonly used prescription-only medications were

amoxicillin, albuterol,

and multivitamins with fluoride (the latter, again, not a medication, but worth mentioning due to its fluoride content).

The most commonly used active ingredients were acetaminophen, iron, ibuprofen, and with cough/cold medications, pseudoephedrine, dextromethorphan, and various 1st-generation antihistamines.

While some of the above medications have become household items, and insomuch considered generally safe when used as directed, a closer look gives reasons for concern. You don't want your little one to "get used" to any of those. Here's why.

Acetaminophen, approved by FDA in 1951, belongs to a class of drugs called analgesics (pain relievers) and antipyretics (fever reducers). It comes under various brand names Excedrin, FeverAll, Genapap, Genebs, Goody's, Tylenol, and others. It also comes combined with many other drugs. It is among top painkiller drugs used in the US. According to the FDA, number of prescriptions for acetaminophen combined with narcotics alone is in billions.

The mechanism of action of acetaminophen is unknown (that's reassuring!).

 According to the U.S. National Library of Medicine, it can cause serious side effects ( http://www.nlm.nih.gov/medlineplus/ ). It is no wonder, since it has narrow therapeutic to toxic ratio. In other words, the effective dose is close to the dose that can harm you.

In fact, just this last June, the FDA advisory committee recommended putting

new restrictions on acetaminophen marketing.

That would include reducing the single maximum acetaminophen dose from 1,000 to 650mg, and lowering the current 4,000mg 24-hour maximum. The committee also voted to eliminate products combining acetaminophen with other drugs, as well as for limiting formulations of liquid over-the-counter acetaminophen to a single concentration level, to make it safer when given to children.

The main concern behind these recommendations was that the over exposure to acetaminophen creates real danger from its toxic effects, particularly liver toxicity.

A comment quite illuminating as to what we are talking about came from Marie Griffin, MD, professor of preventive medicine at Vanderbilt University, who said at the meeting that withdrawing acetaminophen combination products could make people

simply turn to plain narcotics.

She also said that practitioners don't feel they have many other choices. Well, that is probably true, but that doesn't mean that other, and better choices don't exist. Dr. Griffin, and practitioners that only know how to medicate, would certainly learn a lot from books such as "Pain Free In 6 Weeks" by Sherry Rogers, MD. No pills needed.

Next comes ibuprofen (also Advil, Motrin...). Here's what the U.S. National Library of Medicine has to say about it:

"People who take nonsteroidal anti-inflammatory drugs (NSAIDs) (other than aspirin) such as ibuprofen may have a higher risk of having a heart attack or a stroke than people who do not take these medications. These events may happen without warning and may cause death [...] NSAIDs such as ibuprofen may cause ulcers, bleeding, or holes in the stomach or intestine. These problems may develop at any time during treatment, may happen without warning symptoms, and may cause death."

Are you sure you want your little one taking this? This painkiller/anti-inflammatory has the same mechanism of action as the famous Vioxx - inhibiting COX-1 and COX-2 enzymes. Here's more detailed list of - only serious - side effects it can cause:

chest pain, weakness, shortness of breath, slurred speech, problems with vision or balance;

black, bloody, or tarry stools;

coughing up blood or vomit that looks like coffee grounds;

swelling or rapid weight gain;

urinating less than usual or not at all;

nausea, stomach pain, low fever, loss of appetite, dark urine, clay-colored stools, jaundice (yellowing of the skin or eyes);

fever, sore throat, and headache with a severe blistering, peeling, and red skin rash;

bruising, severe tingling, numbness, pain, muscle weakness; or

fever, headache, neck stiffness, chills, increased sensitivity to light, purple spots on the skin, and/or seizure (convulsions).

Amoxicillin, for a change, is antibiotic used to treat infections by microorganisms susceptible to its toxicity (middle ear, tonsils, throat, laryngitis, bronchitis, pneumonia, urinary tract, skin, and gonorrhea). Side effects due to amoxicillin include diarrhea, dizziness, heartburn, insomnia, nausea, itching, confusion, abdominal pain, easy bruising, bleeding, rash, vomiting, irritability, volatile mood swings, disorientation, aggressiveness and easy fatigue.

