Studies Suggest an Acetaminophen-Asthma Link

December 19, 2011
New York Times


Dr. John T. McBride, Akron

Children’s Hospital.

The sharp worldwide increase in childhood asthma over the past 30 years has long perplexed researchers, who have considered explanations as varied as improved hygiene and immunizations. Over the last decade, however, a new idea has emerged.

The asthma epidemic accelerated in the 1980s, some researchers have noted, about the same time that aspirin was linked to Reye’s syndrome in children. Doctors stopped giving aspirin to children with fevers, opting instead for acetaminophen. In a paper published in The Annals of Allergy and Asthma Immunology in 1998, Dr. Arthur Varner, then a fellow in the immunology training program at the University of Wisconsin School of Medicine, argued that the switch to acetaminophen might have fueled the increase in asthma.

Since then, more than 20 studies have produced results in support of his theory, including a large analysis of data on more than 200,000 children that found an increased risk of asthma among children who had taken acetaminophen. In November, Dr. John T. McBride, a pediatrician at Akron Children’s Hospital in Ohio, published a paper in the journal Pediatrics arguing that the evidence for a link between acetaminophen and asthma is now strong enough for doctors to recommend that infants and children who have asthma (or are at risk for the disease) avoid acetaminophen.

Dr. McBride based his assertion on several lines of evidence. In addition to the timing of the asthma epidemic, he said, there is now a plausible explanation for how acetaminophen might provoke or worsen asthma, a chronic inflammatory condition of the lungs. Even a single dose of acetaminophen can reduce the body’s levels of glutathione, an enzyme that helps repair oxidative damage that can drive inflammation in the airways, researchers have found.

“Almost every study that’s looked for it has found a dose-response relationship between acetaminophen use and asthma,” Dr. McBride said. “The association is incredibly consistent across age, geography and culture.”

A statistical link between acetaminophen and asthma has turned up in studies of infants, children and adults. Studies have also found an increased risk of asthma in children whose mothers who took acetaminophen during pregnancy.

For instance, a study published in The Lancet in 2008 examined information collected on more than 205,000 children from 31 countries as part of the International Study of Asthma and Allergies in Childhood, known as the Isaac study. The 2008 analysis found that children who had taken acetaminophen for a fever during the first year of life had a 50 percent greater risk of developing asthma symptoms, compared with children who had not taken the drug. The risk rose with increasing use — children who had taken acetaminophen at least once a month had a threefold increase in the risk of asthma symptoms.

A study published by British researchers in 2000 using data from the Isaac study found that the prevalence of asthma increased in lock step with sales of acetaminophen in the 36 countries examined. The more acetaminophen used in a country, the greater that country’s prevalence of asthma.

A meta-analysis published in 2009 calculated that children who had taken acetaminophen in the past year had nearly double the risk of wheezing compared with those who had not taken the drug. “We know that acetaminophen can cause increased bronchial constriction and wheezing,” said Mahyar Etminan, a pharmacoepidemiologist at the University of British Columbia and lead author of the study.

Still, Dr. Etminan believes it is not yet clear that acetaminophen itself is responsible for the increasing prevalence of asthma. “Children who take acetaminophen are usually getting it for fever control, and they get fevers because they have viral infections, which on their own are associated with developing asthma later in life,” Dr. Etminan said. “It’s hard to tease out whether it’s the drug or the viral infection.”

Another potential problem, Mr. Etminan said, is that many of the studies required parents to accurately recall how much acetaminophen they gave their children, and how often. Parents whose children have asthma are likely to scrutinize the events that preceded an attack, he said, and thus may be more likely than other parents to recall giving their children the drug.

So far, only one randomized controlled trial has investigated the link. Researchers at Boston University School of Medicine randomly assigned 1,879 children with asthma to take either acetaminophen or ibuprofen if they developed a fever. The results, published in 2002, showed that children who took acetaminophen to treat a fever were more than twice as likely to seek a doctor’s care later for asthma symptoms as those who took ibuprofen.

Other trials are in the works. Dr. Richard Beasley, a professor of medicine at the Medical Research Institute of New Zealand, is just completing a 12-week randomized controlled trial of acetaminophen to see if the drug provokes or worsens asthma in adults. The results of that trial will be completed next year. Dr. Beasley said the highest priority now should be rigorous trials to test whether acetaminophen use in infancy increases the risk of developing asthma.

“I cannot say with 100 percent certainty that acetaminophen makes asthma worse, but I can say that if I had a child with asthma, I would give him or her ibuprofen for the time being,” Dr. McBride said. “I think the burden of proof is now to show that it’s safe.”

Not all experts agree. “At this time I just don’t feel you can recommend one over the other,” said Dr. Stanley Szefler, head of pediatric clinical pharmacology at National Jewish Health in Denver. “They both have advantages and disadvantages.”

