Knowing what to recommend, and when
Knowing what to recommend, and when
NICE's Clinical Knowledge Summaries (CKS)9 and NHS10 offer recommendations for mild-to-moderate pain and fever management in children. It is important to consider this guidance to help ensure that children receive the best care possible.
Click on the flashcards to see examples of the guidance for treating mild to moderate pain in children.9
Paracetamol or ibuprofen alone
is the first line recommendation.
For example, 6-year-old Jamila with mild fever and symptoms that indicate a cold could be offered either paracetamol or ibuprofen alone, as they will both be effective in reducing her fever and pain.
If the child does not respond to the first-line treatment, check their adherence and that the appropriate dose is being taken. If appropriate, and if pain is still not being managed, switch to the other medicine.
For example, 8-year-old Charlie, hurt his knee at sports day. He has been taking paracetamol as per the dosage instructions; however, as it has not controlled his pain, he can be offered ibuprofen instead. Ibuprofen may also be more appropriate to treat any swelling or inflammation.
If the child has not responded sufficiently to the appropriate dose of either drug alone, alternating paracetamol and ibuprofen should be considered. However they should not be taken at the same time. A dose of the second drug can be added 1-3 hours after the first drug, provided the parents/carers are confident to do this.
For example, 5-year-old Zarah with a toothache, who is due to see the dentist this week. She has tried paracetamol and ibuprofen separately (as per the dosage instructions) but neither has provided much relief on their own. She could use alternate doses of paracetamol and ibuprofen throughout the day. You can help her mum plan the doses using a treatment diary to ensure they are given safely.
If the child is still in pain or more than short courses of the medicines are required, the child should be referred.
For example, 10-year-old Matilda has had a sore throat for the past week. After a regular regime of alternating doses of paracetamol and ibuprofen, her pain is still not effectively being managed; therefore, she should be referred for further investigation. Matilda may be eligible for the Pharmacy First service as her symptoms could indicate a bacterial throat infection.
NOTE: It is important to remind parents that paracetamol is usually given every 4-6 hours and ibuprofen every 6-8 hours. Care must be taken not to exceed the maximum dose of each drug in a 24-hour period, which will depend on the child's age. A treatment diary may be useful if the parents/carers find it difficult to remember which drug was last given and at what time.
This can help reduce the risk of medication errors.
Fever can sometimes be an indication of something more serious. Therefore, the following advice should be offered when using antipyretics in children:
Similarly to with pain management, if the child still has a fever after taking either paracetamol or ibuprofen, they can be offered the other antipyretic 1 hour later
If the alternative antipyretic reduces the fever, it can be used instead of the initial choice as per the dosage instructions
However, paracetamol and ibuprofen should not be alternated to treat a fever without advice from a doctor or nurse
If neither medicine reduces fever, the child should be referred to the GP
Although pain and fever can be caused by a multitude of conditions, which can be managed in specific ways or with certain medications, there are additional things parents/caregivers can do to help their sick child
Some tips for looking after an unwell child include:
Keep the room airy without being draughty. If the room is too warm, they may feel worse
Do not cover them with too many clothes or bedclothes
Keep the child hydrated and offer them plenty of water and nutritious drinks like milk.
Breastfeeding should also continue as normalIf they are refusing food, offer smaller portions of nutritious foods
Allow the child to rest and take time off school (particularly if they are infectious)
Check on them regularly, including at night
Avoid trying to cool down the child by undressing them or sponging them
– a temperature is a natural and healthy response to infection
Red flags are often dependent on the condition and cause of pain and fever, however there are some general signs and symptoms that would require referral to the GP.
These include children who are:
Suffering with pain that is severe or not controlled with pain relief
Under 3 months with a fever over 38°C or higher
3-6 months with a temperature of 39°C or higher
Suffering with other signs of illness such as a rash, alongside a fever
Suffering with a fever lasting for 5 days or more
Not their usual self, may have lost their appetite and the parent is highly concerned
Dehydrated – signs could include sunken eyes, no tears when crying or passing less urine
You should call 999 if the child has any of the following symptoms:
A stiff neck
A rash that does not fade when you press a glass against it
Sensitive to light
Experiences a seizure for the first time (they cannot stop shaking)
Unusually cold hands and feet
Changes to their skin colour such as blue, grey, paler than usual or blotchy skin (this may be harder to see on brown or black skin), or blue, grey or paler than usual lips or tongue
Drowsy or more tired than usual and hard to wake
Extremely agitated (does not stop crying) or is confused
Difficulty breathing (you may notice grunting noises or their stomach sucking under their ribcage), breathlessness or breathing very fast
Is not responding like they normally do, or is not interested in feeding or normal activities