Paediatric Antipyretic Prescribing

Fever is a regulated rise in body temperature that helps host defence, and antipyretics are given to relieve distress, not to normalise the temperature or prevent febrile seizures. The medicine does not shorten the illness, and the response to an antipyretic does not separate serious from mild infection.

When to treat. Treat a febrile child who is uncomfortable, irritable, not drinking or in pain. A comfortable, drinking child needs no antipyretic. Fever in an infant under 3 months (38 C or more) needs urgent assessment for serious bacterial infection and must not be masked.

Assessment before treatment. Look for red flags: non-blanching rash, stiff neck, bulging fontanelle, grunting, chest indrawing, weak cry, poor perfusion, persistent vomiting, and fever lasting over 5 days. In malaria areas, test for malaria in every febrile child and treat the cause.

• Paracetamol (first line): 15 mg/kg orally every 4 to 6 hours, maximum 60 mg/kg/day and 4 g/day, at least 4 hours between doses and no more than 4 doses in 24 hours. Intravenous 7.5 mg/kg every 6 hours under 10 kg and 15 mg/kg every 6 hours for 10 to 50 kg, only if oral route fails. Rectal dosing is erratic.
• Ibuprofen (alternative or add-on): 5 to 10 mg/kg orally every 6 to 8 hours with food, maximum 30 mg/kg/day and 1.2 g/day. Not for infants under 3 months or under 5 kg.
• Using both: give one first and add the other only if distress persists. Routine alternating is not advised because it increases dosing errors without clear benefit.
• Physical cooling: tepid sponging, fans and cold baths are not advised. Remove excess clothing and offer fluids.

Avoid. Aspirin under 16 years (Reye syndrome), metamizole, and combined cold and flu preparations that contain paracetamol.

Neonates and preterm infants. Term neonates 10 to 15 mg/kg every 4 to 6 hours, maximum 60 mg/kg/day; preterm infants need gestation-based reduction and a maximum of 30 mg/kg/day under 32 weeks.

Kidney impairment and dehydration. Avoid ibuprofen in dehydration, acute kidney injury and nephrotic syndrome. Paracetamol is acceptable with the interval extended to 8 hours when creatinine clearance is under 10 mL/min.

Liver impairment and malnutrition. Use the lower end of the dose, the longer interval and the shorter course, because glutathione stores are low.

Other cautions. Avoid ibuprofen with active bleeding, thrombocytopenia, varicella with skin infection, and asthma that worsens with anti-inflammatory drugs.

Special groups. Adolescents and carers should count all paracetamol-containing products. In East Africa, fever in an unwell child is malaria until excluded, so give the antimalarial without waiting for the temperature to fall.

Monitoring. Judge response by comfort, drinking and activity, not by the temperature. Review within 24 hours if the child is not improving, and sooner if red flags appear.

Referral and escalation. Refer for any red flag, fever over 5 days, fever with a rash that does not blanch, a single ingestion of 150 mg/kg paracetamol or more, or repeated doses over the daily maximum (consider acetylcysteine).

Stopping. Stop the antipyretic when the child is comfortable. Continue other treatment for the cause. Do not give regularly for more than 48 to 72 hours without review.