Published: 10 December 2015

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Use of Aspirin in Children is Not Recommended

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Prescriber Update 36(4): 50-51
December 2015

Healthcare professionals are reminded that the use of aspirin in children is not recommended due to the risk of Reye's syndrome.

The Centre for Adverse Reactions Monitoring (CARM) recently received a report of a 16-year-old patient who was taking the maximum adult dose of aspirin as part of their management for acute rheumatic fever. In this case, the patient experienced nose bleeds, which is a known side effect of aspirin, but also a less common clinical feature of rheumatic fever.

CARM has received a total of 34 reports where aspirin was used in a child under 18 years of age. Of these, four had an indication of rheumatic fever with or without heart involvement. The indication for use was not reported in nine cases. There were no reports of aspirin being used for Kawasaki disease or prevention of thrombus formation following cardiac surgery.

The majority of reports described reactions involving the skin such as rash, urticaria, and angioedema. Of the 34 reports, only five were received by CARM in the last six years.

What is the Age Restriction?

In New Zealand, aspirin product labels are required to include the following statement "Unless a doctor has told you to, do not use this product in children under 12 years of age or teenagers with chickenpox, influenza or fever".

The New Zealand Formulary for Children contraindicates the use of aspirin in children under 16 years of age unless it is being used for Kawasaki disease or for prevention of thrombus formation after cardiac surgery¹. This is in-line with recommendations from the United Kingdom².

Should Aspirin be used in Rheumatic Fever?

Aspirin is no longer recommended for the symptomatic management of joint pain in rheumatic fever due to the risk of Reye's syndrome³. Mild joint pain and fever may respond to paracetamol alone.

Non-steroidal anti-inflammatory drugs (NSAIDs) can also be used. Naproxen is the evidence-based treatment of choice. However, there is no liquid formulation of naproxen available in New Zealand. Ibuprofen is available as a liquid and is often used but there is a lack of published evidence supporting use for this indication.

What is Reye's Syndrome?

Reye's syndrome is a very rare but serious condition that causes inflammation and swelling of the brain and fatty degeneration of the liver⁴. It occurs almost exclusively in children⁴.

The exact cause is unknown but is often triggered by a viral infection and the use of aspirin ⁴. Symptoms start with vomiting and varying degrees of neurologic impairment, including fluctuating personality changes and deterioration in consciousness⁴

Treatment is supportive with a primary focus on reducing increased intracranial pressure ⁵.

References

1. New Zealand Formulary for Children. 2015. Aspirin. NZFC v40. URL: www.nzfchildren.org.nz/nzf_1529 (accessed 6 October 2015).
2. British National Formulary. March 2015 - September 2015. Aspirin monograph. BNF 69: 280.
3. Heart Foundation of New Zealand. 2014. New Zealand Guidelines for Rheumatic Fever: Diagnosis, Management and Secondary Prevention of Acute Rheumatic Fever and Rheumatic Heart Disease: 2014 Update. URL: www.heartfoundation.org.nz/uploads/HF2227A_Rheumatic_Fever_Guideline_v3.pdf (accessed 6 October 2015).
4. Belay ED, Bresee JS, Holman RC, et al. 1999. Reye's syndrome in the United States from 1981 through 1997. The New England Journal of Medicine 340(18): 1377-1382.
5. MSD. 2014. Reye Syndrome. MSD Manual Professional Version. URL: www.msdmanuals.com/professional/pediatrics/miscellaneous-disorders-in-infants-and-children/reye-syndrome (accessed 6 October 2015).