16

Overmedication of Children

An estimated 263.6 million prescriptions were written for children and adolescents in the United States in 2010. Let me recount the case histories of two young patients that illustrate the pitfalls of this kind of overmedication.

Kim

Kim is a two-year-old brought to the pediatric emergency department by her grandmother. The toddler had been agitated and crying inconsolably for the past six hours, and the grandmother was at her wit’s end. Kim’s parents left on a trip that morning and were unreachable. There was no history of trauma or abuse and no time that day when she had been out of her grandmother’s care. Kim was finishing a course of amoxicillin for an upper respiratory illness (URI) but was an otherwise healthy child. Physical exam was normal except for extreme agitation. Results of blood tests, x-rays, and a brain scan were also all normal, as was a spinal tap performed to rule out serious infection or trauma. But results of a urine toxicology screen came back positive for four chemicals: guaifenesin (an expectorant), dextromethorphan (a cough suppressant), phenylephrine (a stimulant and decongestant), and acetaminophen (Tylenol). You can read about the shortcomings and dangers of these drugs in chapter 5. As it turned out, Kim’s parents had given her a generous dose of an over-the-counter (OTC) cough and cold medicine before dropping her off. The child was admitted to the pediatric unit for observation due to accidental overdose and hyperstimulation from the OTC medication. She remained agitated for a total of twenty-four hours before symptoms resolved.

OVERMEDICATING CHILDREN WITH COLD MEDICINES

Each of the drugs found in Kim’s system is a common ingredient in OTC cough and cold medicines. These products generally contain mixtures of drugs, alcohol, sugars, and artificial dyes and account for millions of dollars of annual sales for use in children. They remain very popular despite the fact that this class of drugs was voluntarily withdrawn from the market in 2007 for use in children under age two because of serious safety concerns. Although the US Food and Drug Administration and the American Academy of Pediatrics (AAP) have advised against giving them to children under age six, studies show that use in the two-to six-year-old age group has actually increased.

Parents typically reach for these medications to relieve a stuffy nose, calm a cough, and reduce a fever. Easy availability and colorful displays on drugstore shelves suggest safety. Nonetheless, the 2012 annual report of the American Association of Poison Control Centers lists OTC cough-cold medications among the top three products associated with fatality in children under age five.

The frequency of head colds in children and the potential toxicity of the OTC drugs commonly used in their treatment should motivate us to explore non-pharmacologic alternatives. We should first be informed about the ingredients in the OTC cough-cold products. As noted in chapter 5, guaifenesin is ineffective; large randomized studies have shown it to have no measurable effect. Phenylephrine also lacks demonstrated effectiveness, and there are no studies of its safety in children. AAP clinical policy statements dating from 1997 have found no studies to support the safety or efficacy of dextromethorphan in pediatrics and no indications for its use. In small children, cough is an important protective mechanism to clear narrow airways, making suppression dangerous. Acetaminophen is added to pediatric cough and cold syrups for reduction of fever and pain. Overdoses are common and potentially toxic.

In children, dosing of drugs is uncertain, often approximated from adult studies. Potential interactions with other drugs or dietary supplements is a concern. According to the 2007 National Health Interview Survey, an estimated 2.9 million children and adolescents use some type of dietary supplement, yet many families fail to disclose supplement use to their child’s clinician for fear of a negative response.

Each of these factors is important to consider in thinking about OTC drug use in children. Serious adverse effects and accidental overdose have been reported for every medicine Kim had in her system. The interaction of these drugs put Kim at great risk.

INTEGRATIVE MEDICINE APPROACHES TO TREATING UPPER RESPIRATORY ILLNESS IN CHILDREN

In non-urgent situations, an integrative approach to a common head cold can be quite effective. The following therapies have supporting evidence in pediatric URI:

• Nasal irrigation with saline; a humidifier in the child’s bedroom

• Warm fluids by mouth to help thin mucus

• Buckwheat (dark) honey, in those over one year of age for reducing nighttime cough

• Vapor rub with menthol for congestion

• Oral zinc sulfate, in those over one year of age

• Umcka ColdCare, a homeopathic extract of a species of geranium (Pelargonium sidoides), which has some supporting evidence in children

• Elderberry syrup, which has been shown to be effective in fighting influenza and has a long history of use in children over one year of age

Conversely, therapies currently lacking supporting evidence in pediatric upper respiratory illness include antibiotics, OTC cough-cold medicines, echinacea, and vitamin C.

