Therapeutic Appropriateness of Paracetamol and NSAIDs in Management of Fever and Pain in Pediatric Patients with Comorbidities: An Expert Opinion

Background. Paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) are widely used treatments for mild to moderate pain and fever in pediatric patients. Notwithstanding, greater caution and awareness of their distinct safety profiles is warranted, especially in children with comorbidities. Expert opinion. Herein, expert opinion is presented on the use of these drugs in this setting. Paracetamol is suggested as first-line treatment for managing fever in pediatric patients. For pain, paracetamol is suggested for acute mild-to-moderate pain, whereas NSAIDs are preferred for pain associated with inflammatory conditions. A fixed-dose combination of paracetamol and ibuprofen may be considered for moderate pain, which allows effective analgesia while potentially reducing the risk of adverse events associated with monotherapy. Based on opinion and clinical experience, suggestions were made for pediatric patients considering a large variety of comorbidities. For example, in patients with infection/influenza, the panel concluded that paracetamol should be preferred over NSAIDs. In pediatric patients with inflammatory bowel disease, it was suggested to avoid long-term or high-dose NSAID treatment, particularly in those with active disease. In the presence of skin and soft tissue infections, it was suggested to limit the use of NSAIDs and prioritize paracetamol as first-line therapy. It was also recommended to exercise caution when using NSAIDs in pediatric patients with diabetes. Lastly, shared therapeutic flowcharts were developed that facilitate the patient journey of pediatric patients with comorbidity and fever or pain, which may help promote therapeutic appropriateness and reduce the risk of adverse events, providing practical guidance for general practitioners and pediatricians.