Acetaminophen use in pregnancy linked to child's behavioral problems
latimes.com
latimes.com
I've read the actual referenced paper and not the LA times piece.
This type of research is hypothesis generating. As they acknowledge, this shows a correlation, not causation. The big question here is why were these women taking paracetamol/acetaminophen? Was it the drug or the cause of their pain/fever/discomfort that is more relevant to the outcomes observed?
As part of a cohort study, this was just one outcome measured. It is not clear to me whether this was a outcome measure they had intended to analyse from the outset or whether it was post-hoc. This makes a huge difference to the credibility of the finding
With regards to the relative safety of paracetamol and ibuprofen, well, they are totally different drugs. For most healthy, young people, in short courses both will cause little harm, with paracetamol having the edge in safety. Ibuprofen causes significant, undetected kidney and gastrointestinal injury. Paracetamol can cause liver failure, but generally only in overdose, prolonged use or when associated with poor nutritional intake. A healthy person taking the odd dose will not develop liver toxicity. Prolonged administration of ibuprofen will invariably cause damage. For paracetamol it is less clear.
Source: I prescribe and manage these drugs and their side effects daily. Pain management is a core part of my day job.
Some commenters here seem to like codeine. It should be considered at least as dangerous as morphine (which it is metabolised to). Depending on your genetic background, you may poorly metabolise codeine (causing it to be ineffective), or you may metabolise codeine too effectively (causing it to cause respiratory depression, low oxygen levels and possibly death). The tide is gradually moving against it[2], but not quickly enough in my opinion.
With all pain, the safest treatments don't involve drugs.
[1] http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm [2] http://www.nps.org.au/publications/health-professional/healt...
https://rcoa.ac.uk/faculty-of-pain-medicine/opioids-aware
The medical community tends not to talk about addiction, but tolerance.
People prescribed opiates for long term pain develop a tolerance for those opioids, and thus need more to get the same pain relief effect.
Those patients then end up on very high doses of multiple opiates (which is almost certainly causing them harm, and poses significant risk of suicide, or accidental death (of them or people around them)) and still in pain.
People with long term pain deserve better treatment - rapid access to pain management clinics; access to the wide variety of meds combined with psychological therapy and home adaptations. And, yes, opioids if those are the right choice.
Frankly, I think the summary in that article is a little irresponsible: selling your research a little is normal, but this really asks to be misinterpreted.
Edit, the article summary I'm referring to is:
Children exposed to acetaminophen prenatally are at increased risk of multiple behavioral difficulties, and the associations do not appear to be explained by unmeasured behavioral or social factors linked to acetaminophen use insofar as they are not observed for postnatal or partner’s acetaminophen use. Although these results could have implications for public health advice, further studies are required to replicate the findings and to understand mechanisms.
According to the article:
"Finally, the authors of the study acted to avoid a common problem with research that links adverse pregnancy outcomes to certain medications: that women whose children have some identifiable problem are more likely to recall taking medications during pregnancy. The current study asked women when they were pregnant about their medication use, and then — seven years after her child’s birth — asked her to assess her child’s emotional and social well-being and report a range of problematic behaviors."
No, it's perfectly valid for a drug to only have affect on the growing fetus but where there were not studies proving harm to the child or adult, e.g. Thalidomide.
[1] http://www.ajog.org/article/S0002-9378(10)02524-X/abstract
Fun Hypothesis: There exists an underlying latent variable that determines both of these. It takes the form of a negative affect activation function; ie. at some level of pain/annoyance we start to consider the source a problem and look for solutions. Adding this latent variable to the analyses would mediate the relationship between acetaminophen use and the child's behavioral 'issues'.
The authors do address this a bit with:
"They looked for a link between a child’s behavioral problems at age 7 and his or her mother’s post-natal acetaminophen use, and found none."
I would not suppose that this activation function is linear which may confound the authors attempt to control for this.
http://www.mayoclinic.org/diseases-conditions/liver-failure/...
The tricky thing with acetaminophen is that it is included in products without adequate warning. If I'm sick, I have a headache and take 2 tylenol, plus cold medicine, plus whatever, and BAM I've killed my liver because those 3 things all had acetaminophen in it. The tipping point between being 100% healthy, and 100% needing a liver transplant is really narrow.
http://www.dailymail.co.uk/news/article-2064964/Warning-hidd...
http://www.esquire.com/lifestyle/health/a235/esq1103-nov-bod...
Nevermind what acetaminophen does to fetuses, this drug needs to be treated with a lot more caution. I have dialed my intake waaaaaaay back. I'm sure my liver is happier with me.
