Self Care Pharmacy Blog

Archive for the ‘Pediatrics’ Category


Acetaminophen: Is it Really Your Safest Option?

Friday, November 6th, 2015

By Tori Bumgardner, PharmD Student Cedarville University

Acetaminophen has long been a popular over-the-counter product used to treat pain and fever in both adults and children (1). It is recommended to women as the preferred pain medication while pregnant. The FDA has been approved for dosing in individuals of all ages, from infants to adults, who may be suffering from pain or fevers (2). While it is known that acetaminophen causes liver damage to people who take it at high doses for an extended period of time, recent studies have investigated the possibility that it can lead to dangerous levels of toxins in the body, potentially increasing the risk of attention deficit hyperactive disorder (ADHD) and even autism (3,4). The buildup occurs when one of the metabolites of acetaminophen, N-acetyl-p-benzoquinone imine (NAPQI), inhibits the detoxification of reactive oxygen species (ROS) in the body (5). When ROS builds up, inflammation can occur, giving it the potential to cause ADHD or autism. Additionally, a meta-analysis was conducted looking at the correlation between use of acetaminophen during pregnancy and occurrence of asthma in offspring (6). The study found that mothers who used acetaminophen while pregnant increased the risk of their child developing asthma. This blog post will review the recent evidence on the dangers associated with pre-natal exposure to acetaminophen.

Image courtesy of David Castillo Dominici at

Image courtesy of David Castillo Dominici at

A study from 2014 examined the relationship between mothers who took acetaminophen during pregnancy and the subsequent occurrence of ADHD in their children (4). In this study, 1714 European children were followed for 11 years and their mothers were surveyed when the children were newborn, 1, 3.5, 7, and 11 years old. For the newborn interview, information on the mothers’ pregnancy was collected. The other interviews were focused on the child, paying special attention to cognitive development, behavior, and physical activity. In the final interview, at age 11, the children also completed and interview that asked about topics like behavior, emotions, and self-esteem. The investigators examined the relationships between different drugs that were taken during pregnancy with the results of the strengths and difficulties questionnaire that were completed throughout the study. Interestingly, it was found that the group who used acetaminophen showed higher difficulties and lower social scores. The findings of this study indicate that acetaminophen use during pregnancy is correlated with higher rates of ADHD in children. Limitations to the study included a low follow-up rate, lack of generalization since the study was specific to European women and their children, and a possibility of selection bias if both parents were already predisposed to ADHD. Authors concede that additional research should be done to determine the actual risks associated with exposing children to acetaminophen at young ages. Other data found that children whose mothers used acetaminophen while pregnant had a higher incidence of behavior problems and hyperkinetic disorders (HKDs) like ADHD during a follow up when the children were seven years old (7). Due to the safety concern in allowing pregnant women to continue taking acetaminophen, since research seems to suggest its harm, the FDA has begun looking into the issue (8).

Though research is not yet conclusive, they encourage women to talk to their healthcare providers before taking anything.While it is always a good recommendation to talk to a doctor first, what does that leave women to use when they are in pain, but don’t have time to see or call the doctor, and are left with no options to provide relief? There are certainly alternatives available that don’t include drugs and can help relieve pain caused by headaches and aching in other parts of the body. Sometimes headaches are caused by stress and can be helped by practicing relaxation through deep-breathing, yoga, or any other technique that is convenient and will divert their mind off stress-inducing stimulation (9). A regular sleeping schedule is also important and exercise can help to relieve headaches, so taking a nap or a walk are both ways to relieve stress and pain without taking medication. Pain in other parts of the body may be troublesome, but a gentle massage or an external, topical pain relief product can be used to help establish comfort.

The data is still uncertain on the magnitude of risk with acetaminophen use in pregnant women, it is best to err on the side of caution and avoid use if possible. At the end of the day, the question that is left is one of risk versus benefit. Since nothing is conclusive about the danger that acetaminophen may have on babies, is it ultimately worth the risk to use it as a quick fix for a couple of hours free of pain?



  1. Medline Plus: Trusted Health Information for You Web site. Published 08-15-2014. Updated 2014. Accessed October 16, 2015.
  2. DailyMed (package inserts). National Institutes of Health; National Library of Medicine. (accessed October 26, 2015).
  3. Jennifer Margulis PD. Could A common painkiller cause brain inflammation — and even autism — in children? Published 09-08-2015. Updated 2015. Accessed 10-16-2015.
  4. Thompson JMD, Waldie KE, Wall CR, Murphy R, Mitchell EA, the ABC study group. Associations between Acetaminophen Use during Pregnancy and ADHD Symptoms Measured at Ages 7 and 11 Years. Hashimoto K, ed. PLoS ONE. 2014;9(9):e108210. doi:10.1371/journal.pone.0108210.
  5. Shaw W. Evidence that increased acetaminophen use in genetically vulnerable children appears to be a major cause of the epidemics of autism, attention deficit with hyperactivity, and asthma. Journal of Restorative Medicine. 2013;2:1. Accessed October 26, 2015. doi: 10.14200/jrm.2013.2.0101.
  6. Cheelo M, Lodge CJ, Dharmage SC, et al. Paracetamol exposure in pregnancy and early childhood and development of childhood asthma: A systematic review and meta-analysis. Arch Dis Child. 2015;100(1):81.
  7. Liew Z, Ritz B, Rebordosa C, Lee P,Olsen J. Acetaminophen use during pregnancy, behavioral problems, and hyperkinetic disorders. JAMA Pediatrics. 2014;168(4):313-320.
  8. FDA drug safety communication: FDA has reviewed possible risks of pain medicine use during pregnancy. U.S. Food and Drug Administration Web site. Published 01-09-2015. Updated 2015. Accessed October 16, 2015.
  9. Krinsky D, Ferreri S, Hemstreet B, et al. Headache. In: Young L, ed. Handbook of nonprescription drugs: An interactive approach to self-care. 18th ed. Washington, DC: American Pharmacists Association; 2015:65-83-95. Accessed 10-16-2015.

