Tylenol and asthma

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n2b8me

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http://pediatrics.aappublications.org/content/early/2011/11/04/peds.2011-1106.full.pdf
Is this for real?
I am wondering if this has come up for anyone in their practice. Have you ever recommended not giving Tylenol to a child with a fever because of their asthma? Does this ever come up for adults?

There have been several studies associating Tylenol use with asthma symptoms, some suggesting that even occasional Tylenol use predisposes one to asthma. My husband and I both have pretty severe asthma, so I don't give Tylenol to my kiddo unless he is truly miserable. I'm just a lowly MS4 so I'm not sure how much I will apply this to future practice, but it certainly applies in my home.
 
I've never recommended against acetaminophen due to asthma, but the author is correct in stating there is some possible evidence for an association between acetaminophen use and exacerbation of reactive airway disease in these retrospective cohorts. The recommendation to use ibuprofen as an alternative is reasonable, however, it should simply be recognized that – like acetaminophen – its use probably also has some small, previously undetected adverse effect, as well. The ideal strategy is to minimize the importance of treating fever in children, thereby avoiding any medication issues.

It would be difficult to fault practice in which it were recommended that patients with RAD avoid acetaminophen.
 
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I've never recommended against acetaminophen due to asthma, but the author is correct in stating there is some possible evidence for an association between acetaminophen use and exacerbation of reactive airway disease in these retrospective cohorts. The recommendation to use ibuprofen as an alternative is reasonable, however, it should simply be recognized that – like acetaminophen – its use probably also has some small, previously undetected adverse effect, as well. The ideal strategy is to minimize the importance of treating fever in children, thereby avoiding any medication issues.

It would be difficult to fault practice in which it were recommended that patients with RAD avoid acetaminophen.

Association /= causality. The author is over-reaching in their recommendations. Everything he's saying may be true, but to go from retrospective cohort data to banning tylenol in asthmatic or at-risk for asthma kids is too broad a leap.
 
Association /= causality. The author is over-reaching in their recommendations. Everything he's saying may be true, but to go from retrospective cohort data to banning tylenol in asthmatic or at-risk for asthma kids is too broad a leap.

Yerp; hypothesis-generating. Needs prospective study with better control for possible confounders.

I still wouldn't argue with someone who practiced by saying "There is some possible evidence that Tylenol and asthma are linked. The data is not conclusive, and I am in the minority of physicians with my concerns, but I would suggest that you consider avoiding Tylenol use in your child."
 
I've found kiddos tolerate motrin better anyway prolly cause of the taste:) avoids the whole issue altogether.
 
I've never recommended against acetaminophen due to asthma, but the author is correct in stating there is some possible evidence for an association between acetaminophen use and exacerbation of reactive airway disease in these retrospective cohorts. The recommendation to use ibuprofen as an alternative is reasonable, however, it should simply be recognized that – like acetaminophen – its use probably also has some small, previously undetected adverse effect, as well. The ideal strategy is to minimize the importance of treating fever in children, thereby avoiding any medication issues.

It would be difficult to fault practice in which it were recommended that patients with RAD avoid acetaminophen.

:thumbup::thumbup:
 
I The ideal strategy is to minimize the importance of treating fever in children, thereby avoiding any medication issues.

The ideal strategy must be to minimize the importance of treating fever while not minimizing the importance of treating symptoms which result in too many kids in the ED...

An unnecessary ED visit (and all that goes into it including testing and medications and exposures) is far worse than a little APAP...

HH
 
"Until future studies document the safety of this drug, children with asthma or at risk for asthma should avoid the use of acetaminophen."

:eek::confused::eek:

Come on! Really?

I will have a very hard time reading the rest of this guy's biased article after such a statement of OPINION based - as best I can tell - on nothing but retrospective studies filled with confounding factors and selection bias. (...and nevermind the "biological mechanism of glutathione depletion" studies) [even if you don't mind all the poor methodology, the presented studies do not support this crazy conclusion)

The only motivation I can find right now is based on my presumption that I can tear this opinion apart after reading the studies he has included and pointing out that in no way to they support such a statement.

The editors at Pediatrics should be ashamed.

HH
 
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I've never recommended against acetaminophen due to asthma, but the author is correct in stating there is some possible evidence for an association between acetaminophen use and exacerbation of reactive airway disease in these retrospective cohorts. The recommendation to use ibuprofen as an alternative is reasonable, however, it should simply be recognized that – like acetaminophen – its use probably also has some small, previously undetected adverse effect, as well. The ideal strategy is to minimize the importance of treating fever in children, thereby avoiding any medication issues.

It would be difficult to fault practice in which it were recommended that patients with RAD avoid acetaminophen.

The ideal strategy must be to minimize the importance of treating fever while not minimizing the importance of treating symptoms which result in too many kids in the ED...

An unnecessary ED visit (and all that goes into it including testing and medications and exposures) is far worse than a little APAP...

HH

You guys (both academic types) - could you build up something on this? I mean, I keep reading it, and I am thinking about how I could try to do this, and I am coming up empty. I am thinking what I would say, and nada - bupkus. Throw me a bone here.
 
"minimize the importance of treating a fever"...but then what would the nurses harp about?
 
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I think this editorial makes a lot of suppositions to get to the author's very aggressive conclusion, that the dictum of non-malfeasence should cause us to limit APAP use.

