As the COVID-19 pandemic gains momentum, we’re all going to find ourselves either much busier or stuck at home. Over the next few weeks, I intend to publish a series of short articles, to provide some coffee break sized learning for clinicians on the front line.
If you have any COVID questions of your own, please send them to me.
These posts will not be heavily referenced, if at all. We are in the very early stages of gathering evidence and the risk with early evidence is that it can be very misleading for various reasons.
Much of what is coming out from this crisis is a renaissance of pragmatism.
That pragmatism is born out of necessity but is based in the common sense and experience of the clinicians who look after children. Together we can figure out what’s truly important and cut through the evidence, without ignoring it.
The first question is as follows…
Should we recommend the use of ibuprofen for symptomatic relief in a child with a respiratory tract infection?
France’s health minister, Olivier Véran created a great deal of anxiety for both clinicians and the public when he said that people should avoid using ibuprofen because it may make COVID-19 infection worse. This prompted a variety of responses from organisations around the world. Some recommended against using ibuprofen and some stated that there was no evidence that it made COVID-19 infection worse.
Why was there such a disparity of recommendations?
The answer is that your view will depend on your perspective.
Is there a possibility that ibuprofen could make COVID-19 infection worse?
There is a hypothetical risk because the anti-inflammatory properties of ibuprofen include some elements of the immune response.
Is there any evidence that this biochemical effect has any clinical effect?
There is no clinical evidence that ibuprofen actually makes COVID-19 infection worse.
So with hypothetical harm and no evidence that it is real, what should you recommend?
That depends on whether you think that being able to take ibuprofen is important. If not, then you may as well avoid it. I would argue that there are plenty of reasons to think that avoiding the use of ibuprofen is harmful in children with respiratory tract infection.
It is arguable that the single greatest risk of avoiding Ibuprofen is unnecessary exposure to infection.
Children with uncomplicated respiratory tract infections are best managed symptomatically. Although parents often seek a clinical assessment, this rarely adds anything other than reassurance in the child who has no respiratory distress, signs of sepsis or dehydration. In normal circumstances, the clinical assessment itself is low risk. These times are not normal circumstances.
Any healthcare setting is currently extremely high risk for acquiring COVID-19 infection, so anything that brings you to the doors of a hospital or community clinical environment is itself dangerous.
It, therefore, follows that anything that avoids this attendance is protective.
Analgesia is a good way of helping a child with a respiratory tract infection to feel well and behave in a way that lets the parent know that they are not dangerously unwell. It is also a good way to give the child the best possible chance of hydrating orally, by resolving their sore throat, sore ear or general malaise.
It is interesting that the initial flurry of recommendations against the use of ibuprofen was followed by a steady stream of statements that there was no evidence for such avoidance and a series of retractions and clarifications. I think that the about-turn was brought about by an alliance of evidence-based medicine purists and front-line pragmatists who recognised that symptomatic relief is under-rated and has a genuinely important role in these times.
Even if you have genuine anxieties about the use of ibuprofen in children with potential COVID-19 infection, I would suggest the following principle:
While avoiding ibuprofen may feel safe, my opinion is that ibuprofen may be useful as a way to keep children and the adults who care for them safe by avoiding unnecessary clinical contact.