
Acetaminophen use in pregnancy linked to child's behavioral problems - erdevs
http://www.latimes.com/science/sciencenow/la-sci-sn-acetaminophen-pregnancy-behavior-problems-20160815-snap-story.html
======
fifteenforty
Anaesthesia trainee here (doctor, similar to an anesthesiology resident in US
vocabulary)

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.

~~~
rand_r
Given how taxing these types of drugs are, why are opiates not an option for
most people? They don't cause any long or short-term damage to organs.

~~~
pjc50
Fears about addiction, and a huge dispute over how well-founded those fears
are.

~~~
douche
Which is slightly odd, considering we had something like 100 years during
which codeine, cocaine, heroin, morphine, and a whole bevy of other currently-
scheduled drugs were sold essentially unregulated, over the counter and at
every county fair in patent medicines. Surely there must be some data there
that some conclusions could be drawn from.

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ASpring
Good of the authors to explicitly acknowledge that there is no causal link
indicated here.

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.

------
rabboRubble
Acetaminophen is one of the more dangerous over the counter drugs available.
It is right up there with alcohol for causing liver failure.

[http://www.mayoclinic.org/diseases-conditions/liver-
failure/...](http://www.mayoclinic.org/diseases-conditions/liver-
failure/basics/causes/con-20030966)

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.dailymail.co.uk/news/article-2064964/Warning-hidden-
danger-taking-Paracetamol.html)

[http://www.esquire.com/lifestyle/health/a235/esq1103-nov-
bod...](http://www.esquire.com/lifestyle/health/a235/esq1103-nov-body/)

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.

~~~
marpstar
I never take acetaminophen anymore and generally only take ibuprofen, and only
a few times a year. Serious question: Why do people even take acetaminophen
anymore?

~~~
rabboRubble
The reason I am freaked about acetaminophen is that I suffer from migraines.
The most effective OTC medicine for me is Excedrin Migraine (a combo of
acetaminophen, aspirin, and caffeine). I didn’t realize that this med
contained acetaminophen. I also didn’t realize that the product name Tylenol
equaled acetaminophen. Only put things together when I heard about people
overdosing and examined my medicine cabinet and check product labels. I think
I had 3-4 different medications that contained some amount of acetaminophen,
mostly cold medications. I know I’ve taken most of them in combination and
probably in an unsafe way.

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.

~~~
MichaelGG
Why are you medicating with _anything_ without looking at what it is? Read
label. If not understood, quickly look up the medications involved.

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.

~~~
Broken_Hippo
I worked in a pharmacy (not a pharmacist), and this sort of thing is extremely
common. I helped a nicely dressed fellow one night, who asked where the Advil
was. I showed him, and pointed out the store brand (Much cheaper). The guy
told me that ibuprofin doesn't work for him, only Advil. This happens with the
cough and cold medicines as well - most are the same combination of drugs,
sometimes with or without one, and folks will buy different labeled
combinations at different times.

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.

~~~
rabboRubble
Exactly... you hear that "Tylenol" causes liver damage if taken incorrectly.
What I didn't realize that Tylenol = Acetaminophen = Paracetamol, in a long
list of stuff.

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.

------
kafkaesq
_A.k.a._ paracetamol, Tylenol. If validated, the implications of this finding
are potentially quite troubling.

------
contingencies
OK well I'm not pregnant but I've been downing tonnes of these things for a
sprained ankle recently. I don't like doing it as they are hepatoxic to some
extent, and would prefer codeine, but the authorities make it too hard to get
your hands on in most countries. Grr.

~~~
stephentmcm
For a sprained ankle you likely want a NSAID like ibuprofen...

~~~
ars
Agreed. Acetaminophen is really not safe in high quantities. Ibuprofen has a
much better safety profile.

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.

~~~
contingencies
Thanks. Have ibuprofen too but it apparently has nasty side effects if you
take it too long. Right now I am looking at weeks, so trying to limit
consumption. Was given one SAID and one NSAID but also too many side effects
for my liking.

