Safety of Over-The-Counter Medications – PediaCast 223
Dr Marcel Casavant and Dr Cheryl Laubacher join Dr Mike in the PediaCast Studio for a discussion of over-the-counter medications. We’ll follow the life of a drug as it progresses from Rx to OTC and we’ll take a look at the serious safety risks these medicines can present to children. From fever reducers and cold formulations to antacids and wart removers, we cover just about everything in the family medicine chest!
- Safety of Over-The-Counter Medications
- Dr Marcel Casavant
Chief, Pharmacology and Toxicology
Medical Director, Central Ohio Poison Center
Nationwide Children’s Hospital
U.S. Poison Center Hotline – 1.800.222.1222
[US Poison Control Centers Jingle]
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike!
Dr. Mike Patrick: All right. So a little bit of a different start to the program today. It is PediaCast episode 223. This is Dr. Mike. I'd like to welcome everyone to the program. As always, we are coming to you from the campus of the Nationwide Children's Hospital here in Columbus, Ohio. It is August 22nd 2012. And you may have noticed from the jingle at the beginning of this show, we are going to be talking about safety of over-the-counter medications. And yes, it's true even with over-the-counter medicines, you may have the need to call the Poison Control Center and everyone now can sing along and you know exactly what the phone number is for the Poison Control Center.
You know though it is easy to get a false sense of security towards over-the-counter medications. After all, they are easily accessible without a prescription and many of them have been used for a long time without any apparent safety issue being raised at least in the eyes of moms and dads. Yet, people who work in poison control centers and emergency departments will let you know that over-the-counter medicines are chemicals, they do affect your body and there is significant potential for problems to arise. Accidental ingestions, overdose and side effects lead to frequent calls to poison centers, trips to emergency rooms, overnight hospital stays and sometimes they can lead to significant illness and even death.
We want you to be smart about over-the-counter medicine; we want you to know what's out there; how it works; how to figure out a dose; what safety precautions you should keep and what you should do if the unplanned happens. And if your child accidentally ingests, overdoses or experiences a side effect from an over-the-counter medicine, we want you to know what to do.
We're going to look at fever reducers, pain medication, anti-inflammatory agents, cough and cold medicines and a longer list of other agents from topical antibiotics and anti-fungal creams to wart preparations. We'll include antacids, laxatives, stool softeners, anti-itch creams, teething gels, allergy medications and that's just the partial list.
Of course, to help me talk about this we have two great studio guests joining me today, Dr. Marcel Casavant, MD, is Chief of Pharmacology and Toxicology at Nationwide Children's Hospital and the Medical Director of the Central Ohio Poison Center. Also Dr. Cheryl Laubacher is joining me, a practicing pharmacist with Nationwide Children's. And we'll get to those two in just a moment.
First, I want to remind you that if there's a topic you'd like to hear about on PediaCast it's easy to get a hold of me, just go to pediacast.org and click on the Contact link. You can also email email@example.com or call the voice line at 347-404-KIDS. That's 347-404-K-I-D-S.
All right. Dr. Marcel Casavant, MD, returns to the PediaCast studio. Regular listeners will recall you joined us back in episode 202 to talk about mercury exposure from a broken compact fluorescent light bulb. As a reminder, Dr. Casavant is the Chief of Pharmacology and Toxicology for Nationwide Children's Hospital and a professor of Pediatrics and Emergency Medicine at the Ohio State University College of Medicine. He's also the Medical Director of the Central Ohio Poison Center. So, welcome back to PediaCast, Dr. Casavant!
Dr. Marcel Casavant: Thank you, Dr. Mike.
Dr. Mike Patrick: Appreciate you stopping by. Dr. Cheryl Laubacher, she's a first time PediaCast guest. I'd like to welcome her as well. She received her Doctor of Pharmacy Degree from St. Louis College of Pharmacy and she works as an ambulatory clinical pharmacist at Nationwide Children's Hospital and our network of off-campus close to home clinics. So, it's with the warm welcome that we say hi to you as well.
Dr. Cheryl Laubacher: Thank you for having me. It's an honor to be here.
Dr. Mike Patrick: We really appreciate you stopping by the studio. Let's start with you Dr. Laubacher, what exactly is the difference between over-the-counter medications and prescription medication?
Dr. Cheryl Laubacher: Well, an over-the-counter medication is just one that you can purchase without a prescription from a physician; prescription medications of course are something issued to the patient from a pharmacy pursuant to a prescription given to the patient by their doctor. Some examples of items that have been switched from prescription status to over-the-counter include nicotine replacement products; recently, oral contraceptive pills or birth control; pain and fever reducers, even ibuprofen at one time was prescription; stomach antacids including Zantac, Prevacid, Prilosec and things like that.
Dr. Mike Patrick: Great. Obviously, for a prescription you have to have a prescription from a provider and if it's over-the-counter it's just something you can walk into the pharmacy and get for yourself. The Food and Drug Administration, do they have control over both prescription medicine and over-the-counter medicine, they control both of those things?
Dr. Cheryl Laubacher: They definitely do. As I mentioned, a lot of the over-the-counter products that are available now where at one time prescription only status, available now over-the-counter in a lower dosage form and some of the prescription products are still available as prescription in a higher dosage form. And the FDA does oversee the conversion from prescription status to over-the-counter status.
Dr. Mike Patrick: And they could switch it back if they want it to, I mean if there's something that's over-the-counter that they deem maybe it shouldn't be readily available to everyone without a prescription they could switch it back to make it by prescription only.
Dr. Cheryl Laubacher: Absolutely.
Dr. Mike Patrick: Now, Dr. Casavant, parents have this sense that if it's over-the-counter it must be safer. Is that true?
Dr. Marcel Casavant: That's the way it's supposed to be and if I were to invent a new drug today and it would be very safe and I could prove it, why I might be able to convince the FDA to release it in an over-the-counter status. But a lot of over-the-counter drugs have been available long before the FDA was there and some of them we very commonly use and we just assume they're safe and think they're safe but in fact they're not.
When we look at the Poison Center at the list of drugs that caused deaths, almost every year very high in the list or even the most common is acetaminophen and very high in the list after that is salicylate. Those are both over-the-counter medicines that we would assume are very safe. So, for the most part of more dangerous drugs should be on prescription status but there are some exceptions, part of it could be that acetaminophen and salicylate really are pretty safe and have a much lower rate of complications, but because the number of people using them is so much larger after it's not on prescription status. It maybe that that's why the math sort of adds up against us.
Dr. Mike Patrick: Sure. And I guess parents, we all sort of understand that there's risk in everything that we do. I mean, even when you get in a car and buckle up and you use the ride safety seats for your kids, there's still a risk. And so with over-the-counter medicines even though they've been used a long time and kids generally do well with them there's still a slight risk and we're going to talk about some specific examples of that.
