Why is baby aspirin contraindicated in children and adolescents?

Why Aspirin is Contraindicated in Children and Adolescents

Aspirin is contraindicated in children and adolescents primarily due to the risk of Reye's syndrome, a rare but potentially fatal condition that causes acute encephalopathy and liver failure when aspirin is given during viral infections, particularly influenza and varicella. 1

The Core Problem: Reye's Syndrome

The FDA drug label explicitly warns that "children and teenagers who have or are recovering from chicken pox or flu-like symptoms should not use this product" because these symptoms could be an early sign of Reye's syndrome. 1 This is not a theoretical concern—the association between aspirin use during viral illnesses and Reye's syndrome is well-established and led to government warnings in multiple countries. 2

Key Clinical Features of Reye's Syndrome:

• Presents with behavioral changes, nausea, and vomiting during or after viral illness 1
• Can progress rapidly to encephalopathy and liver failure
• Most commonly associated with influenza and varicella infections 3

When Aspirin IS Used in Children (Important Exceptions)

Despite the general contraindication, aspirin is actually prescribed in specific pediatric conditions where the benefits outweigh risks, but with critical safety measures:

Approved Pediatric Uses:

• Stroke prevention: 3-5 mg/kg/day (can reduce to 1-3 mg/kg/day if side effects occur) 3, 4, 5
• Kawasaki disease: 80-100 mg/kg/day during acute phase, then 1-5 mg/kg/day for antiplatelet effect 4
• Congenital heart disease: Long-term low-dose therapy for shunt thrombosis prevention 3

Mandatory Safety Precautions When Aspirin IS Prescribed:

The American Heart Association recommends the following protective measures for children on aspirin therapy: 3, 4, 5

1. Annual influenza vaccination to reduce viral infection risk
2. Verification of varicella vaccination status
3. Immediate discontinuation of aspirin during confirmed or suspected influenza or varicella infections
4. No consensus exists on whether to stop aspirin during other febrile illnesses—some experts recommend discontinuation or dose reduction, while others favor continuation given the lack of Reye's syndrome reports at therapeutic doses and increased stroke risk during febrile illness 3

Additional Risks in Children

Beyond Reye's syndrome, aspirin poses other pediatric-specific concerns:

• Dosing errors leading to overdose are the main risk in children taking NSAIDs, which can cause significant morbidity and death 3
• May worsen asthma symptoms 3
• Gastric distress and prolonged epistaxis at higher doses 3
• Bleeding risk, particularly when combined with other antiplatelet agents like clopidogrel (subdural hemorrhage reported in children with arterial ischemic stroke) 3

Critical Clinical Pitfall

Despite widespread warnings, studies show that 17-33% of parents still administer aspirin to children under 12 years old, often because package labeling alone is insufficient for health education. 2, 6 This represents a persistent public health concern requiring active counseling by healthcare providers.

The Bottom Line for General Use

For routine fever, pain, or minor illness in children, acetaminophen or ibuprofen should be used instead of aspirin to avoid any risk of Reye's syndrome. 3 The only time aspirin should be given to children is for specific medical conditions (stroke, Kawasaki disease, certain cardiac conditions) under close medical supervision with appropriate viral infection precautions in place. 3, 4