~~~
wahern
The amount and duration needed to see side effects with ibuprofen is much more
compared to acetaminophen. Look at the actual research and the amounts and
durations studied. Ibuprofen is ridiculously safe if you're outside particular
known risk groups, and often even then. Generalized side effects like hearing
loss are far preferable to, e.g., the deaths that acetaminophen regularly
causes. But AFAIU hearing loss is exceptionally rare even for heavy users.

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.

~~~
contingencies
Thanks for sharing your father's story. Luckily my pain isn't chronic level,
so I am tapering off already after a few days. My heaviest use is 6-8 OTC
pills over 24 hours, probably not considered out of normal. Personally,
however, I'm for OTC codeine. It costs nothing to produce, is stupendously
effective, and the only problem is potential addiction (the least of all
opiates IIRC) which is basically a non-issue with (cheap) supply.

~~~
stordoff
I'm also in favour of OTC codeine with appropiate box warnings etc. (it works
very well for me [currently prescribed], and the difference between an
analgesic dose and a fatal dose is fairly wide - 15-60mg vs 100s mg). That
said, calling potential addiction a non-issue is a little on the optimistic
side. Codeine combinations (with ibuprofen or paracetamol/acetaminophen) are
OTC in the UK, and problematic addictions (ever-increasing doses, dependence,
impacts on work/family) are certainly not unheard of.

------
jaboutboul
Ummm maybe it's the actual ailment that caused the mother to take the
acetaminophen that is the root cause?

------
ars
BTW Pregnant women should not take ibuprofen either due to the potential for
premature closure or patent ductus arteriosus.

So if this is true I don't think there are any safe painkillers during
pregnancy.

------
shanacarp
I'm starting to become a little shocked at the lack of black box warnings
involved with Acetaminophen given how easy it is to poison yourself with it,
and what appears to be a growing list of long-term side effects

------
atemerev
That would somewhat explain the rise of prevalence of ADHD.

(My mother didn't take acetaminophen during her pregnancy. Still have adult
ADD. Unlucky me.)

------
erdevs
A more rigorous write-up of this paper: [http://www.npr.org/sections/health-
shots/2016/08/15/49006966...](http://www.npr.org/sections/health-
shots/2016/08/15/490069664/how-big-a-risk-is-acetaminophen-during-pregnancy)

------
pessimizer
What an unnecessary, garbage drug; one that's responsible for half the liver
failures in the United States. Maybe a restriction on pregnant women taking it
could move it behind the counter, or better, into the dimly-remembered past.

~~~
dragonwriter
Given the issues with NSAIDs in general (and even moreso with NSAIDs with
particular populations), acetaminophen being available remains important. It
definitely has dangers particularly if used improperly (and a much narrower
gap between normal and dangerous doses than many other drugs), but its not an
unnecessary or garbage drug.

~~~
caf
Right - for example pain management in Crohns.

------
sangd
"Finding a link between acetaminophen use during pregnancy and an outcome
affecting the child is no proof that acetaminophen is the cause of the
outcome. But the authors contend that the study results do heighten concerns
that fetal exposure to acetaminophen can give rise to neurodevelopmental
problems." This study and its results are misleading. The scope & method
aren't good for the conclusion. It doesn't answer whether people should use
tylernol while pregnant or how much can they consume.

------
glibgil
Or, people with headaches produce offspring with headaches, but kids don't
know they have headaches and just get angry and act out

~~~
redofrac
From the article: "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. They looked for a link between a child’s behavioral problems at
age 7 and acetaminophen use by the mother’s partner during pregnancy. Again,
they found no association."

~~~
hinkley
You guys are downvoting a guy that didn't ask what you're answering. Who isn't
reading for content?

------
kchoudhu
So: pregnant women can't do ibuprofen, and they can't do acetaminophen. What's
left for them?

~~~
jinpa_zangpo
There are non-drug methods of dealing with pain.

~~~
figgis
Can you expand on what non-drug methods you are speaking about? And whether
you are speaking about immediate relief or long term relief? These drugs used
are usually used for immediate pain.

