In the previous post, I gave some general principles about prescribing for children. One person took the time to get in touch about the issue of ibuprofen on an empty stomach. This is an interesting controversy and is an issue well worth understanding.
Ibuprofen is a useful medication when it comes to symptom control in the unwell child. Studies on the benefits of ibuprofen when co-administered with paracetamol (acetaminofen) have tended to show that there is no additional benefit when it comes to controlling fever. However, pyrexia is no longer generally thought to be the enemy and there is no clear indication to normalise an unwell child's temperature. That doesn't mean that the child will not benefit from analgesia. One of the issues with children who have upper respiratory tract infection (URTI) is that they are often reluctant to drink, either due to a general feeling of being unwell or due to the pain associated with trying to drink. If paracetamol and ibuprofen have a clear role in managing the unwell child it is this: making the child feel comfortable and well is an important part of giving them the best possible chance to have good oral intake. If fever is not the enemy then dehydration certainly is. If an unwell child is refusing fluids and a combination of paracetamol and ibuprofen resolves that, why wouldn't you?
One of the anxieties that this situation causes is the fear that these are the very children at risk of the complications of ibuprofen. Ibuprofen, being a non-steroidal anti-inflammatory drug (NSAID) is associated with renal impairment and gastrointestinal (GI) bleeding. Should it then be avoided in children with poor oral intake?
First, let's look at the renal issue. The short answer is that while renal impairment is a risk in dehydrated children (1), it is safe in children who are not dehydrated (2), even if at risk of dehydration. If ibuprofen can potentially aid oral hydration, it seems safe to use, providing the child is not already showing signs of dehydration. It is also worth noting that in the study reporting acute kidney injury (AKI) in children taking ibuprofen, all made a full recovery.
Second, the issue of GI bleeding. Although case reports of children having GI bleeds during short term use of ibuprofen exist (3), these are associated with incorrect administration. Significant GI complications of ibuprofen are associated with long term use, concomitant steroid use, known GI ulceration or coagulation defects (4). Short term, correct use of ibuprofen in children without risk factors seems to be safe.
The way that ibuprofen risks GI complications is a systemic effect. It reduces prostaglandin production, thereby reducing the natural protection of the gastric mucosa. Although we are often told that ibuprofen should be taken with food to reduce GI side effects, there is a debate about whether this should be the case at all.
Advising that analgesia should be given with or after food delays the effect (5) of the pain-killers without clear benefit in terms of gastric protection. It is unclear as to whether taking ibuprofen with food reduces side effects such as nausea but it shouldn't have an effect on the risk of GI bleeding. As one publication puts it: "Apart from providing unsubstantiated ‘safety’ information by advocating food intake with NSAIDs it may be more appropriate to advocate OTC NSAIDs be taken on a fasting stomach in order to achieve a rapid onset of action and hence avoid an ‘extra’ dose of the drug because the rapidity of pain relief did not meet the patient's expectations." (6)
The bottom line is that as long as a sensible clinical assessment has taken place, ibuprofen can be given to a child who has not eaten. It may even be best practice.
Edward Snelson
Unintentionally inflammatory
@sailordoctor
Many thanks to Gina Johnson for her comment on the previous post. Keep them coming!
References
Ibuprofen is a useful medication when it comes to symptom control in the unwell child. Studies on the benefits of ibuprofen when co-administered with paracetamol (acetaminofen) have tended to show that there is no additional benefit when it comes to controlling fever. However, pyrexia is no longer generally thought to be the enemy and there is no clear indication to normalise an unwell child's temperature. That doesn't mean that the child will not benefit from analgesia. One of the issues with children who have upper respiratory tract infection (URTI) is that they are often reluctant to drink, either due to a general feeling of being unwell or due to the pain associated with trying to drink. If paracetamol and ibuprofen have a clear role in managing the unwell child it is this: making the child feel comfortable and well is an important part of giving them the best possible chance to have good oral intake. If fever is not the enemy then dehydration certainly is. If an unwell child is refusing fluids and a combination of paracetamol and ibuprofen resolves that, why wouldn't you?
One of the anxieties that this situation causes is the fear that these are the very children at risk of the complications of ibuprofen. Ibuprofen, being a non-steroidal anti-inflammatory drug (NSAID) is associated with renal impairment and gastrointestinal (GI) bleeding. Should it then be avoided in children with poor oral intake?
First, let's look at the renal issue. The short answer is that while renal impairment is a risk in dehydrated children (1), it is safe in children who are not dehydrated (2), even if at risk of dehydration. If ibuprofen can potentially aid oral hydration, it seems safe to use, providing the child is not already showing signs of dehydration. It is also worth noting that in the study reporting acute kidney injury (AKI) in children taking ibuprofen, all made a full recovery.
Second, the issue of GI bleeding. Although case reports of children having GI bleeds during short term use of ibuprofen exist (3), these are associated with incorrect administration. Significant GI complications of ibuprofen are associated with long term use, concomitant steroid use, known GI ulceration or coagulation defects (4). Short term, correct use of ibuprofen in children without risk factors seems to be safe.
The way that ibuprofen risks GI complications is a systemic effect. It reduces prostaglandin production, thereby reducing the natural protection of the gastric mucosa. Although we are often told that ibuprofen should be taken with food to reduce GI side effects, there is a debate about whether this should be the case at all.
Advising that analgesia should be given with or after food delays the effect (5) of the pain-killers without clear benefit in terms of gastric protection. It is unclear as to whether taking ibuprofen with food reduces side effects such as nausea but it shouldn't have an effect on the risk of GI bleeding. As one publication puts it: "Apart from providing unsubstantiated ‘safety’ information by advocating food intake with NSAIDs it may be more appropriate to advocate OTC NSAIDs be taken on a fasting stomach in order to achieve a rapid onset of action and hence avoid an ‘extra’ dose of the drug because the rapidity of pain relief did not meet the patient's expectations." (6)
The bottom line is that as long as a sensible clinical assessment has taken place, ibuprofen can be given to a child who has not eaten. It may even be best practice.
Edward Snelson
Unintentionally inflammatory
@sailordoctor
Many thanks to Gina Johnson for her comment on the previous post. Keep them coming!
- Balestracci A. et al, Ibuprofen-associated acute kidney injury in dehydrated children with acute gastroenteritis, Pediatr Nephrol. 2015 Oct;30(10):1873-8. doi: 10.1007/s00467-015-3105-7.
- Lesko SM, Mitchell AA, Renal function after short-term ibuprofen use in infants and children, Pediatrics. 1997 Dec;100(6):954-7
- Mărginean, M et al, Ibuprofen, a Potential Cause of Acute Hemorrhagic Gastritis in Children - A Case Report, J Crit Care Med (Targu Mures). 2018 Oct; 4(4): 143–146
- Berezin et al, Gastrointestinal Bleeding in Children Following Ingestion of Low-dose Ibuprofen, Journal of Pediatric Gastroenterology and Nutrition: April 2007 - Volume 44 - Issue 4 - p 506–508, doi: 10.1097/MPG.0b013e31802d4add
- Moore R. et al, Effects of food on pharmacokinetics of immediate release oral formulations of aspirin, dipyrone, paracetamol and NSAIDs – a systematic review, Br J Clin Pharmacol. 2015 Sep; 80(3): 381–388.
- Rainsford K, Bjarnason I, NSAIDs: take with food or after fasting?, J Pharm Pharmacol. 2012 Apr;64(4):465-9.
