It is that time of year again. We are in the midst of flu season, which means that it is time to remind our patients’ parents about the importance of using acetaminophen instead of aspirin. This fact became evident when several guardians of our patients came in within a few days of each other in late November to early December unaware of the dangers of giving their children aspirin and other salicylate medications.
Case 1: A 4-year-old boy presented with mild diarrhea, but otherwise was clinically well. The diarrhea started while visiting family in Mexico. The mother took out a small bottle of Pepto-Bismol (bismuth subsalicylate) liquid, which she gave him 2 days previously. The bottle did have, in small font, a warning about Reye’s syndrome on the label, which the mother did not notice. She also did not think it pertained to her son anyway. During the visit, she was counseled on this being early influenza season and the avoidance of salicylate products since the 1980s in children, with the exception of cardiac uses.
Case 2: A 16-year-old male presented with his grandmother with a few scattered vesicles and low-grade fever. He had plans to go to Florida in a few days with friends and wished to know if he would be able to go. He had one dose of varicella vaccine when he was a toddler. Varicella IgM and IgG were ordered. When asked, the grandmother stated that she did not remember the warning signs about Reye’s syndrome posted in the pharmacies 30 years ago. In addition, she vaguely remembered baby aspirin not being made anymore, but she could not remember the reason why.
Case 3: An 18-year-old female with a medical history of occasional migraines controlled with over-the-counter products presented for a school form. Her mother mentioned that a relative had influenza symptoms. When we looked up the migraine medication, it was a generic aspirin/caffeine product. When counseled on Reye’s syndrome, the mother did not remember it at all, even though she was a teenager in the 1980s; she stated that she did remember her mom using only Tylenol for her illnesses.
Reye’s syndrome, a rare but serious condition causing liver degeneration and encephalopathy presenting in children younger than 18 years, was first described in 1963.1 Symptoms include mental confusion, vomiting, and even coma. The cause is unknown; however, salicylates have been implicated as a possible causative agent.
Products containing salicylate include but are not limited to aspirin and Pepto-Bismol. Studies linked Reye’s syndrome epidemiologically to recent illness with influenza or varicella and the use of aspirin. In 1978, the Centers for Disease Control and Prevention was informed that several children developed Reye’s syndrome during an influenza outbreak, and by 1980, the CDC demonstrated a link between those patients and the administration of salicylate-containing medications.2 Around the same time, more studies came out to support these findings. In 1980, 555 cases of Reye’s syndrome were reported in the United States. To decrease the occurrence, the CDC, American Academy of Pediatrics, and the U.S. Surgeon General tried to raise awareness of the association between Reye’s syndrome and aspirin by publishing journals, releasing warning statements, and including a “Black Box” warning in 1986 informing parents to not give aspirin to children and teenagers with influenza or chicken pox. Baby aspirin was removed from use for routine fevers in the mid-1980s and large warning signs would be found in every pharmacy for about 10 years. These warning signs are gone now.
As pediatricians and other primary care physicians, we have so many topics that we must address in the limited time we have allotted for each patient. However, we need to remind our patients and their parents about Reye’s syndrome and the importance of avoiding aspirin and salicylate products in children. Due to the public awareness of Reye’s syndrome in the 1980s and into the 1990s, the incidence decreased.2 From 1987 to 1993, fewer than 37 cases were reported in the United States and from 1994 to 1997, fewer than 2 cases were reported.
This demonstrates the importance of educating our patients and their parents about this syndrome and ways to avoid it. Based on the three clinical cases presented, it is clear that at least some of our patient’s guardians are unaware of this threat to their children. As physicians, it is our responsibility to educate our patient populations, but we should also ask our friends at our local supermarkets and pharmacies to dust off those old warning signs and help spread the word. While we are in flu season, let’s not forget to take a few minutes to inform our patients about this awful, but preventable syndrome.
References
1. Pediatrics. 1980 Dec;66(6):859-64.
2. J Gen Intern Med. 2012 Dec;27(12):1697-703.
Rachel Masia is a third-year medical student at Rowan University School of Osteopathic Medicine, Stratford, N.J. Dr. Alan Masia, Ms. Masia’s father, has a practice in Toms River, N.J. They said they had no relevant financial disclosures.
