Approaches toward repeated supratherapeutic doses of paracetamol in children: A survey of medical directors of poison centres in North America and Europe

Background: During the last few years there has been an increase in the number of reports of liver failure associated with prolonged paracetamol (acetaminophen) administration in children for therapeutic reasons. Objective: To describe the approach taken by medical directors of poison centres regarding the treatment of repeated supratherapeutic doses of paracetamol in children. Methods: Questionnaires mailed to the medical directors of 76 poison centres in North America and 48 poison centres in Europe asked respondents to comment on the management of a hypothetical case of a child who had received repeated doses of paracetamol at a daily dose of 90 mg/kg during a febrile illness and who presented to the emergency department with mildly elevated serum transaminase levels. Results: The response rate was 62% for North American centres and 44% for European centres. There was a wide range of answers regarding the maximal safe daily dose of paracetamol. For the case described, 71% of the respondents suggested measuring paracetamol serum concentration. Fifty-four percent suggested treating the patient with acetylcysteine and 35% suggested not treating the patient. Conclusions: Our study showed that there is little agreement among medical directors of poison centres on the toxic threshold for chronic exposure to paracetamol in children and on how these cases should be managed.