Dr. Laubacher, how does a drug go from being, you mentioned the FDA sort of regulates things that go from being by prescription-only to being available over the counter, how does that process get started? How does the FDA decide what drugs are going to be available over the counter and which ones aren't?
Dr. Cheryl Laubacher: Well, actually, FDA is usually the last step, the one that gives the final nay or yay on whether it gets converted over. Usually it starts off with the support group, maybe an expert group in a particular disease state such as gastrointestinal looking at a heartburn or anti-nausea vomiting drug, things such as that. And that support group with the drug company put together data showing safety, showing efficacy, things such as that and takes that to the non-prescription drug advisory council.
They take all that in to affect all the data, the safety, the efficacy, but a big part of includes consumer research. And the research that's done with consumers include product label, readability, making sure that the customer can look at the label, read the information there and act on it. And they also consider something called self-assessment, whether the patient can look at the label and say based on the symptoms and the disease state that I think I have, this product is correct for me and I'll go ahead and I'll choose it. Or hopefully, in some cases, they'll even include a group of patients that they know should not use the medicine and that group of consumers, as well, will say this product is not right for me and we'll decide not to buy it.
Dr. Mike Patrick: Right. It sounds like there's a lot of place in that system for politics to kind of inject itself a little bit and for the economy to also play a role. For instance, you have a drug that maybe patented and so only a specific company can make it, but once that patent expires and now generic companies have an opportunity to make it, they may have an interest in them being able to market it directly over the counters, so if they get permission from the FDA to make it to say it safe and make it over-the-counter they maybe able to sell it more. You know, they want to make a profit.
Dr. Cheryl Laubacher: That's true. The drug companies are looking to what's called extender patent on the brand name or the medication. So if you look at things such as Prevacid or Prilosec they came over the counter in lower dosage forms that were available as a prescription, 10mg Prilosec, 15mg Prevacid. They keep the brand name that keeps the money coming in, the politics going. But behind the counter with the prescription that medication is now generic.
Dr. Mike Patrick: Yeah. So the drug company they have the patent finds sort of a new to make money from their drug, otherwise they'd be selling to the, the generic companies would be the ones making the prescription version of the drug.
Dr. Cheryl Laubacher: Correct.
Dr. Mike Patrick: And I suspect that there's probably some pressure from the insurance companies too because if drug goes over the counter then they can say we're not going to cover the cost of it anymore, that comes out of pocket. So I would suspect that there's pressure from some insurance companies to want some medications to go over the counter.
Dr. Cheryl Laubacher: Yeah. It's a tongue-in-cheek type of thing as pharmacers were like, "OK, yeah, this is a good move to have this available to the public, but we know that the insurances will no longer cover it, therefore we get our patients complaining, it's like this cost me more than it did before with my co-pay." With some insurances they'll continue for six months to twelve months to get a rebate from the drug company to continue to do the brand name so even when the generic's available the generic will not be paid for by the insurance company, so you still are not able to get that generic version at a cheaper rate.
Dr. Mike Patrick: Sure.
Dr. Cheryl Laubacher: So it drives up health care cost. That's what it does for a little while.
Dr. Mike Patrick: I think we're just trying to be transparent here in terms of how these things happen. In a perfect world you'd say this is a safe drug, let's make it available over the counter because it may be treating a condition that you don't necessarily have to see a doctor for. But in the real world there are lots of economic and corporate pressures that we just want to identify.
All right. What about when we talk about things going over the counter there is an example of a drug that the DFA looked at and said over-the-counter this may not be safe and so let's make it a prescription again. And it was just a few years ago, it was phenylpropanolamine, what was with that?
Dr. Cheryl Laubacher: Safety reasons was the big thing and they converted it back to like you said prescription. It was available as combination medication with either antihistamine or a cough agent in it. Inevitably, what happened is that that medication actually got pulled of at the market due to an increased risk of stroke.
Dr. Mike Patrick: For those of you who are kind of shaking their head and what was phenylpropanolamine, it was a decongestant medicine and we're going to talk about that class of drugs like Sudafed and Sudafederin and such coming up. But that was one of those and it was a pretty popular decongestant that was in a lot of over-the-counter cough and cold medicines and there was this association with it in particular young women and strokes and that led the FDA to make it back to prescription. And now it's not even available by prescription, is that correct?
Dr. Cheryl Laubacher: That's correct. Yeah.
Dr. Mike Patrick: Let's talk about some specific drugs. Dr. Casavant, you had mentioned acetaminophen. Here in the United States probably the most popular brand of acetaminophen is Tylenol, but of course there are generic versions of it available as well. And we do have a large international audience so I want to mention paracetamol is also a name for acetaminophen and that's the name that's used. I practiced for a while in Florida and we had a large tourist population where I worked and so people would come in and use the term paracetamol pretty frequently, but basically it's acetaminophen. So, Dr. Laubacher, let's start with you. What is acetaminophen? What's it used for and how does it work?
Dr. Cheryl Laubacher: Acetaminophen is probably the most common over-the-counter agent. Dr. Casavant was talking earlier about how they get a lot of calls regarding patients that overdose on it and improperly used it. Improper use, also, in the pharmaceutical world pertains to underuse as well and inappropriate dosing. Just recently there was a conversion of infant concentrated drops to be practically unavailable anymore in the market just to prevent confusion with the child's suspension that's a little bit dilute that the infant drops. I think it's a great move just to try to keep everything uniform. This is an agent that's used for pain treatment and fever treatment in patients of all ages.
Dr. Mike Patrick: Right. How does it work? How does it decrease fever and control pain? This is a podcast for parents but we do have a lot of clinicians in the audience as well, pediatricians and residents and nurse practitioners. So what do we know about the mechanism of action for Tylenol or acetaminophen?
Dr. Cheryl Laubacher: This particular medicine works on the pain and the fever sections of the brain working to combat the pain sensors, the pain chemicals, works solely in the brain compared to a product we'll get to in a moment I can see works a little bit differently, but it works centrally in the brain.
Dr. Mike Patrick: Yeah. I have to admit it was kind of a trick question because we aren't exactly sure how acetaminophen works. I mean there's thought that in some and folks out there in the medical field will have heard Cox 3 or Cox 2 or Cox 1 receptors. I guess in doing some research for this I was kind of surprise that we don't know exactly the mechanism of action for acetaminophen. There's thought that maybe there's an unidentified "Cox 3 receptor" that it's acting on, but we don't really know for sure. So, let's talk safety and I apologize for that.
Dr. Cheryl Laubacher: That's all right.
Dr. Mike Patrick: Let's talk safety precautions. Dr. Casavant, what's the concern with acetaminophen?