Weighing in on Liquid Measurement Error

Friday, December 5th, 2014

By Bryan Feldmann, PharmD student

If someone were to ask you what the difference was between a teaspoon and a tablespoon, would you know what to say? You might have prescriptions from your doctor or medications you bought over-the-counter that tell you to take a number of tablespoons or teaspoons of the medication. A teaspoon will usually be abbreviated as “tsp” and tablespoon as “tbsp.” Because the two abbreviations look very similar, it can be easy to mix them up at a first glance. This can be a big problem, because it is so important that meds are taken exactly as directed.

You may already know what teaspoons and tablespoons are, but many people do not. Tablespoons and teaspoons are two different units of measurement. Similarly to gallons and liters, teaspoons and tablespoons are both used for determining how much volume something has (in other words, how much space it takes up). You will usually see units of volume used when your medication is a liquid.
So, how do these two similar units of measure differ? To begin, a teaspoon is smaller than a tablespoon. You can remember this by thinking of how big a table is compared to a cup of tea. In fact, tablespoons are three times larger than teaspoons. Now, just think about how dangerous it might be if someone accidentally took three times the amount of drug they were supposed to by mistake. According to a new study published by the American Academy of Pediatrics (medical care of children and teens) there are more than 10,000 calls to the poison control center every year because of errors patients made in how much of a liquid medicine they took.1 Just imagine the horror of the parents and caretakers being forced to call the emergency number because of an adverse reaction to a medication error. Since liquid medications are usually given to children, the study also specifically measured how many times parents made a mistake when pouring medicine for their kids. When they were supposed to measure with either teaspoons or tablespoons, they accidentally measured incorrectly 40% of the time, or 2 out of every 5 times!1 What can be done to fix this?

Teaspoon (tsp) and tablespoon (tbsp.) look so alike it is no wonder people can mix them up, but there is another common way to measure volume— the milliliter, or “mL.” A milliliter looks and sounds nothing like a teaspoon or a tablespoon, so it would stand to reason that people would not confuse it with anything else. There are 5 milliliters (mL) in a teaspoon, meaning there are 15 mL in a tablespoon.2 So milliliters are also useful for being more precise, since not everything must be in multiples of 5 milliliters. In another study, parents who had to measure medications in teaspoons or tablespoons were compared to those who measured in milliliters.3 The parents who were asked to use teaspoons and tablespoons were about twice as likely to make a mistake.3 287 single parents or pairs of parents were studied to get these results.3 This is a very small sample when compared to how many parents there are giving medications to children in the country, so more research should still be done.

Just mixing up the units is not the only reason these forms of measurement are so problematic, however. Many homes have kitchen teaspoons and tablespoons spoons just for measuring in teaspoons and tablespoons, but a study in the International Journal of Clinical Practice showed that the spoons that people have differ drastically from one another and are not accurate.4 Another study, published in the Archives of Pediatric and Adolescent Medicine, which is itself published by the American Medical Association, found that oral syringes and droppers are the best tools to use to measure volume and avoid error.5 300 parents were asked to measure out one teaspoon of acetaminophen with dosing cups, dosing spoons, oral syringes, and droppers. 70% of the parents made an error when it came to using the dosing cups with printed markings, and 50% made an error when using dosing cups with etched markings. More than a third of just these mistakes alone would have been highly dangerous overdoses if this study were not conducted in a controlled environment. According to the Institute for Safe Medical Practices’ reporting on this study, “Parents who make mistakes when using dosing cups are often confused about the differences between teaspoons and tablespoons.”6 Mistakes were only made 6% of the time when using a dropper, 10% of the time when using an oral syringe, and 14% of the time when using a dosing spoon. Keep in mind that a dosing spoon is different than a kitchen teaspoon or tablespoon, in that it is accurately calibrated to hold the amount it purports to, unlike the others, which have been shown to vary from spoon to spoon. So we can rest assured that it would be much safer to measure a number of milliliters in a liquid measuring device such as a dropper instead of simply trusting in one of these spoons. Additionally, it is not very easy to measure the exact amount of medication such that it is lying flat at the brim of the spoon without making a mess. This could be much easier if a dropper or oral syringe was used.

It would be great if milliliters replaced teaspoons and tablespoons on all drug labels over time, but at the moment we will likely continue to encounter all three units of measure. Armed with the knowledge of how much each unit represents and being careful when you’re reading instructions will decrease your chances of committing a liquid medication measurement error. As a future pharmacist, I would recommend always using a measuring cup or another device such an oral syringe over a spoon to measure tablespoons and teaspoons, even if the spoons say they are designed specifically for that purpose. Share these important tips with friends and family and always be careful in order to guarantee positive outcomes for yourself and your loved ones. And if you are a health care provider follow the link here to see ISMP’s recommendations for preventing liquid medication errors.

Have you ever mixed up tablespoons and teaspoons? Have you seen someone else mix them up? What steps will you take to avoid liquid medication mistakes?


  1. Schmidt C. Child medication measurements confuse parents. Published July 14th, 2014. Accessed November 6, 2014.
  1. Teaspoon v. tablespoon: What’s the difference? https://www.ismp/org/consumers/teaspoon.asp Updated 2014 Accessed November 6, 2014
  1. Yin H, Dreyer B, Ugboaja D, et al. Unit of measurement used and parent medication dosing errors. American Academy of Pediatrics. 2014;134(2).
  1. Falagas ME, Vouloumanou EK, Plessa E, Peppas G, Rafailidis PI. Inaccuracies in dosing drugs with teaspoons and tablespoons. Int J Clin Pract. 2010;64(9):1185.
  1. Shonna Yin H, Mendelsohn AL, Wolf MS, et al. Parents’ medication administration errors: role of dosing instruments and health literacy. Arch Pediatr Adolesc Med. 2010;164(2):181-186.
  1. Use an oral syringe or dropper to measure children’s medicines, not a cup.ismp.org Published June 2010. Accessed 12/02, 2014.

Will treating a fever lead to wheezing?

