Case 4: A 3-year-old child has fever, signs of acute respiratory viral infections Objectively: the general condition is satisfactory, the pharynx is hyperemic. Body temperature is 38.8 C. In the lungs without pathology. Station 1 1. Identify the problem (diagnosis): 2. Choose your P-medication for this condition: 3. Dosage form 4. Dosage Station 2 5. Pharmacokinetics of the drug 6. Mechanism of action 7. Write a prescription Station 3 8. Duration of treatment 9. Side effects 10. Contraindications
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Case 4: 3-year-old with Fever + Acute Respiratory Viral Infection (ARVI)
STATION 1
1. Diagnosis (Problem Identification)
Acute Respiratory Viral Infection (ARVI) with fever (38.8°C). The child presents with fever, hyperemic pharynx, satisfactory general condition, and no pulmonary pathology — consistent with an uncomplicated upper respiratory viral illness with reactive fever.
2. P-Drug of Choice: Paracetamol (Acetaminophen)
Paracetamol is the first-line antipyretic and analgesic for children with fever due to ARVI. It is preferred over NSAIDs in young children and is safe from 3 months of age. Ibuprofen is an acceptable alternative (for children >6 months), but paracetamol is the standard P-drug selection here.
"Fever is treated with acetaminophen or ibuprofen." — Tintinalli's Emergency Medicine, p. 788
3. Dosage Form
Oral suspension (syrup) — the most appropriate and commonly used formulation for a 3-year-old (e.g., 120 mg/5 mL or 250 mg/5 mL suspension). Rectal suppositories (PR) are an alternative if the child cannot take oral medication.
4. Dosage
- Paracetamol: 15 mg/kg/dose, PO or PR
- Every 4–6 hours as needed
- Maximum 5 doses per day
- Maximum daily dose: 80 mg/kg/day
For a typical 3-year-old (~14–15 kg): approximately 200–225 mg per dose
"The dosage of acetaminophen is 15 milligrams/kg/dose PO or PR (maximum daily dose, 80 milligrams/kg) every 4 to 6 hours, up to five times per day." — Tintinalli's Emergency Medicine, p. 788
STATION 2
5. Pharmacokinetics
| Parameter | Details |
|---|---|
| Absorption | Rapidly and well absorbed from the GI tract after oral administration |
| Distribution | Widely distributed; crosses the blood-brain barrier |
| Metabolism | Hepatic; mainly conjugated to glucuronide and sulfate (inactive metabolites); a small fraction is oxidized by CYP2E1 to NAPQI (toxic metabolite) |
| Elimination | Renal excretion of metabolites; half-life ~2–3 hours |
| Special note | At therapeutic doses, NAPQI is neutralized by hepatic glutathione → nontoxic. Available in oral, rectal, and IV forms. |
"Acetaminophen is rapidly absorbed from the GI tract and undergoes significant first-pass metabolism. It is conjugated in the liver to form inactive glucuronidated or sulfated metabolites." — Lippincott Illustrated Reviews: Pharmacology, p. 1364
6. Mechanism of Action
Paracetamol's exact mechanism remains partially understood, but includes:
- Inhibition of central COX enzymes (particularly a COX-3 variant in the CNS/hypothalamus), reducing prostaglandin E2 (PGE2) synthesis in the thermoregulatory center → antipyretic effect
- Central analgesic effect via inhibition of prostaglandin synthesis in the spinal cord and brain
- At therapeutic doses it has minimal peripheral anti-inflammatory effect (unlike NSAIDs), because it does not significantly inhibit COX-1 or COX-2 peripherally (where arachidonic acid concentrations are high)
- Possible contribution via the endocannabinoid system (AM404 metabolite pathway)
COX-2 expression is induced by inflammatory mediators and can be pharmacologically inhibited; prostaglandins cause fever by acting on hypothalamic thermoregulatory centers. — Lippincott Illustrated Reviews: Pharmacology, pp. 1333–1335
7. Prescription
Rp:
Paracetamoli suspensio 2.4% (120 mg / 5 mL)
100 mL
D.S. Per os, 5 mL (120 mg) every 4–6 hours
(= 15 mg/kg/dose for a ~8 kg child;
adjust volume to 15 mg/kg for actual weight)
Maximum 5 doses in 24 hours.
Do not exceed 80 mg/kg/day.
(Adjust dose volume to child's actual weight. For a ~15 kg child: 225 mg/dose → ~9.4 mL of 120 mg/5 mL suspension)
STATION 3
8. Duration of Treatment
- Use only as needed (pro re nata) while fever persists
- Antipyretics for ARVI: typically 3–5 days maximum
- If fever persists beyond 5 days without improvement, reassess for bacterial superinfection or other pathology
- Do not use prophylactically to prevent fever
9. Side Effects
At therapeutic doses, paracetamol has very few adverse effects — this is a key advantage in children.
| System | Side Effect |
|---|---|
| Hepatic | Hepatocellular necrosis with overdose (due to NAPQI accumulation after glutathione depletion) — rare at therapeutic doses in children |
| Renal | Rare nephrotoxicity at very high/chronic doses |
| Allergic | Rare rash, urticaria |
| Haematological | Very rare thrombocytopenia, leukopenia |
| GI | Minimal (unlike NSAIDs — no GI ulceration risk) |
"At normal therapeutic doses, acetaminophen has few significant adverse effects." — Lippincott Illustrated Reviews: Pharmacology, p. 1364 "Hepatotoxicity is rarely associated with acetaminophen overdose in children younger than 6 years of age." — Henry's Clinical Diagnosis and Management by Laboratory Methods
10. Contraindications
| Contraindication | Reason |
|---|---|
| Severe hepatic impairment / active liver disease | Reduced glucuronidation capacity → increased NAPQI accumulation → hepatotoxicity |
| Known hypersensitivity to paracetamol | Risk of anaphylaxis/severe allergic reaction |
| Severe renal impairment | Accumulation of metabolites |
| Chronic malnutrition / severe depletion of glutathione | Increased risk of hepatotoxicity even at standard doses |
| Concomitant use with other paracetamol-containing products | Risk of inadvertent overdose |
"Acetaminophen should be avoided in patients with severe hepatic impairment." — Lippincott Illustrated Reviews: Pharmacology, p. 1365
Note: Aspirin (acetylsalicylic acid) is contraindicated in children with viral illness due to risk of Reye's syndrome — this is why paracetamol is preferred.
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