Dr. Marcel Casavant: Oh, Dr. Mike, there are so many concerns with acetaminophen. It really does keep us busy in the poison control world. One of the big issues is the number of formulations out there — the vast number of different pill and tablet, sizes and shapes, the different number of concentrations of various liquid products. The day of a pediatrician saying to a mom give your child a teaspoon of Tylenol, I hope that is long since gone, but we still hear that all the time. And so we really have to be very careful in paying attention to what the dose of the product really is – if it's a liquid, what the concentration really is and how much we're prescribing or advising people to take or give them children and how much we're giving our kids.
Another important problem is that we still commonly dispense or provide this in teaspoons or teaspoon units. Give a half teaspoon every four hours – that kind of advice. And we really want to strongly advise folks to abandon spoon units all together and stick with the metric system, especially for this medication where getting it wrong can be so very dangerous.
Dr. Mike Patrick: So, if you're assuming a teaspoon is really 5 ml which is the conversion then you'd be OK. But the problem is parents may just grab a spoon and who knows how much their teaspoon is really measuring.
Dr. Marcel Casavant: I've tested that on a lot of spoons and I've got to tell you I've had a hard time finding a teaspoon that's not 5 ml. The trouble is some teaspoons can be as small as 3 mls and some might be as much as 7 mls. But more importantly is when is that spoon full? And so where's the meniscus and can you pile a little bit extra on top of that or does it have to be just a little bit lower? There's a lot of ways to get it wrong and even switching to syringes that measure out in spoon unit that's a step in the right direction, but it's still not good enough.
Dr. Mike Patrick: But if we just standardize it and say let's do milliliters then we know which line we're working toward on the syringe.
Dr. Marcel Casavant: Exactly right.
Dr. Mike Patrick: OK. I'm sorry I didn't mean to interrupt you.
Dr. Marcel Casavant: No. That's great. Another thing is it's safe, it is my preferred medicine if I've got a headache or a fever and I want something. It is safe if it's taken as instructed and if you'd look at the instructions and read them carefully those really do apply to you. We've heard people, I don't know how many times say oh, I know, but there's a safety margin in there, I can take more. That's not true. Those instructions really are the upper limit of what you're allowed to take, don't take more than that.
I don't know how many young ladies I've met in the hospital the day after their overdose. They get in a fight with mom, dad restricts their privileges, boyfriend doesn't want to see them anymore and they're sort of crying for help and they do something sort of an impulsive, sort of stupid, but to cry for help not really intending to be dead, they take a bottle of Tylenol.
Dr. Mike Patrick: We get because there's this impression that it's safe.
Dr. Marcel Casavant: It's going to be kind of dramatic, I'll get everybody's attention but I'm not going to really lose anything over this. I'm going to get a little attention then I'll be OK. And they end up in the hospital, maybe they get their stomach pumped, maybe they get some charcoal to drink and then they end up getting an antidote to keep their liver alive, to keep them from needing a liver transplant or from dying. And that's the first time they've ever heard this might really be a scary thing. And so grown ups they come to our attention because of overdoses, get liver injury and most of them have done so because of a suicidal overdose.
But little kids get in that trouble too and very few of them are taking an overdose on purpose. What happens more commonly is they get this viral illness that goes on for a little bit longer than expected, they get a little dehydration, mom or dad is continuing to give acetaminophen every four hours maybe every six hours and if that dose didn't work let's try a little bit higher dose, oh, let's run to the pharmacy and grab another bottle because we ran out of this one. And for most of the kids who get in serious trouble there's no intent to give somebody an overdose, we were just weren't paying enough attention to how much we were giving.
Dr. Mike Patrick: Yeah. Yeah. But that safety line between an appropriate dose and what's too much with acetaminophen, in particular, is pretty narrow.
Dr. Marcel Casavant: Very narrow. We talk about a window of safety where we can divide the toxic dose by the safe dose and for some drugs it's 10 times, 100 times, 1,000 times before you end up in trouble. With acetaminophen there's no margin for safety. You can't take more than what's on that label.
Dr. Mike Patrick: Yeah. So, it's going to be really important for parents to make sure that they're using the right dose and if there's any question of what that dose should be, they should absolutely call their doctor.
Dr. Marcel Casavant: Correct.
Dr. Mike Patrick: And get the weight appropriate dose for their child in milliliters.
Dr. Marcel Casavant: And lastly, people end up in trouble with acetaminophen happens all the time. Acetaminophen is mixed in to a lot of other medicines. People may think they know how much acetaminophen they're taking but they're also taking a pain reliever that contains acetaminophen, they're also taking a cough/cold remedy that contains acetaminophen and when you add up how much acetaminophen you've taken or you've given your child at the end of the day it can be very surprising. So, one last caution on the acetaminophen topic is to pay very special attention to all of the medicines you're giving your child and see if any of them contain acetaminophen.
Dr. Mike Patrick: Sure.
Dr. Cheryl Laubacher: You know on that note the FDA has recently and they've been looking at it over the past few years, decreasing the formal daily amount of acetaminophen that's allowed, especially in combination products – prescription products as combination pain medicines. And then when they're looking at the total daily amount that you can purchase over the counter as well. And what they're advertising is the allowed maximum daily limit.
Dr. Mike Patrick: Sure. Now, let's move on to ibuprofen. So this is going in terms of brand names we're talking Motrin, Advil, there are lots of generic ones out there as well. And what exactly is ibuprofen used for and how does that work?
Dr. Cheryl Laubacher: Well, I'd like to add to this class Naproxen. Naproxen is also available over the counter. It's in the same drug class as ibuprofen called NSAID, which is N-S-A-I-D stands for nonsteroidal anti-inflammatory drug. And these are medications that work in the brain and also in the periphery blocking prostaglandins and as you mentioned before the chemical COX that causes inflammation and pain and swelling. These medications are used to treat fever; they're used to treat pain and also used to treat inflammation.
Dr. Mike Patrick: OK. And one of the side effects of those as opposed to the acetaminophen is the platelet issues as well. So they also affect platelet function?
Dr. Cheryl Laubacher: It does affect platelet function in adults that take platelet preventative aspirin doses these medications will interact, but with that by potentially one causing bleeding inside that you may never know about, but also it counteracts the aspirin's action – the anti-platelet action – that you're looking for to prevent another heart attack or another stroke.
Dr. Mike Patrick: Yeah.
Dr. Cheryl Laubacher: So, it's very important to check your over-the-counter medications with your pharmacist or with your physician or any prescribing health care provider that you have.
Dr. Mike Patrick: Sure.