Monday, November 24th, 2014

By Aric Carroll, PharmD Student

A young child is very susceptible to getting sick, and with that sickness often comes fever. How do most parents treat their child’s fever? The answer for the past few decades has been acetaminophen. In many countries around the world, the first line drug approved for treating fever in children is acetaminophen.1 It has been estimated from one study that up to 75% of all children in Western countries are at some time treated with fever reducing drugs such as acetaminophen.2,3 In the United States acetaminophen use without a physician visit is approved for children as young as 2 years old.4,5 In the past decade, a lot of research has looked at a connection between the rise of acetaminophen use and the rise of asthma in young children.6

A recent study from the Journal of Korean Medical Science (JKMS)9 investigated the relationship between acetaminophen use and asthma prevalence, but took it a step further to try to see why acetaminophen use could be associated with the condition of asthma. The study particularly looked at a specific gene for a receptor in the body called toll-like receptor 4 (TLR4). This is one of the first studies to focus on the combination of TLR4 modification and acetaminophen use and the risk of asthma associated with that combination. In past studies, modification of the gene for TLR4 has been associated with a higher prevalence rate of asthma.7 It has been suggested that modification at this particular gene affects how the TLR4 functions. Modifications may cause the body to work harder at dealing with fine particles that are inhaled leading to physical symptoms associated with asthma.8 The authors of the recent JKMS study acknowledge that TLR4 facilitates the symptoms of asthma by contributing to the release of reactive oxygen species, which are molecules that cause excess stress on the body. This excess stress can then lead to the release of cells that cause inflammation, cause the airways to be inflamed, and cause bronchial hyperresponsiveness (BHR) or tightening of the airways. The study suggests that modification of the TLR4 gene could cause the receptor to be more abundant and lead to greater asthma symptoms.9

The study examined 2, 428 children aged between 8 and 13. The parents of each child were asked to fill out a questionnaire, which included questions about whether the child had used acetaminophen, and whether the child had been diagnosed with asthma. Tests were run on each child to determine a forced expiratory volume after a methocholine challenge, which is an indicator of BHR. Methocholine causes constriction of the airways. BHR to methocholine was defined as a PC20 (the concentration of methocholine re-quired to provoke a 20% reduction in FEV1) ≤ 16 mg/mL. Genetic tests were run on each child to determine modification of the TLR4 gene. The results showed that the use of acetaminophen was associated with risk of BHR; however, it was not associated with actual asthma diagnosis. Modification of the TLR4 receptor was not associated with asthma diagnosis or risk of BHR. A combination of acetaminophen use and TLR4 modification was significantly associated with asthma diagnosis as well as risk for BHR. The study concluded TLR4 gene modification may increase the risk of asthma in children who have used acetaminophen.9

While the study had a very large sample size of children, it had limitations that could have affected the study’s results. The study only looked at acetaminophen use in the past 12 months, but did not take into account whether children had used acetaminophen in earlier years. Also, the study looked at patients with a recall of an actual diagnosis of asthma in the children instead of asking about certain symptoms of asthma such as shortness of breath during physical exercise, wheezing, or increased coughing. Many children may have had symptoms of asthma but had never been diagnosed by a physician. The study also did not in any way establish a relationship between dose or duration of acetaminophen use. Acetaminophen use was defined as if they took acetaminophen longer than 3 days in the last 12 months. This was also solely based on patient recall. These limitations are significant and reduced the generalizability of the study. This type of observational study cannot determine a causative relationship. Thus, this kind of research can only suggest potential risks associated with exposure.

While this study, along with others, have evidence to support a relationship between TLR4 modification and asthma, other similar studies have not found this relationship.10 The conflicting evidence on this specific mechanism makes it hard to conclude one way or another whether TLR4 modification is directly linked to asthma symptoms. Also, at this time there seems to be a lack of sufficient evidence to directly link acetaminophen use to asthma symptoms. More prospective research needs to be done looking at acetaminophen use and its relationship with asthma symptoms specifically in combination with TLR4 gene modification. It may be possible that acetaminophen has a greater adverse effect on children who have a TLR4 gene modification which would increase the risk of asthma specifically in those children. With what evidence is available at this time, it is difficult to say that treating a child with acetaminophen will cause them to develop asthma symptoms.

So, what are your thoughts? Even with this possibility of acetaminophen use in children leading to asthma symptoms, do you think it’s still reasonable for acetaminophen to be used to treat a child’s fever?


  1. Gonzalez-Barcala F, Pertega S, Silvarrey A, et al. Exposure to paracetamol and asthma symptoms. European Journal Of Public Health [serial online]. August 2013;23(4):706-710. Available from: Food Science Source, Ipswich, MA. Accessed October 15, 2014.
  2. Jensen J, Tønnesen L, Söderström M, Thorsen H, Siersma V. Paracetamol for feverish children: parental motives and experiences. Scandinavian Journal Of Primary Health Care [serial online]. June 2010;28(2):115-120. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed October 16, 2014.
  3. Sullivan J, Farrar H. Fever and antipyretic use in children. Pediatrics [serial online]. March 2011;127(3):580-587. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed October 16, 2014.
  4. Reducing fever in children: safe use of acetaminophen. FDA Consumer Health Information. Published July 21, 2011. Updated June 6, 2014. Accessed October 15, 2014.
  5. Krinsky, D. L., Berardi, R. R., & Ferreri, S. P. (2011). Handbook of nonprescription drugs: An interactive approach to self-care (17th ed.). Washington, D.C: American Pharmacists Association.
  6. Farquhar H, Stewart A, Beasley R, et al. The role of paracetamol in the pathogenesis of asthma. Clinical & Experimental Allergy [serial online]. January 2010;40(1):32-41. Available from: Academic Search Complete, Ipswich, MA. Accessed October 15, 2014.
  7. Fagerås Böttcher M, Hmani-Aifa M, Vaarala O, et al. A TLR4 polymorphism is associated with asthma and reduced lipopolysaccharide-induced interleukin-12(p70) responses in Swedish children. The Journal Of Allergy And Clinical Immunology. September 2004;114(3):561-567. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed October 16, 2014.
  8. Kerkhof M, Postma D, Koppelman G, et al. Toll-like receptor 2 and 4 genes influence susceptibility to adverse effects of traffic-related air pollution on childhood asthma. Thorax [serial online]. August 2010;65(8):690-697. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed October 18, 2014.
  9. Lee S, Kang M, Hong S, et al. Association between Recent Acetaminophen Use and Asthma: Modification by Polymorphism at TLR4. Journal Of Korean Medical Science. March 2014;29(5):662-668. Available from: Science Citation Index, Ipswich, MA. Accessed October 10, 2014.
  10. Hussein Y, Awad H, Shalaby S, Ali A, Alzahrani S. Toll-like receptor 2 and Toll-like receptor 4 polymorphisms and susceptibility to asthma and allergic rhinitis: A case-control analysis. Cellular Immunology [serial online]. 2012;274(1-2):34-38. Available from: Science Citation Index, Ipswich, MA. Accessed October 18, 2014.

