Given in excessive doses
One of many antipyretic drugs, Paracetamol (acetaminophen), is a widely used over-the-counter medication given to reduce fever and pain. However, if given in excessive doses, it can cause devastating and life-threatening liver damage.
After several days of high fever, vomiting, diarrhea, and confusion, three-year-old Emily* was rushed to the Ruth Rappaport Children’s Hospital at Rambam Health Care Campus (Rambam) and admitted to the Cheryl Spencer Pediatric Emergency Department. At admission, Dr. Mariana Moltedo, a resident in the department and an Advanced Pediatric Life Support (APLS) instructor, led the team in initiating supportive treatment and a diagnostic workup.
Thought to be suffering from a viral illness complicated by dehydration, Emily was treated for those symptoms, but her condition deteriorated, and she was transferred to the Department of Pediatrics B. There, resident physician, Dr. Nadav Shalev Spokone interviewed her parents and discovered that for five days Emily had received an incorrectly calculated dose of paracetamol (acetaminophen) both oral syrup and pediatric suppositories—together amounting to three times the recommended dose for her age and weight.
Emily was then transferred to the Wagner Green Pediatric Intensive Care Unit where test results revealed findings consistent with acute liver failure.
Initial toxicity symptoms may resemble a viral illness
When paracetamol breaks down, a small portion converts to a toxic substance called N-acetyl-p-benzoquinone imine (NAPQI). Typically, the liver neutralizes the toxin, but with excessive dosing, the liver is overwhelmed, and permanent damage can result. Initial toxicity symptoms may resemble a viral illness, thereby delaying diagnosis—as in Emily’s case. More severe symptoms typically appear three to five days later and include jaundice, bleeding, and altered levels of consciousness.
Professor Ronen Arnon, head of the Pediatric Liver Gastroenterology and Pediatric Nutrition Institute, explains that paracetamol poisoning is one of the most common poisonings because it is a readily available over-the-counter medication. Paracetamol poisoning can be caused by a single large dose or by prolonged exposure to the drug, but the liver can be irreparably damaged if treatment is delayed, and a transplant may be unavoidable. Professor Arnon recalls treating a similar case in an infant a few months ago. “Fortunately, with timely treatment, the infant’s condition has stabilized,” he says.
Dr. Yael Lurie, director of the National Poison Information Center at Rambam, emphasizes that drug overdose can be prevented by adhering to some simple rules:
- Use only one antipyretic medication at a time.
- Read the package insert; follow precise dosage instructions, intervals, and daily limits; and record the time of each dose.
- For syrups, use the measuring tool provided with the medication (cup, spoon, or oral syringe).
- Keep to the minimum time interval between doses and do not exceed the maximum daily doses.
- Seek medical help for persistent high fever or other worrying symptoms; parents are encouraged to keep the contact details of their local poison information center readily available.
If excessive dosing is suspected, blood tests are performed, and if confirmed, acetylcysteine—the recommended antidote for paracetamol toxicity—is administered intravenously. Other treatments exist, but effectiveness declines as more time passes from exposure.
Emily has since been transferred to another hospital for monitoring ahead of a possible liver transplant. Her story is a stark reminder that even over-the-counter medications must be used with caution.