Acetaminophen or nonsteroidal anti-inflammatories (NSAIDs) may have a place in treatment if used judiciously for fever and pain; however, each carries its own risks (discussed in chapter 8). Accurate dosing of these medications is very important, especially in young children and infants.

Preventive precautions include standard immunizations, annual flu shots (if there are no existing contraindications), regular hand washing with soap and water, and avoidance of crowds or school if the child is sick to allow time for rest and healing. Emerging research suggests some benefit of probiotics in prevention of acute URI in children. Trials involved a range of probiotic strains given over three months or longer. Use of oral zinc in liquid or lozenge form is associated with fewer colds in children.

The bottom line is that although clinicians often feel pressured by parents to write a prescription or recommend over-the-counter medicine for URIs, taking the time to discuss non-pharmaceutical options is at least as important and likely to be much safer for the child. In Kim’s case, it is very possible that the emergency room visit with its associated stress and expense could have been avoided entirely if non-pharmaceutical approaches had been used from the start to relieve the symptoms of her head cold.

Luis

Luis is a thirteen-year-old boy with a diagnosis of metabolic syndrome (insulin resistance, elevated blood glucose, high blood pressure, abdominal obesity, abnormal blood fats). He arrived in the pediatric emergency department after fainting in physical education class during the first lap of a one-mile run. Students had seen Luis drinking a canned energy drink just before the start of class. On arrival in the emergency department, he was alert but jittery and frightened. Cardiac workup quickly ruled out a serious heart problem. Vital signs showed a rapid heart rate and slightly elevated blood pressure. On questioning he admitted to drinking two 16-ounce energy drinks to help him get a good time on the run.

Luis was unaware that most energy drinks contain on average 70 to 240 milligrams of caffeine and 54 to 62 grams of sugar (13 to 15 teaspoons) per can. In comparison, a typical 12-ounce soda contains 35 milligrams of caffeine and 40 grams of sugar (10 teaspoons). Luis’s fainting spell on overexertion, along with jitteriness and hypertension, are classic symptoms seen when energy drinks are taken in excess. Energy drinks and energy shots, heavily marketed to adolescents and young adults, accounted for $6.9 billion in sales in the United States in 2012. A 2011 AAP statement cautioned that children and adolescents should not consume energy drinks because of their high content of caffeine and sugar. Reports of adverse cardiovascular events, sleep and behavioral disorders, hypertension, seizures, and death have been recorded with their use, especially when they are combined with alcohol, a practice common in young adults.

A review of Luis’s medical history showed that he had experienced rapid weight gain since age nine. He had previously tried an over-the-counter version of orlistat (Alli), a drug used to treat obesity by blocking intestinal absorption of fats, but discontinued it due to uncomfortable side effects (flatulence and diarrhea). The parents stated that Luis’s pediatrician had recently given him three prescriptions: one to lower blood sugar, a second to reduce cholesterol, and a third for depression, and had considered adding a fourth drug for blood pressure control. The parents filled the prescriptions but were alarmed at the list of potential side effects and wanted to help get Luis off the drugs.

A review of Luis’s lifestyle habits showed frequent intake of processed foods high in sugar and flour, processed meats, sugary beverages, and energy drinks to “help him study” and “give him energy.” He spent an average of six hours a day on video games, got only about seven hours of sleep a night, and rarely went outdoors. He took no regular exercise outside of school physical education twice a week. Luis acknowledged feeling depressed due to bullying but denied wanting to harm himself or others.

OVERMEDICATING OBESE CHILDREN

• Approximately one in three children in North America is overweight or obese, including those in preschool and elementary school.

• Obesity in childhood commonly persists into adulthood.

• The majority of obese children have at least one related medical condition, such as high blood pressure, that may require medication.

• Mental health issues such as anxiety, depression, social withdrawal, bullying, binge eating disorder, and low self-esteem are very common in obese children and are often treated with prescription medications.

• Insufficient sleep has been linked to overweight and obesity in children and may be treated with prescription or OTC medications. (Sleep aids are discussed in chapter 6.)

