antipyretics for children with SAM?

Colleagues,

I was surprised recently to learn the Liberia national SAM guidelines recommend that children with fever should not receive antipyretic medications (see below). This is quite confusing for my colleagues and me as we have never heard of this and are trying to optimize care for malnourished children here. We have many malnourished children who present with malaria, pneumonia, and miscellaneous viral fevers, many of whom have fevers which are making them feel ill and decreasing their appetite, so we are eager to treat their fevers as we would for other children, but even more so for these children as a means of improving their appetite.

I checked in the WHO guidelines, the Uganda, Kenya, and Malawi national guidelines, and MSF guidelines, and I am not seeing any mention of contraindications to antipyretics in severely malnourished children in any of those places.

Has anyone heard of this before? Is anyone aware of a rationale for this? Was this a concern in the past but has now been disproven? Any insights on this will be very helpful as we work to update the care provided to malnourished children and work on updating the national guidelines. Thanks for your help.

Here is what the Liberia guideline says regarding fevers in the IPF (inpatient facility):

7.9. Fever

Severely malnourished children do not respond to anti-pyretics. Because they fail to work, caretakers and staff often repeat the dosage inappropriately, frequently leading to toxicity. Antipyretics are much more likely to be toxic in the malnourished than a normal child.

Do not give aspirin or paracetamol to SAM children in IPF.

For moderate fevers, up to 38.5°C rectal,
* Do not treat moderate fevers, up to 38.5°C rectal or 38.0°C underarm.
*Maintain routine treatment.
*Remove blankets, hat and most clothes and kept in the shade in a well-ventilated area.
*Give water to drink.
*Check for malarial parasites and examine for infection.

For fevers of over 39°C rectal or 38.5°C underarm, where there is the possibility of hyperpyrexia developing, iIn addition to the above, also:

*Place a damp/wet room-temperature cloth over the child’s scalp, re-dampen the cloth whenever it is dry.
*Monitor the rate of fall of body temperature.
*Give the child abundant water to drink.
*If the temperature does not decline, the damp/wet cloth can be extended to cover a larger area of the body.
*When the temperature falls below 38°C rectal, stop active cooling. There is a danger of inducing hypothermia with aggressive cooling.

Thank you André for your insight, as always very helpful! I wonder now:

1) Would normal doses of paracetamol (15 mg/kg as needed every 4 hours, no more than 5 doses per day) likely lead to any hepatotoxicity in children with SAM, even those with kwashiorkor?

2) Would ibuprofen be an acceptable alternative?

3) What do others do with febrile severely malnourished children in their settings? External cooling measures only or are others using antipyretics and, if so, which ones? I have always used paracetamol and ibuprofen as I would in normal doses for otherwise healthy children.

Thanks!