Proactive Use of Probiotics

Tuesday, October 28th, 2014

by Sarah Winey, PharmD candidate

According to the World Health Organization (WHO), two leading causes of death in young children, under the age of 5, are respiratory infections and diarrhea.1 Both respiratory tract infections (RTIs) and severe diarrhea are often caused by a bacterial infection, so an effective prevention therapy could reduce the incidence of these infections.  Currently, strategies are rarely employed for the prevention of these disease states, except avoidance of foods and conditions that may have an impact, such as fatty foods and environmental irritants. Avoidance of environment irritants can include avoidance of individuals who may carry infection and appropriate hygienic measures, such as hand washing. However, medical treatment frequently occurs only when the patient becomes symptomatic. The standard treatment for diarrhea involves fluid and electrolyte replacement or zinc supplementation, while the standard treatment for bacterial respiratory tract infections often involves antibiotic therapy.1 Probiotic therapy has been suggested as a potential preventative strategy for combating bacterial infections, including those associated with diarrhea and RTI’s.

Probiotics are live, healthy bacteria that are ingested in the form of a dietary supplement or cultured dairy products.2 The human body holds a significant amount of natural healthy bacteria in various locations, including the gastrointestinal (GI) tract.  When harmful bacteria enters the body, it competes for limited space with the healthy bacteria.  In the case of infection, the harmful bacteria overwhelms the system. The goal of probiotic supplementation is to overwhelm at risk areas, such as the GI tract, with healthy bacteria; in fact, the labeled dose is in terms of number of live cells or colonies, usually upward of one million.  In clinical testing, most patients do not experience side effects or experience only minor GI effects such as gas.3 According to current guidelines, probiotics have not been determined to replace standard treatment; nevertheless, the 2007 National Health Interview Survey found that probiotic-type products were the fifth most used natural product for children.3

In March 2014, the Pediatrics journal published a trial with the goal of determining whether a probiotic, Lactobacillus reuteri, had a significant impact on incidence of diarrhea in preschool children. The study was a forward-looking, random-sample, placebo-controlled trial (placebo- an identical substance to probiotic but has no effect) occurring from April 2011-June 2012 in four different day care centers in southeast Mexico City. The study population was comprised of healthy children aged six months to three years, born full term, and of similar socioeconomic status. The primary outcome, or goal, of the study was to determine if the number of days children experienced diarrhea was impacted by probiotic intervention. In addition, the number of days children experienced RTI’s, days of absence caused by diarrhea or RTI, days of antibiotic use, days of medical visits and cost impact due to intervention were studied. The study’s limitations included the possible lack of generalizability based on study location and choice of probiotic species.4

This study provided additional support to the theory that probiotic therapy can impact the prevention of bacterial infections, specifically diarrhea and RTI’s. The results showed that the intervention significantly reduced the incidence of both diarrhea and RTI.4 Additionally, the days of absence, number of medical visits, and antibiotic use were also significantly reduced as a result of probiotic intervention.4 Several other studies have found similar results. For instance, according to a Cochrane research review, probiotics were found to be a beneficial prevention strategy for infection; specifically, this study found that upper respiratory tract infection rate was reduced with probiotic use.5 Another research review of Randomized Control Trials (RCT’s) showed a decrease in duration and stool frequency as a result of probiotic intervention for diarrhea.6

In conclusion, probiotic therapy is a safe and seemingly effective for the prevention of respiratory infections and diarrhea.  This form of therapy may prove especially useful to parents of young children in daycare centers who are constantly in a crowded environment, which could lead to increased infection.  An additional option is the use of yogurt or other cultured dairy products, which also have the capability to reestablish normal, healthy bacteria in the GI tract. Currently probiotics are not an officially approved recommendation for children, should they be?


  1. World Health Organization.Children: Reducing mortality. Media centre: Fact Sheets Web site. Updated 2014. Accessed September 20, 2014.
  2. EBSCO CAM Review B. Probiotics. Salem Press Encyclopedia Of Health [serial online]. January 2014;Available from: Research Starters, Ipswich, MA. Accessed August 31, 2014.
  3. National Center for Complementary and Alternative Medicine. Oral probiotics: An introduction. 2012.
  4. Gutierrez-Castrellon P, Lopez-Velazquez G, Parra M, et al. Diarrhea in Preschool Children and Lactobacillus reuteri: A Randomized Controlled Trial. Pediatrics [serial online]. n.d.;133(4):E904-E909. Available from: Science Citation Index, Ipswich, MA. Accessed September 24, 2014.
  5. Hao Q. Probiotics for preventing acute upper respiratory tract infections. Cochrane Database Of Systematic Reviews [serial online]. July 26, 2011;(9)Available from: Cochrane Database of Systematic Reviews, Ipswich, MA. Accessed September 20, 2014.
  6. Applegate J, Fischer Walker C, Ambikapathi R, Black R. Systematic review of probiotics for the treatment of community-acquired acute diarrhea in children. BMC Public Health [serial online]. October 2, 2013;13(Suppl 3):1-8. Available from: Academic Search Complete, Ipswich, MA. Accessed September 1, 2014.

