THE PAEDIATRIC SOCIETY
OF NEW ZEALAND
Secretariat:
Email:
Website:
Weee
Denise Tringham
P O Box 22 234
Wellington 6441
Tel:
(04) 938 4827
Fax: (04) 976 4827
denise@paediatrics.org.nz
www.paediatrics.org.nz
26 January 2011
Greg Williams
Therapeutic Group Manager
PHARMAC
P.O. Box 10-254
Wellington 6143
Email: greg.williams@ Pharmac.govt.nz
Dear Greg
RE: Restrictions for dispensed volumes of paracetamol liquid
The Paediatric Society of New Zealand (PSNZ) would like PHARMAC to review the volume
restrictions for paracetamol liquid dispensed by community pharmacies.
We have gathered anecdotal information from the PSNZ listserver that large volumes of
paracetamol liquid are sometimes being issued as STAT dispensings by community
pharmacies eg one litre or more.
Paracetamol remains the most common substance requiring hospital referral for children for
overdose ingestion. Those children who achieve potentially toxic blood levels have usually
had access to large volumes of liquid paracetamol ie more than 200ml of 250mg in 5ml. While
it has been suggested that significant hepatic injury in children is extremely rare (1) it is our
experience, both in New Zealand and the UK, that some childhood paracetamol poisonings
come close to and even require a liver transplant, albeit rarely. The children most at risk are
those under 5 years of age who are tempted to drink whole bottles of liquid “because they like
the taste”.
An additional concern with the large volume dispensing is the difficulty in securing one litre
bottles with safety caps as we understand this size of safety cap is not available in New
Zealand. These large bottles may also be more difficult to store in high cabinets, therefore
ending-up in more-accessible/less safe areas such as bench tops and low cupboards,
We are also aware of families that keep these large volumes of paracetamol liquid for use by
various family members over a number of years. The dispensed bottle will have dosing
instructions for one patient, at a particular age, but no dosing information for other family
members. Smaller dispensed volumes may reduce the potential for families to participate in
this practice with its associated risk of medication error.
Hepatic injury from paracetamol in the < 6 year old age group is reported following a single
ingestion of > 200mg/kg body weight. (1) This equates to a 3 gram or more ingestion by a 15
kg child (average weight for a 2 to 3 year old).
We suggest that the incidence of paracetamol poisoning among young children could be
limited by the introduction of the following recommendations:
1. A 200ml volume restriction for dispensed paracetamol liquid.
This equates to a maximum dispensing of 10 gram of paracetamol which would be
approximately one weeks therapeutic dosing. Ingestion of this total volume would still
be potentially toxic to a young child; however the risk is significantly reduced.
“Health of our children: Wealth of our nation”
2.
An exemption to this supply restriction could apply for situations where paracetamol
liquid is required for the management of chronic pain eg. for children and adults who
are unable to swallow tablets.
In these cases the prescriber could endorse the
prescription
“Certified condition – condition identified in writing”
We look forward to discussing this further with you if more clarification is needed.
Kind regards
Brenda Hughes
Convenor
Pharmacist/Therapeutics SIG
Paediatric Society of NZ
Julie Chambers
Dr Michael Shepherd
Child Injury Prevention
Clinical Director
Starship Trauma ServiceChildren’s Emergency Dept
Starship Children’s Hospital
Letter endorsed by:
Dr Rosemary Marks, President, Paediatric Society of NZ
Dr Simon Rowley, Consultant Paediatrician/Neonatologist, Auckland City Hospital (ACH)
Dr Diana Purvis, Paediatric Dermatologist, Starship Children’s Hospital
Andrew Sutton, Pharmacy Team Leader, Womens & Children’s Health, ACH
Dianne Wright, Clinical Advisory & Paediatric Pharmacist, Taranaki Base Hospital
Caroline De Luca, Senior Paediatric and Formulary Pharmacist, Auckland City Hospital
Roisin Daly, Senior Paediatric Oncology Pharmacist, Auckland City Hospital
Reference:
1. Daly F, Fountain J, Murray L et al. Guidelines for the management of paracetamol poisoning in
Australia and New Zealand – explanation and elaboration. MJA 2008;188: 296-301.