Aspirin and other nonsteroidal anti-inflammatory drugs, including ibuprofen, are known to provoke asthma attacks in some people, Dr. Beasley noted. He suggested a middle course for parents: Simply use acetaminophen (also known as paracetamol) more sparingly. “We should be reserving paracetamol for very high fevers or for major pain relief,” he said. “We know that paracetamol is used much more widely than that — when a child is a bit irritable or teething or having an immunization.”

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I.R.S. Denying Lesbians Legitimate Adoption Credit

New York Times
December 13, 2011

Since the federal government does not recognize same-sex marriage, such couples are viewed as strangers in many spheres of their financial lives. They need to file separate federal tax returns, for instance. And sometimes, that can come with certain advantages.

Take the adoption tax credit. If you adopt your spouse’s child, you cannot claim the credit. But since same-sex married couples are not considered spouses under federal law, they are permitted to use the credit — at least until their unions are recognized.

So when several lesbians seeking to adopt a partner’s child received letters from the Internal Revenue Service that said they could not use the credit, they couldn’t help but wonder: Is the government choosing to recognize our unions only when it’s to the government’s benefit?

As it turns out, the I.R.S. keeps close tabs on many refundable credits: The adoption credit is refundable in 2010 and 2011, which means that the credit reduces the amount of tax you owe, dollar for dollar. And if the amount of the credit exceeds your tax bill, you get to collect that extra cash. Because it’s such an enticing break, it’s also ripe for abuse.

As a result, the I.R.S. conducted more audits by mail last year, and required many couples — gay and heterosexual — to provide more documentation. (In fact, 68 percent of the nearly 100,000 returns on which taxpayers claimed the adoption credit were audited by mail, according to a report by the Government Accountability Office, which reviewed the I.R.S.’s strategy to ensure taxpayers were rightfully claiming the credit.)

But at least two of the reasons that the I.R.S. gave to the lesbians who it turned down were not rooted in the law, according to Patricia Cain, a professor at Santa Clara Law and an expert on sexuality and federal tax law, who blogged about the topic and has assisted some couples who were denied.

The most common explanation for the denial, she said, was that the birth mother did not terminate her rights as part of the adoption. And while it’s typical for many birth mothers to do so when her child is being adopted, that’s obviously not something a lesbian birth mom would do when her partner is simply performing a “second parent” adoption. Nor is there anything in the tax code that requires the termination of parental rights, Professor Cain said.

Another reason the I.R.S. provided for the denials: the adoptive mother is the domestic partner of the birth mother. But again, she said there is nothing in the tax code that says domestic partners cannot claim the credit. “Nobody thinks the adoption credit was created to help lesbian mothers,” Professor Cain said. “But they are certainly entitled to it as long as the clear meaning of the statute grants it to them.”

The report from the Government Accountability Office said that the I.R.S. didn’t adequately inform its tax examiners regarding certain aspects of the adoption credit. So you can argue that the I.R.S. probably didn’t give them specific instructions on how to handle adoptions with same-sex parents either. A spokesman for the I.R.S. said that they were aware of an isolated number of cases where they made a mistake, and that they corrected the errors after they were notified by the taxpayers. In a statement, the agency said that it regrets the inconvenience and that it has provided more training to the examiners on this issue.

The credit, which is for as much as $13,360 in 2011, can only be used once. So if two men, two women, or two other unmarried people adopt a nonbiological child, only one adoptive parent can claim the entire credit or they can split it.

If you or your partner receive any notices from the I.R.S. requiring more information during this coming tax season, send your response to the I.R.S. within the time period allotted. “Most taxpayers, after pushing back hard, have had the credit allowed,” Professor Cain added.

That is the result that Beth Jennings is hoping for. She said that her partner, Coleen Jennings, adopted her biological daughter, Hazel, in 2010, four months after she was born. A couple of months after filing her return, she received a letter from the I.R.S. stating that the adoption credit was under investigation.

After sending more documentation, her partner was denied the credit, a decision they are now appealing. And when they called the I.R.S., Ms. Jennings said the agent seemed confused about the reason for the denial, even though they provided all the required paperwork and went as far as having their lawyer sign an affadavit. “There is probably a place in the flow chart for the guy answering the phone, and it probably stopped or didn’t include this scenario,” Ms. Jennings said, referring to instructions on how to assist same-sex couples.

The I.R.S. said that any taxpayers who feel that they were improperly denied the credit should contact the I.R.S. And if you need more assistance, you can also contact advocacy organizations like the National Center for Lesbian Rights, which may be able to provide more guidance.

Have you or your partner (or spouse) encountered any problems with claiming this credit? If so, let us know in the comment section if and how you were able to resolve the issue.