Dr. Cheryl Laubacher: The other common thing to know about NSAIDs is that the most common side effect is going to be stomach bleeding. It is non-dose related, so even the slightest amount within the drug range, the dosing range can cause stomach bleeding. Parents and patients should know to take the medication with food to protect the stomach and ibuprofen itself is indicated only down to six months of age. Any baby that has fever or pain should result to Tylenol or calling their physician. They should not use ibuprofen or ibuprofen-containing products.
Dr. Mike Patrick: Sure. And I want to point out, too, one other thing that you'd mentioned, so ibuprofen is going to be used again for fever and pain like acetaminophen, but it has more of an anti-inflammatory effect than acetaminophen does so that it's going to be better to use if you have an injury or you have inflammation that's there.
Dr. Cheryl Laubacher: True.
Dr. Mike Patrick: So, let's talk safety issues, Dr. Casavant, with ibuprofen.
Dr. Marcel Casavant: Well, you folks have already mentioned a few of them that it is much safer to take with food and I think to take with lots of liquids too. One of the side effects if you'd used it chronically especially and if you used high doses can be an injury to your kidneys. We can decrease that by taking this medicine with lots of fluids. Another thing to be mindful of is not to take it for too long. If you got an ache or pain that goes on for more than a few days it may be time to go see the doctor. Certainly you don't want to take medicines like this chronically over weeks or months. And then the last trouble that we see folks getting into is this little bit of bleeding that may happen. Generally not a big deal if were a therapeutic dose for a day or two, especially if you take it with food, but if you've just had an operation, like your child's just had the tonsils out, this would not be a good time to use ibuprofen or Naproxen or other medicines like that.
Dr. Mike Patrick: What about with the kidneys, blood pressure kind of stuff? Is that a concern with ibuprofen?
Dr. Marcel Casavant: Yeah. Absolutely. Not for most of us, not for most of our kids, but if your child has kidney disease or heart disease or blood pressure problems, absolutely. Things that are very safe for the general population might not be safe for your child. Certainly you want to discuss those issues with your child's doctor and pharmacist.
Dr. Mike Patrick: One of the side effects from ibuprofen, I have a little story to share, is actually headache. And when I was a resident I had a headache and I took some ibuprofen. I think it was a tension headache and it lasted a couple of days and I kept taking ibuprofen. And then the third day it was still there and then the fourth day and the fifth day. And then you start thinking why, do I have viral meningitis or is there something else going on with me and I'm just sucking down the ibuprofen. And then I did some reading as good residents do and saw that one of the side effects was headache and I stopped the ibuprofen and the headache went away.
Dr. Cheryl Laubacher: That can actually happen with Tylenol or the acetaminophen products as well. If somebody has chronic headaches, tension headaches, use it for migraines and you get on that type of cycle, the only way to treat that rebound headache is to just stop at cold turkey. And it's going to be painful for a while but it's the only way to do it.
Dr. Mike Patrick: Yeah. It was an interesting lesson. To move on to aspirin and we're going to touch on this, we have mentioned we did a whole show on Kawasaki disease and we have talked about Reye's syndrome before, so I think most of the audience out there if they're regular listeners know that we don't use aspirin in kids unless it's under the supervision of a doctor. And the reason is because of its association with Reye's syndrome and it's actually back in PediaCast 211, so if you're interested in knowing about Reye's syndrome and why we don't recommend aspirin these days it was episode 211.
Although the exception to that we do use low dose aspirin in Kawasaki disease and if you want to know more about that it was episode 203 that we talked in depth about Kawasaki disease. So basically, aspirin is another nonsteroidal anti-inflammatory drug kind of like ibuprofen is. Are there any other safety issues with aspirin, Dr. Casavant?
Dr. Marcel Casavant: A couple others, as with the nonsteroidal anti-inflammatory drugs, people with kidney trouble, heart trouble, blood pressure trouble need to be careful with this. And then if you've just had an operation or if an operation is coming up within the next two weeks you'll need to avoid aspirin.
Dr. Mike Patrick: Because it decrease platelet function and can cause bleeding.
Dr. Marcel Casavant: That's correct.
Dr. Mike Patrick: OK. Let's move on to dextromethorphan or DM. So we see a lot of products out there with DM after the name. What is DM, dextromethorphan? What does it do and how does it work?
Dr. Cheryl Laubacher: DM or dextromethorphan is a relative of codeine so it does have that controlled substance, narcotic link. It also works in the brain to suppress the cough center supposedly, it's supposed to decrease cough. It's only the agent in your cough medicines that makes you or your child not like the taste of it very much, very strong, very bitter taste. I personally do not think it's that wonderful of a drug. I do have a handful of patients that when they come to the office and I'm asking are you giving your child anything for this? Oh, yeah, we're giving such and such DM. Is it working? No, not really. It's probably a nature drug, you can stop it or yeah we find that it really works and so then I'll talk to them at that point about how to carefully administer the medication, to read the label, to follow the appropriate dosage of the dextromethorphan for that age.
Dr. Mike Patrick: Sure. And Dr. Casavant, what happens if someone takes too much DM?
Dr. Marcel Casavant: Unfortunately, we see teenagers taking too much of this stuff and they do it on purpose using this as a recreational drug of abuse. They get sick, they have some vomiting, many of them get wild and crazy, they get high blood pressure, they get hallucinations. They require a lot of treatment in the emergency department and often in the intensive care unit. Very scary drug to see children overdosing on this and it's disgusting that it's often on purpose. But that's something for your listeners to be aware of that if they get those teenage children just to be careful that maybe something that their children or their children's friends might appreciate as a drug of abuse.
Dr. Mike Patrick: Let's move on to the decongestant type medicines. So we're talking Sudafedrin, Phenylephrine, what do these drugs do, Dr. Laubacher and how do they work?
Dr. Cheryl Laubacher: Well, as you mentioned, these are decongestants. They work at constricting the blood vessels everywhere in the body, but specifically where you want them to work is in the nose and then the sinuses. Constricting those blood vessels causes less congestion, less engorgement of the vessels that cause that congested feeling. Phenylephrine and Sudafedrin are available as oral agents. Phenylephrine is also available as topical, which many patients know as being a nose spray.
Highly recommend for patient, for normal patient, without seeing an ear, nose and throat specialist to not use the topical nasal decongestant. It should only be used for three days if at all because you end up getting rebound congestion. So when you get the rebound congestion you're like "Uh! I was getting better, now I'm not. I better use more." So use more and it works. And then you start getting worse, so you end up developing a tolerance to it and becomes a very vicious cycle. Not one of my favorite agents.
Dr. Mike Patrick: Yeah. So when you do use the nose spray initially, that swelling was there, your body responds to there being a virus and you're making more mucus and that swelling is there as part of your body's immune system. But it can get to the point where the swelling is just there and you have to use the nose spray to make it go away and it won't go away until you stop it. Kind of like the headache thing.