The medications prescribed for Luis are recommended routinely in cases of pediatric obesity:

Metformin

Used to treat insulin resistance, which often accompanies obesity, metformin (Glumetza, Glucophage) is also used “off label” to enhance weight loss in some obese children. (Its approved use in diabetes treatment is discussed in chapter 14.) Its most common side effects are nausea, vomiting, diarrhea, and increased gas. In adults, long-term treatment with metformin has been shown to increase the risk of vitamin B₁₂ deficiency; long-term studies in children and adolescents are lacking.

Statins

Universal cholesterol screening is recommended between ages nine and eleven years to identify children at risk for abnormally high levels. We have very limited data on the impact of statins in children. (See chapter 2 for detailed information on these drugs.)

Antidepressants

Weight gain is a relatively common side effect of antidepressant medications, a compounding problem for overweight adolescents like Luis. (Use of these and other psychiatric medications in children is discussed in chapter 10.)

Antihypertensives

Obese kids often have high blood pressure and are prescribed the same antihypertensive drugs used in adults. (These are discussed in detail in chapter 13.)

Orlistat

Sold over-the-counter as Alli and by prescription as Xenical, orlistat is a lipase inhibitor, meaning it inhibits the enzyme needed for breakdown of fats and prevents their absorption from foods. The main side effects are flatulence, oily loose stools, and oily spotting on clothes, which not surprisingly result in poor compliance. Because it interferes with absorption of fat-soluble vitamins, orlistat can also affect growth and development. Long-term studies on its effects in children and adolescents are lacking.

Pediatric obesity is a prevalent and complex problem that resists pharmaceutical treatment. This has fueled interest in more extreme approaches, such as bariatric surgery in adolescents (gastric banding or bypass). Although surgery can result in weight loss and reversal of type 2 diabetes, it is associated with vitamin deficiencies, chronic malabsorption, and other significant risks and should be reserved for carefully screened, dangerously obese adolescents.

INTEGRATIVE MEDICINE APPROACHES TO TREATING OBESITY IN CHILDREN

Expert consensus is that non-pharmacological approaches should be first-line treatments for obesity, yet few pediatricians are trained to help patients with comprehensive lifestyle change. This gap in medical education presents an important opportunity for integrative medicine practitioners, who are trained in these areas:

• Nutrition counseling to promote healthy whole foods in place of processed foods and sugary beverages

• Motivational interviewing to catalyze and support behavior change

• Mind-body therapies to manage anxiety and depression and cultivate self-regulation of emotions

• Advising about low-impact physical activities, such as yoga and tai chi

• Counseling on sleep hygiene

• Environmental health education to reduce exposures to endocrine-disrupting chemicals linked to obesity

• Use of selected dietary supplements to fill gaps in the diet, such as omega-3 fatty acids, vitamin D, and probiotics

• Promotion of family and community support to build positive social connections.

After the emergency department scare, Luis was determined to lose weight and stop all the medications. His pediatrician brought in a registered dietician and a behavioral therapist to help. Motivational interviewing enabled Luis to make the shift to a healthier diet and find physical activities he enjoyed. He eliminated the energy drinks. He tried clinical hypnosis and guided imagery along with breathing exercises to boost his self-esteem and cope with school challenges. Luis lost weight gradually and was able to wean off the medications over the course of a year. The following year he won a regional science fair prize for a project on their harmful effects.

BOTTOM LINE

Between them, Kim and Luis were put on a total of eight medications for the treatment of two common medical conditions. These included guaifenesin, dextromethorphan, phenylephrine, acetaminophen, amoxicillin, metformin, a statin, and an SSRI, each with potentially serious adverse effects. The caffeine in Luis’s energy drinks added a potent stimulant to the tally. Kim’s story highlights the risks involved with seemingly safe and easily available OTC medications. Luis’s story emphasizes the dangers of direct marketing of stimulating beverages to children and the futility of relying on pharmaceutical treatment for lifestyle-driven diseases. Both parents and physicians should be alarmed at the widespread overuse of medications—in millions of children—for treatment of other common conditions such as asthma, attention deficit hyperactivity disorder (ADHD), autism, diabetes, arthritis, gastrointestinal disorders, anxiety, and depression.

The prevalence of medication use in children, along with the unpredictability of individual response and high risk of overdose, add up to a powerful argument for the role of integrative medicine in young patients. The emphasis should be on prevention, maximum engagement of the child’s innate healing response, reduction of medications, and lifestyle counseling. I would argue that these approaches must be supported by proactive health care reform and fair insurance reimbursement.