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Letters Paracetamol with ibuprofen

Ibuprofen increases soft tissue infections in children

BMJ 2008; 337 doi: (Published 23 September 2008) Cite this as: BMJ 2008;337:a1767
  1. Carlos A Calderon Ospina, assistant professor, pharmacology unit1,
  2. Alejandra Salcedo, chief of medical education and assistant professor1
  1. 1Faculty of Medicine, Universidad del Rosario, Bogota, Colombia
  1. carlos_calderon74{at}

    Because ibuprofen is more effective as monotherapy than paracetamol in controlling fever in children Hay and colleagues conclude that ibuprofen should be administered first to feverish children in discomfort.1 Paracetamol should be added after 24 hours if recovery is not occurring as expected.

    However, a few reports suggest an association between ibuprofen or ibuprofen and paracetamol and an increased risk of soft tissue infections, some of them very serious—such as necrotising fasciitis.2 3 4 5 Paracetamol carries no increased risk of such infections.3 4

    The main risk factors for developing necrotising fasciitis associated with non-steroidal anti-inflammatory drugs include age and a co-existing viral infection. The study by Hay and colleagues included 57 children with viral diseases (36.5%), and although five children were admitted to hospital because of serious adverse events, no additional information is given other than the medicines taken.

    Although the combination of ibuprofen and paracetamol may be more effective for treating fever in children, precautions have to be taken when administering this combination to children with viral infections—especially chickenpox. In such children, paracetamol should be considered as monotherapy, lowering the risk of developing soft tissue infections such as necrotising fasciitis.


    Cite this as: BMJ 2008;337:a1767


    • Competing interests: None declared.


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