Dr. Cheryl Laubacher: Yeah. Like the headache. I think the oral agent if they're going to work they're going to work just as fine and you can stay away from the nasal agents.
Dr. Mike Patrick: Sure. What other safety issues with the decongestant class of medicines, Dr. Casavant?
Dr. Marcel Casavant: You know, over the last couple of years the FDA and the American Academy of Pediatrics have been increasingly concerned about small children using these products. First, they said you shouldn't use it in under a year, then under two years and the latest is really to discourage parents from using this at all in children under four years old. Great to use saline sprays without any actual drugs inside for taking care of the nose. Bulb suction can take those congestions on the little babies and then a vaporizer in the bedroom.
One of the problems in this medicines is you look at the shelf at the pharmacy and there are dozens of them and they have all kinds of different combinations of products/medications in there for various signs and symptoms to be dealing with. Very confusing, very difficult for folks to get that right. There can be some interactions between different ingredients in different products. These are a very tricky group and it's worth your time to read those labels carefully and feel free to discuss the products with your doctor or pharmacist.
Dr. Mike Patrick: So these cause the blood vessels to constrict which then can affect heart rate, blood pressure. Is that the primary reason that these are dangerous for young kids?
Dr. Marcel Casavant: Yes. We see hypertension, high blood pressure in kids that come to the emergency department if they're not acting right after using some of these products. And it turns out in overdose they had looked just like amphetamine poisoning. Even without overdose there can be an interaction between this and caffeine, which acts in the same way. Kids can get nervous, jittery, anxious, they get a very high heart rate and high blood pressure from using these products.
Dr. Mike Patrick: I have noticed, at least here on Ohio and I'm not sure if this is a state issue or a FDA issue, I think it's probably a state issue, that you actually can't get these over the counter, just on the shelf, itself, you actually have to go to the pharmacist and request them and sign something that says you're getting them. I suspect that has to do with the manufacturing of drugs of abuse.
Dr. Marcel Casavant: Exactly right. They are very closely related to amphetamine and the Sudafedrin product in particular can be used by some wise guys in their garage to make methamphenamine.
Dr. Mike Patrick: So it's an effort. Is that an Ohio thing?
Dr. Cheryl Laubacher: No. It's a federal thing.
Dr. Mike Patrick: It's through the FDA that this…
Dr. Cheryl Laubacher: Each state has their own laws, their own regulations. So like you said, here you present your driver's license, you sign something away, they put you in a database and you're allowed to purchase only a certain amount among 30 days. Pharmacists as well have stipulations. They're only allowed to sell or dispense so much in a 30-day time period.
Dr. Mike Patrick: But that's something here on Ohio that this done, but other states may do it as well.
Dr. Cheryl Laubacher: Other states do similar things.
Dr. Mike Patrick: All right. Let's move on to antihistamine medicines and probably the most common of those is Diphenhydramine, also known as Benadryl, but there are other sedating antihistamines that are often times part of cough and cold formulations. What are the antihistamines and how do they work?
Dr. Cheryl Laubacher: Antihistamines are the only drug class I can think of where the name tells you what it does. It works against an agent, a chemical in the body called histamine and histamine gets very hyper when your body is exposed to something it doesn't like and causes an allergic reaction. So as you mentioned, Diphenhydramine is the most popular one, one that everybody knows; agents that are found in combination cough and cold medicines go by the name of chlorpheniramine, brompheniramine, things such as that.
The tricky thing is is that these antihistamines are indicated to only work against allergic reactions because that's when histamine comes about in the body. When it's put into a cough or a cold preparation to be used against runny nose, congestion, cough, we're actually using the side effect, the anticholinergic effect of it, which is drying things up, making you sleepy, things such as that.
Dr. Mike Patrick: Yup. So it help the stuffy nose and helps you sleep.
Dr. Cheryl Laubacher: It does.
Dr. Mike Patrick: And that's where we get in to our safety issue, Dr. Casavant?
Dr. Marcel Casavant: Exactly right. It does help you sleep. These are sedating but that's not an acceptable use for this drugs. These were not to be given to our kids to calm them down so we can have a nice evening with our significant other or something like that. It's not an appropriate use of these medicines to sedate kids. And as I mentioned, we're instructed now not to use cough and cold medicines at all really for kids under four years old.
They can cause trouble staying awake in school and so it can be a problem for some of the older kids. And then if you have other medical problems it really could make thing a whole lot worse, particularly if you use to take medicines under the tongue and now we've dried up your mouth or if you have some bowel or bladder problems, the nervous control of those can be affected by these medicines as well.
Dr. Mike Patrick: Sure. And I believe these antihistamines can lower the seizure threshold, so if you have a kid with epilepsy it could make them more prone to seizures if they have these medicines on board as well.
Dr. Marcel Casavant: You're right. And sometimes it can also have a side effect although we call them sedating and they usually are. Some children react very differently and can be pretty wild and crazy from even therapeutic doses, especially from high doses of these products.
Dr. Mike Patrick: Right. What about the non-sedating antihistamine? So things like Claritins, Zyrtec or Allegra, how do those work and what do they do?
Dr. Cheryl Laubacher: So, Allegra is the new one brought over the counter. If I'm correct, I think now all the formerly prescription antihistamine allergy medicines are now available over the counter. There's even generic or store brands of those available so everything should be pretty comparative and incomparable. They do the same thing as the sedating antihistamines – they work against histamine, which is active when you have allergies, when you have allergic reactions. These are more popular in effect that they're supposed to be less sedating. They are given just once a day to help control allergies and you may also find them being given on a chronic basis for patients that have eczema or severe eczema, idiopathic itching/pruritis, things such as that, where you don't really have a cause for it but you think there must be some sort of reaction going on. We need to suppress it. We need to control it. We need to make it as possible for the patient to have a good quality of life.
Dr. Mike Patrick: The difference between sedating antihistamines like Benadryl and the non-sedating antihistamines has to do with how much of the drug gets through the blood-brain barrier and can have an effect on the brain. Is that correct?
Dr. Cheryl Laubacher: That is correct. Cetirizine or Zyrtec does seem to cause the blood-brain barrier a little bit more than the other ones, which is why it does seem to have a possible sedative effect on patients that will be susceptible to that.
Dr. Mike Patrick: Yeah.
Dr. Cheryl Laubacher: I personally will not try Zyrtec because I'm very susceptible to those things so I'll stick with the Loratadine or the Claritin.
Dr. Mike Patrick: Sure.
Dr. Cheryl Laubacher: The other thing to know about these agents and treating allergies in general is that it's not a one size fits all. Some patients may do well with Loratadine or Claritin, others may try it, it doesn't work and you go on to something else. This besides colic or gas is got to be probably one of the safer things to try to treat and self-manage over the counter with antihistamines.
