Aspirin Use in Children with Viral Illnesses: Contraindications and Risk Management

Risk of Reye Syndrome

Any dose of aspirin can precipitate Reye syndrome in children < 18 years who have an acute viral illness such as influenza or varicella; therefore aspirin should be avoided for fever or viral symptoms in this population. 1, 2, 3
Epidemiologic data show a dramatic decline in Reye‑syndrome incidence after public health warnings against aspirin use in children, supporting a causal relationship. 1

The Advisory Committee on Immunization Practices (ACIP) recommends that aspirin or aspirin‑containing products not be administered to any person ≤ 18 years with suspected influenza. 2, 3
The American Diabetes Association advises that aspirin therapy should not be recommended for patients under 21 years because of the increased risk of Reye syndrome. 4
MMWR Recommendations and Reports identify children and adolescents aged 6 months to 18 years receiving long‑term aspirin as being at risk for Reye syndrome following influenza infection. 5, 6

Annual influenza vaccination is advised to reduce the risk of Reye syndrome in children who require chronic aspirin therapy. 7, 8, 9, 10, 11
Verification of varicella vaccination status is recommended before initiating or continuing chronic aspirin in these children. 7, 8, 9, 10, 11
Aspirin should be withheld during any suspected influenza or varicella infection, even in children on chronic therapy. 7, 8, 9, 10, 11
Therapeutic doses used for chronic conditions typically range from 3–5 mg/kg/day, and no cases of Reye syndrome have been reported at these doses when viral infections are avoided. 7, 8, 9, 10, 11

After a viral illness (most often influenza B), children develop protracted vomiting and encephalopathy within 24–48 hours, often while afebrile. 1
Altered level of consciousness, lethargy, or marked irritability may accompany the encephalopathy. 1
Hepatic dysfunction is evident by a > 3‑fold rise in transaminases (ALT/AST). 1
Serum ammonia levels are elevated, reflecting hepatic failure. 1
Hepatomegaly occurs in approximately 50 % of cases. 1
Mortality has fallen from ~50 % to < 20 % with earlier diagnosis, yet remains around 31 % in some series. 1

The incidence of Reye syndrome fell sharply after warnings about aspirin use in children were issued, illustrating the public‑health benefit of the restriction. 1

Over‑the‑counter “children’s aspirin” formulations are not safe during viral illness; any aspirin‑containing product carries risk. (supported by guideline statements)
Aspirin‑containing combination products (e.g., bismuth subsalicylate/Pepto‑Bismol) must be avoided in children with viral infections. 2, 3
For fever relief in children with viral illness, acetaminophen or ibuprofen should be used instead of aspirin. 2, 3
Children < 4 years should not receive over‑the‑counter cold medications without prior consultation with a healthcare provider. 2, 3