MEDICATIONS FOR PAIN & FEVER IN CHILDREN

There are a wide range of medicines on the market for pain and fever that make it confusing for parents to know which one to choose. All medicines are potentially dangerous so it is vital you know what you are buying.

There are two main groups of analgesics – opioids and non-opioids. I will not discuss opioids any further for now as these are usually reserved for severe pain and given the side effects of even the low efficacy opioids, such as codeine, I do not routinely recommend their use in children.

Non-opioids are further divided into three groups. There are a number of generics out there, so it’s important to read the product label carefully to know exactly what it is you are giving your child.

1. Paracetamol (acetaminophen)

• Indicated for mild-moderate pain and fever.
• Has no anti-inflammatory properties.
• Is non-sedating.
• Includes but not limited to: Panado, Calpol and Empaped suppositories.

2. NSAIDs (Non-steroidal anti-inflammatory drugs)

• NSAIDS have anti-inflammatory, analgesic and antipyretic properties.
• There are many NSAIDs available but most are not licensed for use in children or for pain and fever.
• Is non-sedating.
• Contraindications:
  • Children with asthma;
  • Children with dehydration;
  • Children with impaired renal function;
  • Children with impaired clotting or bleeding; and/or
  • A previous allergic reaction to any anti-inflammatory drug.
• Includes but not limited to:
  • Nurofen (ibuprofen): >3 months and >5 kgs.
  • Ponstan (mefenamic acid): >6 months
  • Voltaren suppositories (diclofenac): > 2yrs.

3. Aspirin (acetylsalicylic acid)

• NOT RECOMMENDED for children and adolescents (<18 years) for routine analgesic and antipyretic use – AVOID!
• Aspirin is associated with a rare, yet fatal disease known as Reyes syndrome.

4. Combination preparations

• These are usually a combination of Paracetamol with any one or more of the following; NSAID, codeine, caffeine, meprobamate, promethazine, dephenhydramine, doxylamine and/or other.
• Indicated specifically for pain relief only.
• These preparations are not superior to paracetamol alone for relief of fever.
• These preparations can be sedating depending on the composition.
• Includes but not limited to: Ibumol, Lentogesic, Lotem, Mybulen, Myprodol, Stilpane and Stopayne.

PARACETAMOL OR NSAID?

Now that you have a brief overview of what is out there, let’s discuss what to give your kids.

Keep it simple! Avoid combinations, as they are not any more effective than single preparations. Paracetamol is the first line drug for mild-moderate pain and fever. This is because of its high tolerability profile. Do not routinely use Paracetamol AND an NSAID together at the same time or alternatingly. I would recommend using Paracetamol first and if there is no response within an hour, try Ibuprofen.

From personal experience, Paracetamol works wonders and within 30-60 minutes your child will be running around like his/her normal self again.

Please use analgesics and antipyretics only if necessary and regardless of which one you choose, use it for the shortest time needed to control symptoms.  If you decide to use an NSAID DO NOT use more than one type at a time.

VOMITING

• If your child vomits within 30 minutes of having ingested a dose of Paracetamol or NSAID it is safe to give that same dose again.
• If your child vomits more than 30 minutes after having a dose of Paracetamol or NSAID DO NOT give another dose. Wait until the next normal dose.

SUPPOSITORIES

• Oral administration of medicine is preferred since the rectal absorption of medicine is unpredictable, however, if your child is refusing to take medicine or vomiting, a suppository can initially be used.
• Do not give an oral dose together with a suppository of the same drug at the same time.
• Rectal administration of NSAIDs has fewer GUT side effects.

SIDE-EFFECTS*

Paracetamol:

• Rarely causes any side effects if given at the correct dose.
• Paracetamol overdose is VERY toxic to the liver and can cause liver failure and death.

NSAIDs:

• Stomach pain, indigestion and/or heartburn;
• Nausea and/or vomiting;
• Diarrhoea;
• Allergic reaction;
• Bronchospasm;
• Ringing in the ears; and/or
• Kidney damage (little or no urine and/or blood in the urine).

*This is not a comprehensive list of all the side effects but rather a list of the more common and/or dangerous ones.

DOSAGE

When it comes to dosing, weight is more important than age, so please read the product label carefully and familiarize yourself with your child’s weight.

I suggest administering medicine using a syringe in order to measure up the dose correctly. Squirt the medicine into the space between the gum and cheek. This will reduce contact with the tongue and taste receptors making the medicine more palatable and having a higher chance of being swallowed.

Paracetamol:

• 3 months: 15mg/kg/dose every 4-6 hours
• < 3 months: 10mg/kg/dose every 4-6 hours
• Max: 60mg/kg/day, up to 1000mg/dose or 4000mg/day, up to 4 doses/24 hrs.

Ibuprofen:

• 5 mg/kg/dose every 6-8 hours
• Max: 20mg/kg/day, up to 3 doses/24 hrs.
• Administer Ibuprofen with food in order to reduce gastric side effects.

RESOURCES

de Martino, M. & Chiarugi, A. (2015) Recent Advances in Pediatric Use of Oral Paracetamol in Fever and Pain Management. Pain and Therapy. [Online] 4 (2), pp. 149-168. Available from: https://doi.org/10.1007/s40122-015-0040-z [Accessed 18 June 2018].

Gazarean, M. and Graudins, L.V. (2006) Safe use of NSAIDs in infants and children. Medicine Today, 7 (11), pp. 71-73.

Green, R., Jeena, P., Kotze, S., Lewis, H., Webb, D. and Wells, M. (2013) Management of acute fever in children: Guideline for community healthcare providers and pharmacists. S Afr Med J. [Online] 103 (12), pp. 948-954. Available from: doi:10.7196/SAMJ.7207 [Accessed 20 June 2018]

Jannin, V., Lemagnen, G., Gueroult, P., Larrouture, D. and Tuleu, C. (2014) Rectal route in the 21st Century to treat children. Advanced Drug Delivery Reviews. [Online] 73, pp. 34-49. Available from: doi: 10.1016/j.addr.2014.05.012 [Accessed 20 June 2018].

Marzuillo, P., Guarino, S. & Barbi, E. (2014) Paracetamol: a focus for the general pediatrician. European Journal Of Pediatrics. [Online] 173 (4), pp. 415-425. Available from: https://doi.org/10.1007/s00431-013-2239-5 [Accessed 18 June 2018].

Raffaeli, G., Orenti, A., Gambino, M., Peves Rios, W., Bosis, S., Bianchini, S., Tagliabue, C. and Esposito, S. (2016) Fever and Pain Management in Childhood: Healthcare Providers’ and Parents’ Adherence to Current Recommendations. Int. J. Environ. Res. Public Health. [Online] 13 (5), 499. Available from: https://doi.org/10.3390/ijerph13050499 [Accessed 18 June 2018].

Sharif, M.R., Rezaei, M.H., Aalinezhad, M., Sarami, G. and Rangraz, M. (2016) Rectal Diclofenac Versus Rectal Paracetamol: Comparison of Antipyretic Effectiveness in Children. Iranian Red Crescent Medical Journal. [Online] 18 (1): e27932. Available from: doi:10.5812/ircmj.27932 [Accessed 20 June 2018].