Dr. Mike Patrick: Yeah. I suspect that they're fairly safe because when you notice the dosing, the adult dosage is age six and up, so if you've given a six-year old the adult dose they must not have too much of a safety issue. Would you concur?
Dr. Marcel Casavant: I would certainly agree with that. I do like calling this the less sedating antihistamines as opposed to the non-sedating and really in the other ways they are so much safer than the older antihistamines. Because of the possibility of sedation it's a good idea to save that first dose for a time when it's OK to be sedated. And certainly if your child has the big test coming up tomorrow this might not be a good time to take the first dose of this for allergies.
Dr. Mike Patrick: Yeah. I want to go back to the sedating antihistamines really quickly because I don't think we actually said this and I want to make sure it's really clear for parents. The reason that these are a safety issue in kids with the sedation is because the next step of sedation is respiratory depression. You can potentially stop breathing if you overdose on the sedating antihistamines. Is that correct?
Dr. Marcel Casavant: You know, before you get to that stage there's a lot of other toxicity that's also very ugly. These things can cause hallucinations, it can cause very high blood pressure, abnormal heart rhythms, lots of scary stuff just before somebody stops breathing; seizures. The older antihistamines have a lot of toxicity issues when they're in overdose.
Dr. Mike Patrick: Sure. I mean, these are things that take seriously, the older antihistamines.
Dr. Cheryl Laubacher: And actually, all of these preparations, many of the preparations I should say, that are available for children in a liquid formulation. They're called elixirs, which means that they're mixed with alcohol because they're not soluble in other more favored agents such as water. So then you have to add the effects of alcohol as well. They're also put on there as percentage of alcohol just like any alcoholic beverage would be.
Dr. Mike Patrick: Yeah. We're going to kind of do a rapid fire run through of some other common over-the-counter medicines. And the way I kind of envisioned this is I'll just name an agent and just everyone can, you think about something with that particular agent and just kind of jump in and then that something maybe oh yeah, that's safe, it's not something to worry about. So let's go ahead and run through these.
So topical antibiotics – so Neosporin, the generic ones, any issues with those?
Dr. Cheryl Laubacher: Those are good agents to use, obviously. Pretty benign in trying to treat a cut with an antibacterial. Things you get into concern about those that you may be treating something that's going to need a lot more power. So you need to seek aid from your physician or your prescriber on that. Anti-fungal, the only problem we really get into there is the fact that those types of infections are very resistant and they take a very long time to treat. A lot of patients are not going to do that type of self-management over the counter and be successful at it and eventually end up going to your physician.
Dr. Mike Patrick: Sure. The topical antibiotics those are going to be good if you're trying to prevent a skin infection, so if you have a little scrape or something. But if you have a skin infection you shouldn't try to self-treat that at home with the topical antibiotic. You may want to see your doctor in case you need an oral antibiotic.
Dr. Cheryl Laubacher: Yeah.
Dr. Mike Patrick: What about ingestion-wise? The topical antibiotics over the topical anti-fungals, are those safety issue if a kid would squirt the package in his mouth?
Dr. Marcel Casavant: Antibiotics are pretty darn safe. The anti-fungals in small little doses are pretty darn safe and bigger dose is a little bit more concern.
Dr. Mike Patrick: Great. OK. What about the anti-itch medicines, like 1% hydrocortisone cream, are those fairly safeties for anti-itch?
Dr. Cheryl Laubacher: I think for your minor issues such as a little bit of poison ivy here or a little bit of baby eczema that eventually goes away, you can use it on the non-facial areas, non-groin, non-armpit areas. It's always very important to follow the instructions. We'd say if this condition lasts longer than three days, seven days or gets worse, gets irritated with use, call you physician.
Steroids are not benign however. There are higher strengths of these products but they're available prescription-only. They can cause thinning of the skin and the skin of course is our number one barrier inside the body to preventing harm, infection, things such as that. So normal skin you do have to be careful with that. Overuse can also cause hypo-pigmentation or also a lighter coloring of the skin as well. So that does tell you that the medicine gets absorbed and it does do things to the body inside.
Dr. Mike Patrick: If a lot of it gets absorbed it can make your own body's production of steroids decrease and then when you stop it you may have too few steroids, your own steroids that you're making.
Dr. Marcel Casavant: That is possibility with the steroids. Yes. Another issue with the steroid cream and self-treatment, using over-the-counter products, if you have a fungal infection like athlete's foot or ringworm the steroid medicine will make that look a lot better for a few days and then things will get a whole lot worse and it really impedes your body's ability to keep that infection under control. Some of the scariest ringworms I've seen that been treated at home for a few days with some steroid cream to start off.
Dr. Mike Patrick: Yeah. So the steroid decreases your body's immune system and so that you were effectively holding that infection at bay and then when you use the steroid cream the infection kind of has free reign. What about antacids?
Dr. Cheryl Laubacher: Oh. Antacids.
Dr. Mike Patrick: So, Maalox, Mylanta, Tums.
Dr. Cheryl Laubacher: They're used for a myriad of things. They can work against heartburn, for sour stomach. They'll also be prescribed and recommended for calcium supplementation possibly for patients – children, teens, adults – that are not able to tolerate dairy products and get their calcium. However, they can cause problems. Too much calcium is not a good thing, it can cause kidney stones. There's magnesium-type of antacids that can cause diarrhea which eventually leads to dehydration and trip to the emergency room or possible admission for IV fluids.
Aluminum is another agent that is used in antacids. You have products such as Ranitidine or Zantac; you have Tagamet or Cimetidine – my least favorite one just because of the potential drug-drug interactions and the fact that that one is over-the-counter really still kind of floors me.
Dr. Mike Patrick: And that's an issue with heart rhythms.
Dr. Cheryl Laubacher: Yes. Heart rhythms, but also it can affect the metabolism of other medications. So, it can make certain medications be cleared from the body faster, which means that they don't work as well, or it can slow down the metabolism, which means it stays in the body longer, possibly causing toxic effects.
Dr. Mike Patrick: Yeah. I think it's fair to say if you need any antacid for a very long period of time or rather short period of time, you probably ought to at least be talking to your doctor to see what exactly are you treating and are you treating it appropriately.
Dr. Cheryl Laubacher: It could be a lot more serious that, you know, just like Dr. Casavant said earlier about topical products, it makes you feel better at first, but who knows what you're really treating inside and letting grow bigger.
Dr. Mike Patrick: Yeah.
Dr. Marcel Casavant: And if you are on other medicines for medical problems you really need to discuss even simple things like antacids with the pharmacist.
