What are the recommended anti-inflammatory medications for children?

Anti-Inflammatory Medications for Children

For pain and inflammation in children, ibuprofen is the first-line NSAID choice for most conditions, while naproxen is preferred specifically for juvenile idiopathic arthritis (JIA) and chronic inflammatory conditions. 1, 2

Primary NSAID Recommendations

Ibuprofen

• Ibuprofen is the drug of first choice for inflammatory pain in children aged ≥3 months, as it is the only NSAID approved for use in this age group 3, 4
• Effective for multiple pain conditions including musculoskeletal pain, ear pain, acute otitis media, toothache, oral/pharyngeal inflammation, and postoperative pain 4
• Has the lowest gastrointestinal toxicity among NSAIDs with a superior safety profile 5, 3
• Provides mild-to-moderate analgesia with anti-inflammatory effects 5

Naproxen

• Naproxen is the preferred NSAID over other selective COX-1 or COX-2 inhibitors for children with JIA due to its established efficacy and safety profile 1, 2
• Recommended as adjuvant therapy for pain and inflammation in chronic inflammatory conditions 1, 2
• Requires an adequate trial period of at least 8 weeks for conditions like JIA, given the time course to response of approximately 1 month 1, 2
• If naproxen is contraindicated or unavailable, alternative NSAIDs (ibuprofen, indomethacin, meloxicam, tolmetin, etodolac, ketorolac, oxaprozin, or celecoxib) can be used based on FDA/EMA approval for pediatric use 1, 2

Paracetamol (Acetaminophen)

• For fever and mild pain without significant inflammation, paracetamol should remain first-line therapy due to its superior tolerability profile compared to NSAIDs 5
• Dosing: 10-15 mg/kg per dose every 4 hours, maximum 4 doses per day 6, 7
• Paracetamol and ibuprofen show equivalent analgesic efficacy for short-term pain treatment in children, with no difference in safety 1
• Paracetamol is preferred over ibuprofen when inflammation is not a primary component of the pain 5

Clinical Decision Algorithm

For Inflammatory Conditions:

1. Chronic inflammatory disease (JIA): Start naproxen as adjuvant therapy 1, 2
2. Acute inflammatory pain: Use ibuprofen as first-line 3, 4
3. Postoperative pain: NSAIDs (ibuprofen, ketorolac, diclofenac) alone or as adjunct to regional anesthesia 5

For Non-Inflammatory Conditions:

1. Fever with discomfort: Paracetamol first-line 5
2. Mild-to-moderate pain without inflammation: Paracetamol first-line 7, 5

Critical Safety Considerations

Absolute Contraindications:

• Never use ibuprofen in neonates 3
• Avoid ibuprofen in children with dehydration, vomiting, or diarrhea due to risk of renal damage 3, 4
• Do not use ibuprofen during varicella infection 3
• Contraindicated in children with wheezing, persistent asthma, or NSAID sensitivity 3
• Avoid aspirin in children due to Reye's syndrome risk, controversial efficacy, and toxicity concerns 1, 2, 5

Important Warnings:

• Ibuprofen should not be used routinely as an antipyretic except in rare cases where inflammation accompanies fever 3
• Ketorolac use after tonsillectomy remains controversial due to potential postoperative hemorrhage risk 5
• NSAIDs should be used as adjunct therapy in JIA and should not delay introduction of disease-modifying antirheumatic drugs (DMARDs) 1, 2

Special Populations

Juvenile Idiopathic Arthritis:

• NSAIDs are conditionally recommended as adjunct therapy 1
• Intraarticular glucocorticoids are conditionally recommended as adjunct therapy 1
• Triamcinolone hexacetonide is strongly recommended over triamcinolone acetonide for intraarticular injections 1
• Methotrexate remains the cornerstone DMARD, with NSAIDs serving as adjunctive treatment 1