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Student: Nicole Sycamore
Supervisors: Dr Ruth Savage, Kathryn Henshaw
Sponsor: Pegasus Health

Lay Report

Paracetamol is an analgesic used widely in infants and children in the community. It has few side effects when recommended doses are used but very rarely can cause serious liver damage in overdose. It appears that some of these liver reactions that have been reported in children may have been due to overdose caused by inaccurate dosing and prolonged use. As paracetamol can be obtained from pharmacies as well as by prescription and tablet forms are sold from various outlets, there is a need to ensure that parents receive adequate, relevant information that they can understand about the use of paracetamol. However, there is limited knowledge about what parents currently know and understand making it hard to provide focussed, relevant advice.

The aims of this study were to investigate parents' knowledge about the recommended use of paracetamol in children under 12 years, and to assess how paracetamol is used and administered by parents attending a general practice with a focus on the last use prior to interview in a child under 12 years.

A written questionnaire and a face-to-face interview were designed to administer to parents waiting for appointments at five general practices around Christchurch. The written questionnaire consisted of 20 questions based upon the last time the parent treated their child with paracetamol. These consisted of parent and child characteristics, source of paracetamol and advice received, patterns of paracetamol use, and awareness and observation of adverse effects. The face-to-face interview involved inviting a smaller subset to explore more complex issues associated with use, such as strength and doses of paracetamol, concerns, and specific details of advice received. These parents were also asked to select from a range of measuring devices and household spoons to measure out the dose which they last gave to their child (paracetamol dose by age and weight charts were available for reference). They were asked to select the measure or spoon that was similar to the one they used for their child

Overall, 200 completed written questionnaires were obtained, and 51 face-to-face interviews were carried out from visits to the five practices. Only one parent declined to complete the questionnaire. Of the 200 completed questionnaires, one was rejected because the parent had not administered paracetamol to a child although she had received a prescription.

Findings from questions in the written questionnaire regarding parent and child characteristics revealed that 77% of parents identified themselves as New Zealand European, with 13% identifying as Māori. Nearly 80% of parents had educational qualifications at secondary level or higher. Nearly half (46%) of parents had administered paracetamol to one of their children within the last week and over 70% in the last month. The age range of the child last treated with paracetamol was between one month and 11 years, with a median age of 2.3 years.

From questions about sources of paracetamol and advice received, 82% of parents reported that they obtained paracetamol through a prescription from their doctor. This indicates that the parents interviewed in a general practice setting were seeking medical advice to obtain their prescriptions, however this study confirms that paracetamol is not always used for the illness for which it was prescribed as 54% of parents had not consulted a doctor or nurse for the illness of their child last treated with paracetamol. Nineteen percent of parents gave paracetamol obtained or prescribed for a different child.

A third of parents recalled receiving information about correct doses from their doctor. In the face-to-face interview, 47% of the 43 parents who had been prescribed paracetamol by their doctor reported receiving or being directed to written information to help them remember. A lack of written information could have implications for parents' future administration of paracetamol to their children as recall of advice received may be difficult, and the dose printed on the bottle may not be appropriate as the child grows. Parents were most likely (26%) to seek advice from Healthline if they had concerns about the use and administration of paracetamol, with 19% reporting they would seek advice from their practice nurse.

Results from questions related to paracetamol use indicated that,seventeen percent of parents reported “fever” as the sole indication for use without other symptoms such as discomfort. The routine use of medicines for mild to moderate fever alone (to normalise temperatures) is not usually considered necessary. A further 14% of parents treated their child with paracetamol for non-specific reasons such as the child being unsettled, upset or generally unwell.

A very high proportion of parents (86%) correctly measured out the dose they last administered to their child, and those who measured incorrectly did so because they used a household spoon This is a marked improvement from the 67% accuracy in a 1997 study. Greater distribution and use of measuring devices may have contributed to this.

Other indications of less then optimal use that were of more concern were identified. Three parents had given the maximum recommended daily dose for three days or more without consulting although a medical consultation is recommended if paracetamol is needed by a child for more than two days. Seven other parents exceeded the recommended number of daily doses.

Finally, questions relating to the awareness and observation of adverse effects revealed nearly three-quarters of parents were unaware of any adverse effects of paracetamol, including those resulting from overdose, and 77% of parents had no concerns about paracetamol. This lack of awareness of potential harm may be related to the observations in this study of paracetamol use for non-specific and apparently trivial reasons. From observations made by parents in the questionnaire and face-to-face interviews it was noted that many believed that paracetamol was harmless and could be used for almost any reason to treat their children.

Overall, parents attending a general practice generally had a good knowledge about how to use paracetamol, and were accurate in measuring doses with the correct devices. Further education is needed to improve parents' knowledge about the correct reasons for use to help aid in the prevention of harmful effects, as well as to raise awareness about potential adverse effects particularly with excessive doses. Targeted interventions may be needed for a minority of parents who use paracetamol inaccurately and further work is needed to identify any particular characteristics of this group.

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