Acetaminophen Toxicity in Children

To the Editor.—After reviewing the position statement on “Acetaminophen Toxicity in Children” by the American Academy of Pediatrics’ Committee on Drugs,1 we were left with a question regarding treatment. Why does the Committee recommend the use of activated charcoal if treatment is initiated within 6 to 8 hours of ingestion? The position statement on the use of activated charcoal by the American Academy of Clinical Toxicology and the European Association of Poison Centres and Clinical Toxicologists2 advocates the use of activated charcoal within 1 hour of ingestion of a potentially toxic amount of poison. This position statement further states that there is insufficient data to support or exclude the use of activated charcoal if administered more than 1 hour after ingestion. We are concerned that the Committee on Drugs is perpetuating use of a therapy that is very unlikely to be efficacious. We can understand recommending the use of activated charcoal within 1 hour of ingestion, but 6 to 8 hours seems unreasonable. What is the Committee’s rationale in making their recommendation?In Reply.—The authors seem to interpret the statement “there is insufficient data to support or exclude the use of activated charcoal if administered more than 1 hour after ingestion” to indicate there are sufficient data to conclude that later charcoal treatment is not efficacious for any ingestion. The Committee on Drugs does not interpret the data that way.The Committee on Drugs considered the toxicity of activated charcoal to be minimal and felt that newer sustained-release forms of acetaminophen represent an important risk for toxicity, even death, from prolonged exposure. The Committee on Drugs concluded that the possibility of reducing absorption during an interval longer than 1 hour justified treatment with a relatively benign, although messy, drug such as activated charcoal. This position is consistent with recent recommendations for treatment of acetaminophen overdose by toxicologists as cited in the statement1 and with earlier recommendations of other pharmacologists.2 The Committee on Drugs doesn’t interpret “insufficient data” to represent a contraindication to a relatively benign treatment, such as charcoal, that has the potential for removing acetaminophen more than one hour after ingestion.