If you take tylenol, make sure you take no more than the suggested dose. Make sure you aren't getting duplicate dosing bundled with other medications. Make sure you don't routinely take it longer than the bottle dose instructions indicate.
When in real pain, I combine half a regular acetaminophen dose with the regular ibuprofen. Works miracle since the two have different acting mechanisms and they are safe taken together or so I've been told by my doctor. Oh, and a little caffeine will further boost the effect for some reason.
But yes, acetaminophen ridden medication is dangerous, especially with flu and cold stuff since we can be in quite a confused state when sick. I always select a product without acetaminophen when possible.
Relevant to the article, ibuprofen is a pregnancy category D drug, which is basically "do not take this, period". It substantially increases the chance of heart and lung issues in the child, reduces amniotic fluid levels, and puts the mother at severe risk of excessive bleeding during delivery. Thus, if you're in need of pain management when you're pregnant, acetaminophen tends to be the go-to recommendation.
Personally, I take Excedrin for the occassional headache, because the combination of acetaminophen/aspirin/caffeine reliably kills my headaches in a way that ibuprofen doesn't. Ibuprofen tends to be my go-to for anything inflammation-related.
I also had no idea the overdose margins were so thin. I’ve taken a shit ton of Excedrin Migraine over my life. And Theraflu. And double doses of Excedrin Migraine after a does of straight aspirin or Tylenol didn't work alone.
Given the easy ability to overdose, I am of the opinion that acetaminophen should be sold singly and not in combination with anything else. Even if that means Excedrin Migraine doses come in a two pill combo. This way, people could easily calculate a total daily dose without it being in an unexpected product.
It's a miracle I still have a functioning liver.
Unless they are marketed very misleadingly (possible - opiates get tons of bad press, Tylenol doesn't), seems like you have zero reason to complain. You voluntarily consumed medications without even reading through the basic info that's on the box!
Splitting into two pills? Why would that work? Presumably most people will take both, so the packaging needs to reflect that. It helps nobody except people that are aware enough to know they want the caffeine but not acetaminophen, but not to just buy such a product in the first place.
When the word got out about tylenol and liver damage, one of the causes they cited was the same situation as above - multiple drug compounds. Migraines. Folks thinking tylenol was the safe choice, impossible to overdose on. Folks generally think the stuff on the shelf is really, really safe.
It isn't like they teach this stuff in school. While I might have known to look out, I didn't always know this. And if this sort of information misses you when it was the 'big news'... well, out of luck.
I'd much rather the products be in different pills most of the time as I think it means consumers might think a bit more about what they take and match it up with symptoms. Either that, or have many be only available without receipt after asking pharmacist or trained personel.
I had a mix of stuff purchased from a couple of different countries and in 2-3 languages. So yeah label reading was a bit of a challenge.
Migraine sufferers are sort of known for desperate self medicating. Not an excuse but it happen.
There are different formulations of Excedrin (ex: Migraine Tension has no aspirin) but the Migraine formula is identical to the regular formula.
https://www.theguardian.com/business/2015/dec/14/nurofens-ma...
- why did you stop? If you're an otherwise healthy person (not an alcoholic or don't have liver disease) then paracetamol is a great drug. A low level anti-inflammatory that doesn't cause GI upset or have anti platelet action
My understanding was that the biggest risk of Acetaminophen is that it's easy to overdose and it's relatively safe when one knows that and stays well below the safety limits (and likely with less side effects than ACC and Ibuprofen).
But the bottom line is probably that all painkillers have risks and one should avoid taking too much of them and consult a doctor if one takes them on a regular basis.
Because taken properly, its often the safest drug for pain and/or fever reduction there is? NSAIDs aren't exactly without risks, either, after all.
(The dangers are mostly from people either deliberately taking more than the recommended dose, or doing so accidentally by combining different multi-drug products without realizing that they all contain acetaminophen.)
PS. Don't walk on the ankle just because you don't feel the pain! You can turn a 3 month recovery into a 2 year recovery if you do that.
My father fell off a roof, feet first, onto hard clay and shattered his feet. Doctors said he'd never walk again and it took awhile to find and cajole a doctor to pin his bones back together. He's been on his feet for well over ten years.
The pain is still excruciating, though. 24/7. He refuses prescription pain medication, and has been eating ibuprofen like candy for the entire time. His hearing is bad, but not much different than typical old-man hearing, especially considering he used a skill-saw for most of his life.
There are plenty of bad things ibuprofen is capable of. But the point of my anecdote is that the actual risk is, relatively speaking, much less than you'd think. Consumer warnings lead us to equivocate risks when in fact relative risks can be worlds apart. Look at the actual studies and make informed decisions. I'll run things past a doctor or pharmacist for anything serious or if it involves a child, but 9 times out of 10 they'll know nothing more than the literature and the commonly understood exceptions and unknowns. They always give me the thumbs up for my over-the-counter, make shift drug formulations.