The Unexpected Dangers in Your Medicine Cabinet

Friday, October 24th, 2014

by Josh Knoebel, PharmD Candidate

Your doctor prescribes medications to help you control the pain you are feeling. The drugs do their job, and the pain gradually stops. This doesn’t prevent you from keeping the medicine though; after all, it was expensive, and who knows when you may need it again? This is a common scenario in many households, and a recent study published in Pediatrics: The Official Journal of the American Academy of Pediatrics confirms a concern many health professionals share regarding household medication management. The common opinion is to keep medication up and out of sight of children, but is that enough? As parents know far too well, children are not limited to what they can reach from the floor. If they see mommy put that “candy” in the cabinet, they may just try to climb onto the counter and get it themselves. The Center for Disease Control and Prevention (CDC) claims that more than 1.4 million emergency department visits were related to pharmaceuticals in 2011, and of the 41,340 drug overdose deaths in the United States, 22,810 (55%) were related to pharmaceuticals.1 Over 60,000 of these emergency department visits were for children six years or younger, and over 500,000 calls were made to poison control centers concerning these youngsters.2

Twelve specific active ingredients were found by the Pediatrics study that caused nearly half of the poisonings in the United States.2 Opioids (17.6%) and benzodiazepines (10.1%) top the chart as the classes of drugs with the highest number of poisonings. The twelve most common active ingredients of poisoning cases in children age six and under are listed in order of decreasing incidence:

  1. Buprenorphine (734 cases)
  2. Clonidine (701 cases)
  3. Glipizide (386 cases)
  4. Clonazepam (368 cases)
  5. Metoprolol (314 cases)
  6. Lorazepam (309 cases)
  7. Lisinopril (298 cases)
  8. Amlodipine (295 cases)
  9. Bupropion (265 cases)
  10. Glyburide (257 cases)
  11. Hydrocodone (252 cases)
  12. Oxycodone (249 cases)

The number of medication poisonings has continued to rise from 2004 to now3, a trend that is certainly reversible with diligence.

There are measures you can take to keep not only small children, but teenagers and adults alike safe from accidental medication poisoning. The first step is to make sure that all medications are kept in child-safe containers. Daily pill containers are convenient to remember medication use, but are often not child proof. Second, properly dispose of any and all out dated medications. Disposal of medications in the trash is not advised as they are still accessible to a curious child, or even the family pet. Contact your local pharmacist and ask about take back programs in your community.4 If there are no medication disposal programs available, there are three steps endorsed by the FDA for disposal in household trash. First, remove the medication from its original packaging and scratch out any personal information. This helps to protect your identity and sensitive health information. Second, make the medications unusable by mixing with inedible materials such as kitty litter, old coffee grounds, or sand. Lastly, put the mixture into sealable containers to prevent medication from falling out of the trash can.4

The most important change in preventing medication poisonings is to take your medications out of the medicine cabinet and keep them in a secure location. The best options are a lock box or a combination safe in a low traffic area of the house such as the bedroom closet. Ironically, the bathroom medicine cabinet is one of the least effective places to keep medications. Not only is it easy to access for children, but humidity from the bath or shower can damage the medications.5

What other preventative methods do you use with your medicine? Leave a comment below and let us know how you keep your medications secure!


  1. Paulozzi LJ. Prescription drug overdoses: a review. Journal of Safety Research. 2012;43(4): 283-289.
  2. Substance Abuse and Mental Health Services Administration. Highlights of the 2011 drug abuse warning network (DAWN) findings on drug-related emergency department visits. Substance Abuse and Mental Health Services Administration. /DAWN127/DAWN127/sr127-DAWN-highlights.pdf. Posted February 22, 2013. Accessed September 29, 2014.
  3. Lovegrove MC, Mathew J, Hampp C, Governale L, Wysowski DK, Budnitz DS. Emergency hospitalizations for unsupervised prescription medication ingestions by young children. Pediatrics. 2014;134(4): e1009-1016.
  4. Office of the Commissioner. Consumer updates – how to dispose of unused medicines. U.S. Food and Drug Administration. /ucm101653.htm. Posted December 24 2013. Updated May 19 2014. Accessed October 13 2014.
  5. Dugdale DC, Zieve D. Storing medication safely. Medline Plus. /medlineplus/ency/article/007189.htm Updated 3/26/2011. Accessed 10/22/2014.

Seeking relief when your child is coughing?

Wednesday, October 22nd, 2014

by Laura Farleman, PharmD candidate

Is your child’s nagging cough keeping you up at night? The honey in your kitchen may be the alternative to drug-laced syrups parents are searching for to calm their children’s coughs. The thick syrup nature of honey helps to soothe the throat and increase saliva, which can help reduce the urge to cough. Although not always severe, cough causes anxiety and disrupts sleep for parents and children. This drives many parents to seek immediate relief for their children. In recent years popular opinion has drifted toward the use of honey, but has research proven this golden nectar effective?

The current standard of care for cough in children under the age of 6 recommends talking to a doctor. In 2008, manufacturers voluntarily updated cough and cold product labels to state “do not use” in children under 4 years of age. There are few options available when treating cough in children under 4 years old without talking to a doctor. Main treatment options for children over the age of 4 have focused on cough syrups, such as Delsym or Benadryl containing dextromethorphan (DM) or diphenhydramine (DPH), respectively.1

Honey for acute cough in children, a Cochrane review published in June 2014 looked at the effectiveness of honey for cough in children compared to two commonly used cough medications. A Cochrane review is an organized review of primary research in human health care and health policy. It is recognized worldwide as the highest standard in evidence-based health care. In other words, Cochrane reviews provide the most reliable source for health care information. However, this Cochrane review is limited by only including two small studies each with high risk of bias. This review included two random-control trials involving 265 children (aged 2 to 18 years old) comparing the effect of honey to DM, DPH and ‘no treatment’ on cough relief.2 According to Honey for acute cough in children, researchers determined honey to be a better option than ‘no treatment’ and diphenhydramine (Benadryl) options. Honey was found to be equal to dextromethorphan (Delsym) for reducing frequency, severity, and impact of cough on sleep quality.2

The first study used for this review was published by Paul et al. in 2007, included 105 children (aged 2-18 years) and found honey to be a better option for treating cough than no treatment. Comparison of honey and DM did not show differences in the 2007 Paul study. 3 Compared to DM and no treatment, parents favored honey for relief of their child’s nighttime cough and sleep difficulty.3 The second study used for this review, Shadkam 2010, included 139 children (aged 2-5 years) with a cough and revealed that a 2.5-mL honey dose before sleep provided greater relief of cough compared to DM and DPH.1

A journal review by Dr. Ron Feise from 2008 about the Paul 2007 study stated that honey was better than no treatment for cough frequency, but DM was not a better treatment than ‘no treatment’.4 According to this journal review, DM used to treat childhood cough is not supported by the American Academy of Pediatrics (AAP)5 or the American College of Chest Physicians (ACCP)6. DM is associated with several adverse side effects in children, such as nausea, vomiting, constipation, and/or dizziness.7 In contrast, honey is generally recognized as safe with the exception of a severe form of food poisoning in children under the age of 1.8 Honey is not appropriate in this age group, because the bacteria in the stomach of infants (less than one year of age) has not fully developed.8 Honey provides a safe and effective option for children (1 year and older) over OTC cough and cold medications, which aren’t recommended for children younger than 6 years old.

