Mary Barna Bridgeman, PharmD Rupal Patel Mansukhani, PharmD
Case 1—Fever Relief
AC is the mother of an 8-month-old girl who comes to your pharmacy seeking a recommendation for an acetaminophen- containing product to treat fever in her daughter. AC was instructed by her daughter’s pediatrician to pick up acetaminophen and was also provided directions for dosing and frequency of administration. AC’s daughter has no known allergies to medications and takes no other medications. Provide AC with information regarding new changes to acetaminophen-containing products and counseling to assure the safe use of a product for treatment of her daughter’s fever.
Fever represents one of the most common complaints that sends parents into the pharmacy seeking treatment recommendations and to pediatricians’ offices for evaluation. Although most cases of fever are usually self-limiting, children suffering from very high temperatures, who experience symptoms of infection, experience fever for longer than 3 days, or develop signs of dehydration should forgo self-treatment without the advice of their physician.1 The mainstay of nonpharmacologic therapy for fever is to ensure adequate hydration to prevent dehydration. Unless contraindicated, children with fever should increase fluid intake by at least 1 to 2 oz of fluid each hour.1
Acetaminophen is commonly administered to improve patient comfort and reduce temperature in patients suffering from febrile illnesses. Most recently, acetaminophen has garnered much attention in the news media related to product availability, accuracy of drug dosing, and product labeling revisions.
Within the next several weeks to months, in accordance with recommendations from an FDA Advisory Committee, pharmaceutical companies that manufacture single-ingredient acetaminophen products will no longer produce concentrated infant drops (80 mg/0.8 mL or 80 mg/1 mL); the children’s strength liquid concentration (160 mg/5 mL) will become the standard available concentration.2 The availability of multiple strengths and concentrations of liquid acetaminophen products has been cited as a causative factor contributing to overdose and acetaminophen toxicity. Accordingly, over the next few months it will be imperative for the pharmacist to remind consumers of these labeling changes and product withdrawals.
Additionally, over the next year, the FDA has recommended a product labeling change to include dosing information for children from 6 months to 2 years of age based on weight. Although acetaminophen products currently contain dosing information according to a child’s age and weight, labeling revisions will emphasize that weight—and not age—should be preferentially used when determining the dose of medication for administration to an infant or child.3
Case 2—Water-Clogged Ears
EM is a 13-year-old boy brought into your pharmacy by his father, who is seeking a recommendation for removing water from his son’s ears. His father reports that EM has been in the water all summer in their backyard swimming pool. Over the past 2 days, EM has been complaining of having water moving around in his ear canals whenever he moves his head. EM denies having pain or fever. His father reports he has never had problems with chronic ear infections or ruptured tympanic membranes in the past. EM has no known medication allergies and takes no other medications. What OTC medication and counseling points can you offer to EM to alleviate his symptoms?
Water-clogged ears result from water becoming trapped in the ear canals, usually due to the anatomy of the ear canal or due to accumulation of excessive cerumen.4 Symptoms of water-clogged ears can include discomfort, a feeling of fullness within the ear canal, or even hearing impairment, and can be caused by showering, bathing, or swimming.5 The easiest means of preventing water from becoming trapped in the ear canals is to instruct the patient to use ear plugs or thoroughly dry the ears after partaking in water activities. Tilting the head to expel excess water or using a blow dryer on the lowest setting are other mechanisms for minimizing excessive moisture.
OTC ear-drying agents approved for use in children 12 years and older for the treatment of water-clogged ears contain isopropyl alcohol and anhydrous glycerin. Isopropyl alcohol serves as a drying agent to help with evaporation of excessive water. Anhydrous glycerin is added to these products to prevent over-drying and to protect the skin of the inner ear from maceration. Counsel EM’s father that his son should instill 4 to 5 drops into each affected ear each time he gets out of the swimming pool.5 If his symptoms persist for several days after using these agents or pain or fever develops, physician referral is warranted. PT
Dr. Bridgeman is an internal medicine clinical pharmacist in Trenton, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University. Dr. Mansukhani is a clinical pharmacist in South Plainfield, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University.
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