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    Avoid acetaminophen use in children with asthma

    When it comes to the possible link between acetaminophen and asthma, the most prudent response might be “primum non nocere,” or “first, do no harm.”

    That’s the advice offered in a review of recent clinical studies on the issue. Acknowledging the challenge facing pediatricians, policy makers, and professional organizations in the absence of incontrovertible evidence, John T. McBride, director of the Robert T. Stone, MD, Respiratory Center at Akron Children’s Hospital, advocates that physicians “give particular weight to avoiding harm” and advise any child with asthma or a family history of asthma to avoid using acetaminophen.

    In advocating acetaminophen avoidance, McBride noted that nonpharmacologic approaches or ibuprofen treat most children with fever or moderate pain as safely and effectively. Furthermore, “studies have documented such a strong association between acetaminophen exposure and asthma that it is possible that much of the dramatic increase in childhood asthma over the past 30 years has been related to the use of acetaminophen,” he wrote.

    The most recent epidemiologic study on the subject, Phase 3 of the International Study of Allergy and Asthma in Childhood, involved 122 centers in 54 countries, each with at least 1,000 enrolled children. Researchers reviewed data on 200,000 children aged 6 to 7 years and 320,000 children aged 13 to 14 years and found a dose-dependent increase in the prevalence and severity of asthma in both groups.

    Across all cultures, geographies, and stages of economic development, the risk of current asthma was 1.61 times more likely in children who took acetaminophen more than once a year but less than once a month and rose to 3.23 times in those who took the drug at least once a month. In the older group, the risks were 1.43 and 2.51, respectively. On the basis of these results, researchers estimated that eliminating exposure to acetaminophen would reduce the incidence of asthma by 38% in 6- to 7-year-olds and 41% to 43% for wheezing or severe asthma symptoms, respectively, in 13- to 14-year-olds.

    A prospective study among children supports the epidemiologic findings. The Boston University Fever Study randomly assigned 84,000 febrile children to 1 of 3 groups for treatment: low-dose ibuprofen, high-dose ibuprofen, or acetaminophen. The 1,879 participants with preexisting asthma were evenly distributed among the groups. Asthmatic children with respiratory infection treated with acetaminophen were 2.3 times more likely to require a subsequent outpatient asthma visit than those treated with ibuprofen.

    McBride concluded that on the basis of the current evidence, further studies are needed “not to prove that acetaminophen is dangerous but, rather, to prove that it is safe.”

    Go back to the current issue of the eConsult.

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