Page 89 WHO - Guidelines on the pharmacological treatment of persisting pain in children with medical illness

A2.2.2 Paracetamol versus non-steroidal anti-inflammatory drugs

Clinical question
In children with persisting pain due to medical illnesses, should paracetamol as compared to NSAIDs be
used at step one of a two- or three-step approach?

Recommendations
2. Paracetamol and ibuprofen are the medicines of choice in the first step (mild pain).
- The panel opted not to recommend either paracetamol or ibuprofen in preference to one another.
Both these medicines have a place in the first step of the two-step analgesic approach.
3. Both paracetamol and ibuprofen need to be made available for treatment in the first step.
Strong recommendations, low quality of evidence

Domains and considerations

Quality of evidence
There is evidence for the superiority of the analgesic properties of ibuprofen versus paracetamol but
only for acute pain (Annex 4. Evidence retrieval and appraisal, GRADE Table 1A and other studies
in Annex 4 comparing paracetamol versus ibuprofen). This was considered low-quality evidence
based on the indirectness of the condition treated and the absence of long-term safety evidence. No
evidence for the safety and efficacy of other NSAIDs other than ibuprofen was found.
Uncertainty: yes, due to the lack of comparative long-term safety data.

Risks/benefits
Benefits
The panel recognized the widely-held clinical view that NSAIDs and paracetamol are indicated in
different pain conditions. However, no direct evidence for this approach was identified or retrieved.
Risks
The long-term safety of both paracetamol and NSAIDs in children is unknown. There are concerns
about potential renal and gastrointestinal toxicity and bleeding with NSAIDs. There are well-described
risks of acute overdose associated with paracetamol. There is age restriction in the use of ibuprofen
below three months of age.
Uncertainty: yes, in relation to long-term safety data and to comparative safety data with NSAIDs
other than ibuprofen.

Values and acceptability
In favour
The panel places high value on having the two alternatives (paracetamol and ibuprofen).
Against
None.
Uncertainty: none.

Cost
Both paracetamol and ibuprofen are widely available and relatively inexpensive. Child-appropriate
dosage forms – such as liquid oral forms – exist, but divisible dispersible oral solid dosage forms are
still needed.
Uncertainty: none.

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