Have you seen the social media post about a small boy with chickenpox and a very nasty bacterial infection to boot? It’s now made some national media, and is trying to raise awareness about not using ibuprofen with kids who have chickenpox.
Well that’s news to me!! As I’ve mentioned before, both of mine had chickenpox so mildly that I didn’t notice until it was pretty much over, but had they been really uncomfortable, I would have reached for either the paracetamol or ibuprofen, and would have been none the wiser to any potential risks.
So what is the current advice about pain medicine for chickenpox? What are the risks? And why isn’t it more widely known?
I’ve written before about the use of ibuprofen or paracetamol to reduce a fever. In many cases, if the child isn’t too uncomfortable it can be better to withhold any treatment. The problem is with chickenpox, they are often uncomfortable too! That makes paracetamol and ibuprofen an obvious choice.
Current guidance: easy to miss
The NHS have a long page on treating chickenpox, and state:
“Paracetamol is the preferred painkiller for treating the associated symptoms of chickenpox. This is due to a very small risk of non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, causing adverse skin reactions during chickenpox.”
So there is some advice on the NHS site, but you would think they would perhaps draw more attention to it? Part of the problem is that following this sentence is a generic paragraph about which groups should use ibuprofen – confusing, and easy to misread. Another issue is the language – paracetamol, is the preferred choice. They don’t state to avoid ibuprofen use, even though the guidelines from the National Institute for Clinical Excellence (which is what the Drs follow) do:
“Evidence suggests that there are elevated risks of of skin complications in people with varicella [chickenpox] when exposed to NSAIDs. These findings have been replicated in several studies… For this reason it is recommended that NSAIDs are avoided in children with varicella.”
Worded slightly stronger than the NHS guidelines, but not on the main chickenpox page, only on the general page about ibuprofen. Again, potentially easy to miss.
[As an aside, the NICE review of evidence for other remedies is an interesting read for anyone with a kid suffering from chickenpox]
The risk of bacterial skin infections after chickenpox is low, but they can be life-threatening. In a study of reported chickenpox cases in the UK between 1994 and 2005, only 386 cases were reported (0.28% of primary chickenpox cases).
There is evidence that ibuprofen use may increase the risk of bacterial infection following chickenpox, and some plausible mechanisms for what might be happening. However, many of the studies have methodological issues. In some, it is not possible to determine whether ibuprofen was the reason that these children developed these infections, or whether children with these infections were more likely to use ibuprofen because of their severe illness. In others, the majority of children started ibuprofen after developing these infections.
The most recent study, and that quoted by NICE, does seem to show a correlation between ibuprofen and bacterial skin infections after chickenpox, but calls for more investigation (that was in 2008). The rarety of the illness, and ubiquity of ibuprofen use makes it quite hard to study though.
My heart goes out to the poor little boy in the social media post, and I don’t know the details of that particular case, but it does seem to be raising awareness.
It’s clear that the NHS advise against the use of ibuprofen in children with chickenpox, though that advice could be clearer and more strongly worded. Maybe because the science is still inconclusive they have purposfully vague, or maybe they just havent worded it quite right.
Regardless, a bigger problem is that for many parents (myself included), and perhaps also for some GPs, paracetamol and ibuprofen are standard over-the-counter drugs that we all have in our medicine cabinet. I wouldn’t think of checking whether I could use them in any particular scenarios, as I know my children are generally fine with both. That makes any message about not using them hard to communicate, even if it is written well!
If I did check, I’d just check the bottle. I’ve just checked, and the leaflet with my bottle of Calprofen has no mention of chickenpox at all. I guess until there is strong, conclusive evidence of a risk the manufacturers of these products don’t need to put warnings in the box? I have to say, I was a little suprised not to see it mentioned.
I know if my two get it again (I wouldn’t be suprised if Boybug did given he was pretty young and had it so so mildly) I would definitely avoid ibuprofen unless there was an exceptional clinical reason for using it. In this instance, for my kids, I would go with “better safe than sorry”.