As all antibiotics, amoxicillin kills off friendly intestinal bacteria. As little as several days of use can cause chronic intestinal dysbiosis, with all its potential health negatives down the road.

It can also cause allergic reaction, including anaphylactic shock. The initial onset of such a reaction may be hard to distinguish from the common side effects, but can develop very quickly, requiring immediate emergency assistance.

Albuterol (or Salbutamol) is a known asthma medication. While it is helpful in suppressing asthma symptoms, long-term reliance on it is likely to worsen the underlying disease. It also can and does cause many adverse side effects.

Pseudoephedrine (PSE) is commonly used in over-the-counter decongestant drugs, either alone or combined with acetaminophen, ibuprofen and/or antihistamines. Common adverse reactions associated with pseudoephedrine include: insomnia, nervousness, excitability, dizziness and anxiety. Less frequent side effects include tachycardia and palpitations; infrequently, it causes cardiac arrhythmia, hypertension, colitis, severe skin reactions, systemic contact dermatitis, hallucinations, episodes of paranoid psychosis, seizures, and even stroke.

How's that for a little over-the-counter decongestant?

Dextromethorphan (DXM), a cough-suppressing ingredient in over 100 over-the-counter cold and cough medications (any with "DM" or "Tuss" in its name), is a semisynthetic morphine derivative. It is so routinely abused as a narcotic (so called "recreational drug") that it has secured place on the US Drug Enforcement Administration's list of Chemicals and Drugs of Concern.

While the official view is that it has "almost no psychoactive effects" at medically recommended doses, it becomes a bit more complicated in the real life. A single DXM dose is not supposed to be more than 0.16mg per pound of body weight, no more than 3-4 times a day. But can we reasonably expect that an OTC drug will be handled with such a meticulous care? Not really: "Here, take one more, it'll work faster".

And with so many combined medications containing DXM, tracking down its total intake becomes rather elaborate procedure.

Even 4 proper doses, added together, come very close to the the lower level of so called "first plateau" in its use as a street drug (affectionately called Orange Crush, Triple C's, C-C-C, Red Devils, Skittles, DXM, Dex, Vitamin D, Robo, Robo-trippin', Robo-dosing, Poor Man’s PCP, etc.) at about 0.65mg per pound of body weight.

But it is only an average. It is known that there are wide differences in the efficiency of metabolizing DXM. Slow DXM metabolizers retain it much longer in their system, and are so much more exposed to its effects. Additional risk factors are possible interactions with MAO inhibitors, or antihistamines, resulting in serious,

including life-threatening effects

(DXM should not be used if either has been used within the past 14 days).

Giving DXM to children younger than 4 is not recommended; over 4 years of age it is not recommended as primary treatment of cough - you should use honey instead (FDA recommendations 10/2008).

Why not just use honey?

Anyway, the step between accidental overdosing on DXM, and purposeful abuse is not a big one. In 2004 California Poison Control System report, about 75% of abuse cases are adolescents (9-17 years). Their 6-year retrospective study (1999-2004) showed

15-fold increase of DXM abuse cases among adolescents.

When abused as narcotic, DXM causes euphoria, psychedelic and dissociative behavior. Side effects include impaired judgment, loss of coordination, dizziness, nausea, seizures and panic attacks. If abused while using cold medications, other drugs or alcohol, DMX can and does - according to US Drug Enforcement Administration - cause coma and death.

Finally, the last of the most frequently used drugs by U.S. children 11 and younger, are antihistamines. Many allergy-suppressing OTC drugs contain antihistamines. Other than possibly causing dangerous interactions with some drugs (such as those containing DMX), antihistamines - particularly their 1st generation - often cause drowsiness, urine retention, dry mouth, blurred vision, and other adverse effects.

Do you really want that to your child? More attention paid to identifying and avoiding triggers, correct nutritional deficiencies, or using allergy-neutralizing injections when avoidance is not enough, sure seems to be a better choice.

Well, these are the drugs most commonly - and quite frequently - used by U.S. children 0-11 years of age. Aside the question why some of those drugs - in fact, nearly all of them - are freely available, the more important one is whether you want your child to use them too often, and too easily, for even minor complaints. Not only that it can do serious harm to a child, it can also victimize it for life by imbedding in its brain the blind mentality of "convenient" medicating, as opposed to practicing educated healthy lifestyle.