Dr. Cheryl Laubacher: Antacids can prevent a lot of medicines from being absorbed. So again, if it's interacting in the stomach with this other medicine it's not getting absorbed, that other ailment that you have is never going to be treated because that medication is not going to be absorbed.
Dr. Mike Patrick: Yeah. Very good point. What about laxatives and stool softeners?
Dr. Cheryl Laubacher: Laxatives and stool softeners have a lot of side effects as well. Eventually, people may use these for real reasons of being constipated. There was a product a long time ago probably dating myself here, called Phenolpthaleine used to be a laxative, used to be use as an agent in chemistry lab. They found a link to cancer, pulled it off the market. Current laxatives and stool softeners there are a lot of them out there. They work in a lot of different ways and certain ones can lead to dangerous side effects. For patients that using them for weight loss agent never indicated for that, you end up having to use a lot of these products, which again leads to diarrhea, electrolyte imbalances and dehydration.
Dr. Mike Patrick: Yeah. And this is one of those things too where if your child is constipated there are real medical issues that could be causing that – things like Hirschsprung disease, hypothyroidism, you definitely want to see your doctor and not just be treating that at home without at least being under their supervision.
Dr. Cheryl Laubacher: Absolutely.
Dr. Mike Patrick: What about the anti-diarrheal drug like Imodium? I hear that a lot when I see kids with diarrhea the parents will say can I give him Imodium to make the diarrhea go away?
Dr. Cheryl Laubacher: I was always told you have to let the disease run its course. There's something in there that should not be in there and there's only one way to let it out. And it's not pleasant but you have to do it. Years ago, I witnessed somebody who'd taken Imodium, had a lot of diarrhea. He was an adult, but what it does is it stops the intestines from moving and it did that in this guy and he was cramped up for the longest, longest time. So it's just really important unless, again, it's a product, especially in children, anti-diarrheals really should not be used in children unless under the advice of a physician. The patients, the kids that I see it using are usually under the advice of a GI specialist. They have something chronically wrong and they need something like this to maintain their health.
Dr. Mike Patrick: Yeah. So just because something is available over the counter doesn't mean it ought to be used.
Dr. Cheryl Laubacher: And that's true with all these products.
Dr. Mike Patrick: Yeah.
Dr. Marcel Casavant: One of these anti-diarrheal drugs is Pepto-Bismal and that has a couple of different medicines and then the bismuth can turn your tongue black, but the other part is salicylate, which is just like aspirin. So all of the reasons not to use aspirin on kids certainly would apply to this product as well.
Dr. Mike Patrick: Sure. And it just doesn't taste that great.
Dr. Mike Patrick: What about teething gels? So, Orajel, Anbesol. Dr. Casavant, what are the concerns with that?
Dr. Marcel Casavant: So the primary concern is these are local anesthetics. They are good at turning off nerves that are complaining about pain. But they have a toxicity on the blood stream as well. They cause hemoglobin to turn into methemoglobin. Methemoglobin cannot carry oxygen. It's a very rare side effect, but children are more likely to get it than grownups. And so just this year the U.S. FDA said we don't even want small kids using low concentrations like baby Orajel anymore. If you're less than two years old we don't want you using these products at all.
Dr. Mike Patrick: Sure. And I ought to mention numbing eardrops also have benzocaine in it which is the medicine that's the problem, so you got to be careful with those too. Obviously, diaper rash, ointments aren't going to be too much of an issue, but baby powder could be an issue if the powder is breathed in to the lungs. Is that correct?
Dr. Marcel Casavant: So there is this terrible, horrible disease called talcosis and that's not really but we're trying to avoid. It's very uncommon to get that. We no longer recommend using powder on babies just because it's hard for them to get away from that if they wanted to sneeze or cough that out. It can be irritating, kind of nasty to get in to the lungs. It's not so much that it's going to develop into that horrible disabling talcosis disease that we see in some workers, but still we don't want kids having to breathe that and they can't get out of the way fast enough.
So a little bit of lotion is OK for your babies but let's stay away from the powders. When the diaper rash happens, it turns out that one of the really effective things to relieving that is fresh air and changing those diapers a lot more frequently. If you want to add some ointment to that Desitin or Balmex are OK. Diaper wipes that are ordinarily just fine for kids can actually be more irritating once the diaper rash starts.
Dr. Mike Patrick: Great. Great advice. What about wart removers? Are there any safety issues with those?
Dr. Marcel Casavant: There are a couple. Yes. More and more of these things are available over the counter now. And if you're very comfortable in your treating a common wart or a plantar wart it's really OK to get some of these products and to apply them. The important thing here is to read the instructions carefully and read all of the warnings carefully and apply it just to the wart. These chemicals can really be very effective against the wart but they can cause burns to normal skin nearby, so you have to apply just to the wart and be very careful with that.
Sometimes, blisters form after that and that's OK. Leave those blisters alone, don't pop them, we'd like them to protect the skin underneath from the environment. And it's perfectly normal for some these warts after they're killed by these products to last for a couple of weeks. The fact that the wart is still there tomorrow or even there next week does not mean we need to start reapplying these medicines. So give them a couple of weeks to fall off. One last thing on the freezing spray that's actually pretty flammable, so use that without anybody smoking nearby.
Dr. Mike Patrick: And again this is one of those things where there may be a lot of different products available over the counter to treat warts, but it's still a good idea to touch base with your doctor and say hey, what do you recommend; what works and how do I use it, just to get some guidance even for over-the-counter stuff.
I've just some other over-the-counter agents for parents to keep in mind. Head lice medications like Nix; there's motion sickness medications like Dramamine and Bonine; acne medications, all of these, anything that you can think of that's over the counter, we just keep in mind they are chemicals, they are going to have a good effect in the body, the effect that you wanted to have, but there's also a potential for bad effects and side effects as well.
And so it's really important that you touch base with your doctor when you're treating pretty much any medical condition, especially when your kids are involved, to get their advice and to find out exactly what to use, how much, how long, how often, all that. And to be aware that if any side effect start occurring while they're on a new medicine to make sure that you're touching base with your doctor. It's really important for any of these agents.
Dr. Casavant, what advice do you have for parents in terms of just buying and using over-the-counter medications?
Dr. Marcel Casavant: First thing is the advantage of these things is supposed to be that you don't have to go to the doctor's office. You don't have to use all those insurance dollars. You don't have to buy the high priced prescription stuff. But sometimes, wow, your doctor really does know what you need and what's really going on with this condition and what's the right product. And even if you're going to use over-the-counter things be comfortable asking your doctor about those and asking the pharmacist for help selecting among the many products that are out there. Especially if your child is already on prescribed meds, make sure before adding over-the-counter medicines that you review those with your doctor and your pharmacist, make sure there aren't any interactions to be alerted for.