Practically, what does this mean? The next time your child develops a cough you might consider grabbing some honey from the kitchen or local grocery store. When your child begins to develop a cough, start by giving your child (12 months or older) ½ teaspoon of honey (2.5 mL), or (if 2 years old or older) two teaspoons (10 mL) of honey. Honey may be taken/given as often as is needed to relieve coughing. The thick syrup of honey coats and soothes the back of the throat, while the sweet taste results in salivation, which thins mucus and reduces the urge to cough. Honey may also help the body fend off colds by alleviating cold symptoms and reducing the length of a cough or cold. In addition to honey, ensure your child drinks enough fluid and consider increasing your child’s intake of vitamin C.9

It is important though, to remember that coughing isn’t completely terrible. It’s the body’s way to clear mucus from the airway. If your child is otherwise healthy and sleeping relatively well, typically there is no reason to suppress a cough. If your child has a fever, prolonged or worsening cough, wheezing, or cold symptoms lasting longer than two weeks please talk to a doctor.10

Have you tried using honey for cough in the past? Did you find it effective? In the future, will you use honey to relieve coughing?



  1. Shadkam MN, Mozaffari-Khosravi H, Mozayan MR. A comparison of the effect of honey, dextromethorphan, and diphenhydramine on nightly cough and sleep quality in children and their parents. J Altern Complement Med. 2010;16(7):787-793.
  2. Oduwole O, Meremikwu MM, Oyo-Ita A, Udoh EE. Honey for acute cough in children. Evidence-Based Child Health: A Cochrane Review Journal. 2014;9(2):401-444.
  3. Paul IM, Beiler J, McMonagle A, Shaffer ML, Duda L, Berlin CM,Jr. Effect of honey, dextromethorphan, and no treatment on nocturnal cough and sleep quality for coughing children and their parents. Arch Pediatr Adolesc Med. 2007;161(12):1140-1146.
  4. Feise R. Journal review II. [commentary on] paul IM, beiler J, McMonagle A, shaffer ML, duda L, berlin CM jr. effect of honey, dextromethorphan, and no treatment on nocturnal cough and sleep quality for coughing children and their parents. arch pediatr adolesc med 2007. Journal of the American Chiropractic Association. 2008;45(8):20-1.
  5. Committee on Drugs. Use of codeine- and dextromethorphan-containing cough remedies in children. Pediatrics. 1997;99(6):918-920.
  6. Chang AB, Glomb WB. Guidelines for evaluating chronic cough in pediatrics: ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1 Suppl):260S-283S.
  7. Kelly LF. Pediatric cough and cold preparations. Pediatrics in Review. 2004;25(4):115-123.
  8. Grant KA, McLauchlin J, Amar C. Infant botulism: Advice on avoiding feeding honey to babies and other possible risk factors. Community Practitioner. 2013;86(7):44-6.
  9. SCHARDT D. Cold front. Nutrition Action Health Letter. 2014;41(2):11-13.
  10. Teitze, JK. Cough. In: Krinsky DL, Berardi RR, Ferreri SP, et al. Handbook of nonprescription drugs: an interactive approach to self-care. 17th ed. Washington, D.C.: American Pharmacists Association; 2012:205-215


Are you “Pro” Probiotic Supplements?

Thursday, December 5th, 2013

by Heather Evankow, PharmD student

In recent years, the popularity of probiotic supplements has risen. Probiotics are bacteria that help maintain the natural balance of organisms (microflora) in the intestine.1 The idea of probiotics is not a new concept. The idea was first developed around 1900 by the Nobel Prize-winning recipient Elie Metchnikoff. Metchnikoff theorized that the fermented milk products Bulgarian citizens ingested were a major factor in their longer life spans when compared with other countries.2 It was not until the year 1989 when R. Fuller popularized the term “probiotics”.3 Today, probiotics can be seen in the news claiming to improve the immune system, aid in skin health, defend against depression, clear up a bloated gut, prevent urinary tract infections, and even delay allergies.4

The Daily Herald recently released the article, Probiotics are all the rage, and experts say there are results behind the hype. The author, Gabriella Boston, Boston combines the opinions of several healthcare professionals to emphasize the health benefits behind the evolving topic of probiotics.

The first healthcare provider, Megan McCusker, is a dermatologist who believes probiotics are an important treatment therapy for treatment of anything from acne to psoriasis.4 While the Federal Drug Administration (FDA) does not approve any health claims for this supplement, McCusker could recommend 5-20 billion units per day depending on the patient’s needs. There were no clinical research references to show how McCusker developed these recommendations.

A nutritionist Boston featured, Jared Rice, also believes in the benefits of probiotics. Rice has not observed any downsides with his patients taking probiotics, but still advises patients to seek medical attention before taking high doses. Rice believes it is essential to buy the healthiest probiotic supplement. Also, he believes it is important to create a probiotic-friendly body by eating whole grains, bananas, and onions while steering clear of nondigestible carbohydrates.4 Unfortunately, there was no data referenced to confirm the benefits of Rice’s claims.

Ebeth Johnson, a nutritionist and chef, also gave her expert advice for this article. She believes this probiotic trend is here to stay. She encourages incorporating probiotics into your diet by consuming unpasteurized miso, live cultured pickles, tempeh, unsweetened kefir and yogurt, and kombucha teas.5 It is unclear how Johnson came up with these supplement sources. In addition, she also did not mention any specific research to validate the quality of these sources.

While the experts in Boston’s article seem confident in their recommendations of probiotics supplements, the clinical research is still limited for probiotics. The varieties of strains make it problematic in understanding the health benefits.