He really glosses over the confounders. Kids with asthma will use more tylenol more often. His putative physiologic causation of decreased pulmonary epithelial glutathione levels needs a lot of bench research to see if it really happens and if it is physiologically significant before even considering prospective trials.
 
You guys (both academic types) - could you build up something on this? I mean, I keep reading it, and I am thinking about how I could try to do this, and I am coming up empty. I am thinking what I would say, and nada - bupkus. Throw me a bone here.

The point is to treat them if miserable. Otherwise, don't worry about it. Just like hypertension.
 
The point is to treat them if miserable. Otherwise, don't worry about it. Just like hypertension.

Exactly. The fever # doesn't mean much. If they're 103 and running around playing and happy then don't treat it. But if they're 102 and laying around mopey and miserable then tylenol/ibuprofen to the rescue.
 
The point is to treat them if miserable. Otherwise, don't worry about it. Just like hypertension.

But what do you say to the parents, as in the way Birdstrike pictured it?

Considering I've never been anywhere where nursing didn't give an antipyretic from triage to a ped fever, it would take quite a paradigm shift for me to change to a perception model where fevers didn't get treated if no one was aggro about it.

I mean, to me, it just seems counterintuitive to search for a cause of fever, without treating it. If anything looks like it would be grounds for a complaint (or bad PG), it would be "the doctor didn't do anything! My child didn't even get anything for his fever! Not even Tylenol or Motrin!" The parent writes a letter, and your director gets it, or they send it even higher in the chain, and it comes back to you, and what do you say? Complete honest truth is "the child had a fever, and I did not order anything to treat that fever". The next question is "why not?" That is my honest question.
 
Because they weren't seizing or suffering heat stroke. I give the "you don't have to treat fever" talk to parents of almost every child with fever.
 
Because they weren't seizing or suffering heat stroke. I give the "you don't have to treat fever" talk to parents of almost every child with fever.

But has nursing already given the patient an antipyretic?

I am asking a legitimate question. I am not trolling. If people can't give a logical reason for it, I am not going to be a convert. All it takes is one kid to have a febrile seizure, after I said that you don't have to treat fever, and I am forever and ever and ever going to recommend and order antipyretics. As it is, I haven't heard anything persuasive. I have given the "you don't have to treat fever" talk, but I have never dissuaded a caregiver from giving any Tylenol or ibuprofen. There is a difference.

You have responded, after a sort, so, thank you, but I would hope that the others that have advocated would clarify their statements.
 
But has nursing already given the patient an antipyretic?

I am asking a legitimate question. I am not trolling. If people can't give a logical reason for it, I am not going to be a convert. All it takes is one kid to have a febrile seizure, after I said that you don't have to treat fever, and I am forever and ever and ever going to recommend and order antipyretics. As it is, I haven't heard anything persuasive. I have given the "you don't have to treat fever" talk, but I have never dissuaded a caregiver from giving any Tylenol or ibuprofen. There is a difference.

You have responded, after a sort, so, thank you, but I would hope that the others that have advocated would clarify their statements.

Giving antipyretics won't prevent a febrile seizure
 
Giving antipyretics won't prevent a febrile seizure

That is an interesting way to word it, and it gave me pause.

From a lay public information sheet from NINDS, "If a child has a fever most parents will use fever-lowering drugs such as acetominophen or ibuprofen to make the child more comfortable, although there are no studies that prove that this will reduce the risk of a seizure." "No studies to prove" and "won't prevent" are quite separate. You are saying that a formerly febrile, now euthermic, patient that seizes is one that you are comfortable in "treating and streeting"?

And, I promise you, that WILL cloud the waters for many practitioners if the sequence is as follows: fever --> antipyretic --> defervescence --> seizure.
 
That is an interesting way to word it, and it gave me pause.

From a lay public information sheet from NINDS, "If a child has a fever most parents will use fever-lowering drugs such as acetominophen or ibuprofen to make the child more comfortable, although there are no studies that prove that this will reduce the risk of a seizure." "No studies to prove" and "won't prevent" are quite separate. You are saying that a formerly febrile, now euthermic, patient that seizes is one that you are comfortable in "treating and streeting"?

And, I promise you, that WILL cloud the waters for many practitioners if the sequence is as follows: fever --> antipyretic --> defervescence --> seizure.

There are multiple studies demonstrating that prophylactic treatment with Tylenol/Ibuprofen do not reduce the rate of febrile seizures. I can link them when I get a chance later, but our peds neurologists agree with it. There are also concerns about overdosing kids on antipyretics due to frantic concerns about bringing the temp down. The goal is to make the kid comfortable. Moreover, there is data suggesting that antipyretics also prolong the illness (though not by much), and that by allowing a kid to be febrile, it helps their bodies fight infection.

I generally give this speech to parents before sending them home and it's taken fairly well. I advise not worrying about a specific number, but if the kid feels hot and is miserable, give them a dose of something, then keep careful track of what you gave them. We send home typical febrile seizures quite frequently with this plan. And yes, it's often difficult to educate newer nurses about this idea.
 
until it worsens their bronchospasm....:laugh:;)

totally forgot that. well, guess we just have to give morphine to all asthma patients now who complain of pain. or maybe dilaudid. Start 'em off early.
 
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