Those labels, sometimes the print is small, sometimes the text is a little confusing, it really is worth your time and trouble to read those instruction labels very carefully. I know sometimes they open up to have six or eight pages and it's all squeezed up in this little thing, get out the reading glasses and read those very carefully. And if you've got any questions, talk to one of the experts about that.
If your child has allergies, look for the ingredients list and also the inactive ingredients list, which are sometimes on those labels or boxes in a couple of different places. Check the expiration dates too. That's something when you're getting a prescription your pharmacist does before you get the prescription, but for over-the-counter agents you need that extra safety feature to do that tracking yourself.
Dr. Mike Patrick: Right. What about storing over-the-counter medications at home, what advice do you have for parents there? They come with child safety caps, are those be trusted?
Dr. Marcel Casavant: Oh, those are very good things and you should definitely use those. But we call them child-resistant caps not child-proof caps. They delay the average child from being able to get into them when you turn your eyes away just for a second. But if you leave your child alone with them for long enough most anybody can get into those things. So they help. They're important. And when you're getting medicines, even over-the-counter medicines, get those child-resistant caps.
When you take medicines home, put them out of sight and out of reach. As the Poison Center's advice out of sight and out of reach. The CDC says store them up and away and out of sight, which is another way to look at it.
Dr. Mike Patrick: Sure.
Dr. Marcel Casavant: We talked about poison-proofing the house and we've really want to emphasize that that's a process. It's not a one-time event. Let's go home today and poison-proof our house. Really every time you bring products into the house that might be dangerous you have to think about could my child get into this and how can I protect my child from this.
Dr. Cheryl Laubacher: The CDC does have that 'Up and Away' program. There's a website for it for tips on how to properly store your medicines and it's very simple, upandaway.org and it's about a six-page scroll down list on different things to do in terms of safely storing medications, whether it's prescription or over-the-counter, on how to properly store those and keep them away from your kids.
Dr. Mike Patrick: upandaway.org.
Dr. Cheryl Laubacher: upandaway.org
Dr. Mike Patrick: I'll make sure we put a link to that in the Show Notes. Also, I would add to keep medications in the original containers so that you have the manufacturer lot information and everybody knows exactly what is in that bottle, so don't reuse any bottles or containers at home too. What do you do when something goes wrong, Dr. Casavant? So you have a child, they have ingested something, they've gotten into it or maybe you're not even sure but there's the possibility that they may have ingested something or you know you gave too much or they began having a side effect from a drug. What do you do?
Dr. Marcel Casavant: So lucky for you there's a group of doctors, nurses and pharmacists who are ready to answer your questions and that's at your regional poison control center. Here in the United States we all share the same phone number which is 1-800-222-1222. Give them a call, explain what your concern is, what happened or what might have happened, what's going on and let them ask you a few questions. The nurse or pharmacist or physician on the phone will get some information, will figure out what's happening, will give individualized advice and let you know what's right to do at that point.
Dr. Mike Patrick: Great. And obviously, if your kid is seriously ill you want to call EMS too or call 911, get the Emergency Medical System moving.
Dr. Marcel Casavant: So, many times when children are that ill that will be the first advice from the Poison Control Center is in it to hang up and call 911. And the value of calling the Poison Center early on even on those cases is sometimes it seems very scary to us as parents, but it's really not. And the nurse or pharmacist will ask a couple of questions and figure out what's really happening. If somebody's having trouble breathing, if someone's in the coma, if someone's having a seizure the advice would be hang up and call 911.
Many people need doctor treatment for overdoses but they don't need to get an ambulance ride to the hospital. Many times they can call their own doctor and the Poison Control Center will be able to give that advice to you. And then fortunately, many times folks can stay at home and there are very simple things that can be done at home. Mom and dad can take care of their child without having to go and take the day off or go to the hospital, tie up in ambulance or the doctor's time.
Dr. Mike Patrick: Sure. How is it that the person at the other end of the phone when you call the Poison Center, how do they know everything? I mean there's this huge resource but you can't know everything about every agent that you could get into. So what's the secret?
Dr. Marcel Casavant: There are a few secrets. One of them is a lot of the folks at the Poison Control Center have been there for a very long time. We've got staff who'd been answering Poison Control questions full time, day in, day out, night-day, holidays, weekends included for 20 or 30 years. They're just amazing!
The other thing is our Poison Center and every poison center we spend a fortune every year on resources to make our specialists very smart. We have one commercialized database that now has more than 1.5 million products in it. It includes the name of the product, the ingredients, the concentrations of the various ingredients and then links to current up-to-date expert management and treatment advice for all of those poisons.
So a nurse hears the acetaminophen story a dozen times a day at the Poison Control Center. They don't have to look up that product anymore. But if you come up with something else, maybe that it only shows up at the Poison Center once every five years and that nurse may not be on duty, they have a great resource available to them.
We still sometimes don't know the answer. The database that we subscribe to is updated quarterly. Four massive DVDs show up every quarter, they're packed with data. It's amazing! And yet, still sometimes it's not there and so the nurse or the pharmacist at the Poison Center has physicians on call. They have access to the Internet and manufacturers' websites; they'll be able to get access to the CDC. They'll find that information to help you and your child.
Dr. Mike Patrick: Sure. So the 1-800-222-1222 it's kind of like calling 911, if you call that number then you're going to get your local poison center
Dr. Marcel Casavant: Exactly right.
Dr. Mike Patrick: And I actually have to help parents remember and I think I mentioned this the last time that you're on the program that there's a jingle that's out there. So I have that and I'm going to play it here, I'm going to play a part of it and at the end of the show when we're all done we'll have the entire thing. And I have it in Spanish too. But while you're here on the show I definitely want you to hear this.
Dr. Mike Patrick: OK. So again, at the end of the show if you stick around we'll have the entire jingle for you. And here it is in Spanish.
Dr. Mike Patrick: All right. So that will be helpful to moms and dads out there. And actually, I'm going to put a link in the Show Notes so that if parents want to actually download these or physicians that are out there you may want to actually put these jingles on your website because it will definitely help parents remember what those phone numbers are.
All right. And of course we'll also put a link to the Central Ohio Poison Center in the Show Notes for this particular episode. And I just want to take time to thank Dr. Marcel Casavant and Dr. Cheryl Laubacher for stopping by. And of course I want to thank you, the listener for taking time out of your day to make PediaCast a part of it.
Also, I want to remind you that iTunes reviews are helpful as our links on your webpages and mentions in your blogs, on Facebook, in your tweets and on Google+. Be sure to join our community by liking PediaCast on Facebook. You can also follow us on Twitter, tweet with hashtag #pediacast or hang out with us over on Google+.
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And until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So long everyone.
Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.
[US Poison Control Centers Jingle]