One of the most researched probiotic strains is Lactobacillus rhamnosus GG (LGG). LGG has been proven to help pediatric patients with pain-related gastrointestinal (GI) disorders in many clinical studies.5 In a 2011 meta-analysis, researchers systematically searched for randomized controlled trials assessing LGG supplementations in children with functional dyspepsia (FD), irritable bowel syndrome (IBS), abdominal migraine and functional abdominal pain (FAP).5 The major limitations for this analysis included incomplete outcome data and the number of trials with a small sample size. The results revealed a decrease in severity in pain with the overall study population and the IBS subgroup.5 The frequency was also decreased in the IBS subgroup.

Another hopeful probiotic strain is Streptococcus thermophilus VSL #3. A multicenter, randomized, placebo-controlled, double-blind, crossover study has shown VSL #3 to be successful and safe in helping the lives of children with IBS.6  59 patients from ages 4-18 years of age completed the study with no untoward adverse effects reported. Researchers found no significant difference was found in the stool pattern of patients, but abdominal pain, abdominal bloating, and family life disruption were all significantly more effective to the placebo.6

Have you had any encounters with probiotic supplements? Comment and share your experiences. Please include the main therapy goal, specific probiotic strains, and the dosage.

If you have had no experience with probiotics, based on the information above, would you personally try probiotic supplements? Share your rational.


1. “Probiotics – Topic Overview.” WebMD. Healthwise, 04 FEB 2011. Web. 29 Nov 2013. <>.

2. Parvez, S. and Kang S. “Probiotics and their fermented food products are beneficial for health.” Volume 6. Web. 29 Nov. 2013. <>.

3. Ouwehand, A., S. Salminen, and E. Isolauri. “Probiotics: an overview of beneficial effects.” Vol 82.Issue 1-4 (2002): 279-289. Web. 29 Nov. 2013. <

4. Boston, Gabriella. “Probiotics are all the rage, and experts say there are results behind the hype.” Daily Herald. N.p., 28 Oct 2013. Web. 29 Nov 2013. <>.

5. Horvath, A., P. Dziechciarz, and H. Szajewska. “Meta-analysis: Lactobacillus rhamnosus GG for abdominal pain-related functional gastrointestinal disorders in childhood.” Alimentary Pharmacology & Therapeutics. Vol 6.Issue 12 (2011): 1302-1310. Web. 29 Nov. 2013. <>.

6. Guandalini S., G. Magazzu, and A. Chiaro. “VSL#3 improves symptoms in children with irritable bowel syndrome: a multicenter, randomized, placebo-controlled, double-blind, crossover study.” J Pediatrics Gastroenterol Nutr. 2010 Jul;51(1):24-30. Web. 04 Dec. 2013.

Over the Counter Probiotics May Be Able to Sooth Baby’s Colic

Thursday, December 5th, 2013

by Mallory Martin, PharmD student

This article posted by the BBC, “Probiotics ‘soothe some babies with colic’”,1 explores an option into easing or possibly preventing your baby’s colic. The article describes an analysis of 12 studies looking into probiotics as a treatment for colic. The analysis was done by a team of scientists in Australia and reported in the Jama Pediatrics Journal. However the article didn’t cite where in the journal this article was found. This seemed uncharacteristic and it made it difficult to evaluate their findings. All this aside, their findings were quite exciting because although colic is not a harmful condition to babies and resolves itself after 3-4 months1, it can be quite stressful for caretakers. An option for soothing baby’s colic would be highly valued for this reason.

When attempting to sooth colic, parents can be scared away by ambiguity, not wanting to give something to their baby unless it is proven. “Research shows” is a phrase that may be thrown around a lot, but what people really want to know is whether a treatment is safe for their child and if it is effective. Taking these people into consideration and with the incomplete citation by the BBC article, I wanted to explore several articles published on this topic in an attempt to come to a conclusion on whether or not to recommend probiotics for colic.

Probiotics must first be understood on their own before exploring them as a treatment for colic. Probiotics are a mixture of different microorganisms that when orally ingested are considered to have several overall health benefits.1 The word itself means “promoting life”.2 They generally have very low risk in normal adults because the cultures so closely resemblethe natural flora of the gut. 3 Probiotics are also naturally present in food. Some foods that contain probiotics are fermented vegetable such as sour kraut and most commonly yogurt.2 Probiotics contain many different types of bacteria but among the most common is Lactobacillus reuteri. It is this strain of bacteria that is considered to have the most health benefits. 2

Certain health benefits have been discovered with probiotic use. Probiotics, L. reuteri specifically, has been shown to lower LDL levels, kill bacteria that causes tooth decay, lessen the harmful effects of gingivitis, and lower your likelihood of developing episodic diarrhea or traveler’s diarrhea. Some reports even show that this bacterium can lessen a child’s risk of developing eczema through probiotic-filled breast milk. Studies in women’s health showed that it may help balance the bacteria present in the vagina and lower the risk of yeast infections, bacterial vaginosis, and urinary tract infections. Some additional benefits include its ability to reduce upper respiratory infections when compared to placebo, provide relief to baby’s colic, and reduce bloating and gas.2

Although the results are promising, research in this area is not concrete. Probiotics may have both risks and benefits for different people. Risk for special populations, such as small children and older adults, is unclear since there is little to no research done on these groups.2 So far, healthy, full-term babies who have received high doses of probiotics have not presented with any negative effects.4 However there is some evidence that young children who are pre-term or not fully healthy, such as children with weakened immune systems, catheters or other medical devices inside them, may be at risk if taking probiotics.4 When considering L. reuteri in treatment of colic, one study by Savino concluded that it is inconclusive whether L. reuteri reduces colic but it appears to reduce levels of harmful E. coli. 5,6 Savino performed a follow up study after comparing L.reuteri with simethicone and compared the bacteria against a placebo in treatment of colic.7 This study had a better study design for its desired outcome because the infants involved were chosen based on Wessel’s Criteria, a more systematic approach than the first study. The results concluded that L. reuteri DSM 17 938 at a dose of 108 colony-forming units per day in early breastfed infants improved symptoms of baby’s colic and was well tolerated and safe.7 Some factors that could contribute to the varying results in these studies include the differences in the care the infants received in different homes and different study designs. An article put out by Fox News article reported on this as well. The conclusion was that probiotics may not be effective. However in young infants, they can potentially reduce risk of asthma and eczema.4 This positive effect, while unrelated, is something to consider when evaluating probiotics for your child.