Regarding acetaminophen, I always told my wife during her pregnancy that she should only take as little as necessary, if at all, but of course she shouldn't needlessly suffer. I'm only just learning about this new research, but it's been obvious to me that the safety of acetaminophen has largely been based on a lack of contrary evidence and by the level of comfort that comes with group-think. Like Microsoft, nobody ever got fired for prescribing Tylenol (the brand name in the U.S.). In medicine absence of evidence often is evidence of absence, but only in so far as people have been paying close attention, and only in so far as alternatives have been explored.
But ibuprofen has gotten an undeserved bad rap in the U.S., and in some other countries requires a pharmacists' prescription. That's ridiculous. It seems we're much too risk adverse when it comes to ibuprofen, while dramatically underestimating the risk of acetaminophen. If anything the situation should be the reverse. OTC acetaminophen causes incredible harm. The biggest risks for ibuprofen relate to interactions with other, invariably prescription, medicine, and so there's ample opportunity to inform people to avoid ibuprofen.
Some people would like laws to restrict the sale of both. IMO trying to bifurcate medicines into safe-at-any-dose, OTC and prescription medicine has caused caused both medical professionals and regular consumers to lose our critical faculties. It's caused OTC medicines to become ineffective. And it's caused prescription medicines to become too widely prescribed and abused when people and situations fit the letter of the marketed indications. In both cases professionals and non-professionals aren't thinking as critically as they should, and aren't taking into account how little we actually often know about this stuff. It also substantially increases the cost of care.
> He [...] has been eating ibuprofen like candy for the entire time
That's not a ringing endorsement for this wonder drug.
The pain in his feet comes from the severe arthritis. Ibuprofen only helps to moderate it a little. AFAIU, for something like arthritis ibuprofen is much more effective than acetaminophen, and safer than naproxen for prolonged use.
But it's so severe that significant relief could only come from serious pain medication, which he refuses. He's seen too many people become addicted. The stress levels from the pain probably aren't doing his body any favors, but it's his decision.
The short of it: NSAIDs inhibit chemical processes the body uses to heal more thoroughly. Also, they tend to act on the kidneys and can "cook" them if you take too much.
TANSTAFL
So if this is true I don't think there are any safe painkillers during pregnancy.
(My mother didn't take acetaminophen during her pregnancy. Still have adult ADD. Unlucky me.)
I can tolerate a single pill of ibuprofen, maybe 2 in 24 hours but that's it. I don't take acetaminophen frequently, but it is one of the only things I can tolerate for pain (sinus/tension headaches mostly).
(In the UK, you can buy it OTC but only in regulated small pack sizes, as it used to be the most common drug used in attempted suicide-by-overdose.)
They thought about that. Doesn't look like it.
From the guidelines:
Please don't insinuate that someone hasn't read an article. "Did you even read the article? It mentions that" can be shortened to "The article mentions that."
> They failed to discern a pattern of increased medication-taking by women who were carriers of genetic variations linked to behavioral problems.
The mothers carrying known behavioral genetic markers were not more likely to take acetaminophen. If the headaches were correlated to a known marker then you would expect it to also be passed on to an offspring in a statistically significant way.
But if there's an unknown marker that correlates with pain complaints? I know of at least one psychologist who is going back to some of Jung's commentary on behavioral issues and trying to carve out a set of people who are diagnosed as 'shy' or 'ADD' but who just have heightened senses.
The gist of it is that some people have a less aggressive filter on their senses, and eventually they can't cope with the information overload and they begin to act out, not unlike an exhausted child. Depending on environment and luck, they might develop shyness, ADD like symptoms, become scarily perceptive (extreme case: Sherlock Holmes, Psych), or some combination of all three.
These people also complain about physical discomforts and pain with a higher frequency than normal people. The question of how exactly they eliminated pre-natal painkiller use of the mother as a predictor for behavioral problems wasn't addressed in either summary but might be buried in the data.
What if there's a marker that not only correlates the aspirin use and the child's behavioral problems, but subjects with the marker more strongly correlate the relationship than subjects who don't?
That kind of statistical analysis is how we find out a random stretch of DNA is a marker in the first place. All forms of human study will advance dramatically once this becomes standard practice, as indeed it must.
Of course, you're completely throwing out the fig leaf of 'anonymous' health data. But it turns out that for the vast majority of health studies, deanonymizing the data is quite practicable in most cases already. And the gain to medicine would be enormous.
Edit: I shouldn't say it's poor quality research. It's misleading reporting.