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A 4 year old child presents to the paediatric accident and emergency department with a history of fever for 12 hours and clinical signs of an upper respiratory tract infection. The temperature on assessment is 39.5°C. There is a past medical history of asthma. The attending emergency doctor prescribes ibuprofen. The mother is not willing to give ibuprofen to her child, as she was told in the past that it is contraindicated in children with asthma.
Structured clinical question
In febrile children with a past medical history of asthma [patient], is ibuprofen in antipyretic doses [intervention], compared to paracetamol [comparison], more likely to cause an acute exacerbation of asthma [outcome]?
Search strategy and outcome
Cochrane Databases of Systematic Reviews—none relevant.
Pubmed: “Paracetamol” OR “Ibuprofen” AND “Asthma”. Limits: All child: 0–18 years, English Language; 30 hits, three relevant.
in Athens (ovid) database: “paracetamol” OR “acetaminophen” AND “Ibuprofen” AND “Asthma”; 218 Hits; three relevant (one, same study as above).
See table 3.
All three references1–3 highlighted by Pubmed using the above search strategy were published by Lesko et al. The data used in all papers were originally derived from the Boston University Fever Study.4 Therefore, the data described in 20022 and 19993 are overlapping.
The original study4 was double blind, randomised, and controlled; patients received either paracetamol in a dose of 12 mg/kg or ibuprofen in a dose of 5 or 10 mg/kg.
To establish the asthma morbidity after the short term use of ibuprofen in children,2 the data were restricted to include only children being treated for asthma, defined as those who had received a β-agonist, theophylline, or an inhaled steroid on the day before enrolment in the clinical trial. Morbidity from asthma was defined as a report of hospitalisation or outpatient visit for asthma in the month after enrolment.
The data suggested that there was a significantly lower rate of exacerbations of asthma in children receiving ibuprofen compared to children receiving paracetamol. The authors argue that this could be due to the anti-inflammatory action of ibuprofen.
The study by McIntyre and Hull5 was conducted on an inpatient population, which included children with asthma or wheezing. The results showed that no child receiving ibuprofen (including 32 with asthma or a past medical history of asthma) developed symptoms of asthma or wheezing.
In both studies, patients were excluded if there was a known hypersensitivity to paracetamol, ibuprofen, aspirin, or any NSAIDs. Children were also excluded if they had nasal polyps, angioedema, or bronchospastic reactivity to aspirin or other NSAIDs. This small group of children remains potentially vulnerable to ibuprofen or other NSAIDs.
CLINICAL BOTTOM LINE
Ibuprofen used as an antipyretic in febrile children with a past medical history of asthma is as least as safe as paracetamol and not likely to exacerbate asthma.
Ibuprofen should not be used in children with known hypersensitivity to NSAIDs. The possibility of adverse reactions remains in children who have not received NSAIDs at any time in the past.