Considering all this information, I would recommend probiotics as a means of treatment for infantile colic. The best option would be for a nursing mother to start a regimen of daily probiotics and allow the probiotics to transfer through the breast milk. However, L. reuteri is available for infants to ingest. Gerber has a colic relief drop that specifically has L. reuteri in it which includes sunflower oil. Gerber also has a powder for formula around 30 dollars for 24 ounces. BioGaia has a straight L. reuteri drop for around 20 dollars for 5 mLs. There are options. Even if it may not be 100% guaranteed to be effective, if your colicky baby is becoming too much to handle and you have tried many other options, I would say it is worth a try. Especially considering no bad effects have been found and several unrelated positive effects have been suggested. Probiotics would be a safe and natural way to go in your attempt to soothe your baby and get a good night’s rest yourself. Some may not agree with me. With the lack of research and uncertainty, risks could exist. Just because no negative effects have been found does not mean that it is completely safe. Would you take that risk with your own child?


1. Roberts, M. Probiotics ‘soothe some babies with colic’. The BBC. October 7, 2013. Accessed December 3, 2013.

2. Maier, R. Surprising Benefits of Probiotics. Healthine Web site. April 13, 2013. Accessed December 3, 2013.

3. Probiotics – Topic Overview. Webmd Web site. February 04, 2011. Accessed September 15, 2013.

4. Rettner, R. Are Probiotics Safe for Kids?. Livescience Web site. October 06, 2011. Accessed December 3, 2013.

5. Woznicki, K. Probiotics May Reduce Crying From Colic. Webmd Web site. August 16, 2010. Accessed October 15, 2013.

6. Savino F, Cordisco L, Tarasco V, et al. Lactobacillus reuteri DSM 17938 in infantile colic: a randomized, double-blind, placebo-controlled trial. Pediatrics. 2010;126(3):e526-33.

7. Savino F, Pelle E, Palumeri E, Oggero R, Miniero R. Lactobacillus reuteri (American Type Culture Collection Strain 55730) versus simethicone in the treatment of infantile colic: a prospective randomized study. Pediatrics. 2007;119(1):e124-30.

Keeping Kids While Traveling: Medicate or Not?

Saturday, November 16th, 2013

By Jesse Hickey, PharmD Student Cedarville University

 Parents often use self-care methods and OTC medication to help control a child’s behavior, especially when faced with situations where the child needs to be quiet.  However, this off-labeled use of medication for its side effects can be dangerous.  The main side effect most parents look for is drowsiness.  Some adults know what medications to use for self-care, but children are essentially blind to what their parents give them.  Unfortunately, it seems like the parents are unaware of the risks themselves.  According to an article, “Should parents drug babies on long flights”, some parents are using diphenhydramine (Benadryl®) to put their children asleep.  A parent referenced in the article stated, “Children accept their parents’ handouts without question not knowing the potential risk.”1 Parents want their infants or toddlers to be comfortable and to help with jetlag.  In American society today, many people understand that diphenhydramine will cause drowsiness or sleepiness in most patients and people use it all the time for this reason.  Therefore, many parents already have an underlying assumption that diphenhydramine is a safe and effective drug to put babies or toddlers asleep.  Not all parents, however, feel the same way about the use of these medications.  Some parents feel that the use of these medications is an abuse of parental power.1  The stance of the article seemed to fair against the use of medications due to multiple reasons suggested by parents and doctors.  In a clinical study on diphenhydramine’s effects on children, the researchers noted the drug’s ability to cross into the blood brain barrier causing a more potent effect on the central nervous system.2  Therefore, diphenhydramine can stimulate the central nervous system causing irritability, restlessness, and nervousness.2  Furthermore, using this drug irresponsibly can be deadly because children have also died by the misuse of the drug.3

First generation antihistamines such as diphenhydramine are well known for their drowsiness effects.3  One parent noted, however, that their child could not fall asleep and felt miserable throughout the trip similar to the clinical trial noted earlier.1 The use of diphenhydramine to drug a child is not only an abuse of parental power but, furthermore, a misuse of a drug.  Parents should also be aware of the child’s tolerance of the drug.  The article noted that the worst place to have a reaction is in the air away from medical attention.1  When diphenhydramine is used for its intended purpose to stop an allergic reaction, the use of the medication is much safer.  Diphenhydramine is a well-established antihistamine that is still a great option when used appropriately for allergic reactions.3  I believe parents need to be simply aware that a drug should not be used for its side effects but simply for its intended use.  The chances of having an adverse effect outweigh the need to sedate a child.  Other methods can be used to help a child sleep or keep them busy during a trip such as keeping the child up before the trip or even giving them something to do to keep them occupied.  If the child is still restless on the plane, try using soft, mellow music to encourage sleeping and avoid distracting sounds.

Unfortunately, Morris’s article and clinical studies have certain limitations that need to be addressed.  No studies have researched how many parents actually give their children diphenhydramine for drowsiness.  Furthermore, this article does not address if all the parents understood how to dose their child’s medication by weight.  Without the proper dosing, parents could be overdosing their children causing some of the reactions addressed earlier.  Another online article by Pediatrician Jennifer Shu, Is it safe to sedate my baby for travel, discussed the same issue with diphenhydramine and came to similar conclusions.4  She suggested against the use of diphenhydramine for drowsiness due to the possibility of hyperactivity.4  She also stated, “Even more important is that, with any medication, there can be dangerous side effects, such as a fast or irregular heartbeat, seizures, and changes in blood pressure.”4  If there are so many negative effects possible with misusing diphenhydramine for its side effects, why aren’t health care providers more involved in addressing this issue to parents?




  1. Morris R. Should parents drug babies for long flights? April 2, 2013.  Accessed September 27, 2013.
  2. Chae KM, Tharp MD. Use and safety of antihistamines in children. Dermatologic Therapy. 2000;13(4):374-383.
  3. Berardi R, Ferreri S, Hume A, et al. Disorders related to colds and allergies. In: Handbook of Nonprescription Drugs. Vol 17. 17th ed. American Pharmacists Association; 2012:195.
  4. Shu J. Is it safe to sedate my baby for travel? Baby Center: Expert Advice. Accessed September 27, 2013.