Tools for Practice


#28 Are Acetaminophen and Ibuprofen Equivalent in the Treatment of Paediatric Fever?


CLINICAL QUESTION
If we provide a recommendation regarding the treatment of paediatric fever, is acetaminophen or ibuprofen superior?


BOTTOM LINE
Treatment of pediatric fever is debated and should be discussed with parents/patients.  If clinicians are going to recommend a treatment, ibuprofen offers superior fever reduction with no increase in adverse events.  



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EVIDENCE
A meta-analysis and two randomized controlled trials (RCT) provide some guidance. 
  • Review of Ibuprofen versus Acetaminophen:1 
    • 10 trials, 1,078 patients. 
    • Dose: Ibuprofen 5-10 mg/kg and acetaminophen 10-15mg/kg. 
    • Outcome:  
      • Ibuprofen statistically superior at 2, 4 and 6 hours. 
      • At 4-6 hours approximately 15% more ibuprofen patients will have fever reduction [number needed to treat (NNT) 7]. 
    • Similar results in pooled analysis of 2 RCTs of children 6 months to 11 years (319 patients) of single dose ibuprofen versus acetaminophen.2    
  • PITCH:3 RCT (156 children age six months to six years) comparing ibuprofen 10mg/kg q6-8 hours, acetaminophen 15mg/kg q4-6 hours or both. 
    • Outcomes (statistically significant): 
      • Time without fever in first four hours: Combination superior to acetaminophen by 55. 3 minutes but not ibuprofen.   
      • Combination had reduced fever time in first 24 hours. 
        • Acetaminophen 4.4 hours more. 
        • Ibuprofen 2.5 hours more. 
      • Authors recommended ibuprofen due to superiority to acetaminophen, similar to combination with less risk of excess dosing. 
    • Cochrane4 review of PITCH plus 5 other studies found similar. 
Context:   
  • Overdosing of medications reported in 21% children in PITCH.3   
  • Debate:  
    • No evidence that fever itself is harmful.5 
    • Antipyretics not shown to prevent febrile seizures.6,7  
    • No evidence that treating fever in mild infections is harmful (unless overdosed) and present evidence shows it does not prolong illness.8 
    • If treated, goal should likely be comfort (although no studies have investigated “comfort” in fever). 
  • Adverse effects of ibuprofen compared to acetaminophen: 
    • Asthma: Ibuprofen carries the same or perhaps slightly lower risk versus acetaminophen9  
    • Reye Syndrome: No increased risk.10,11 
    • GI Effect & Renal: No evidence of risk.12 Canadian Pediatric Society advises against ibuprofen if a child is not “drinking reasonably well.”13 
    • “Systemic” Reaction: No evidence of risk.12 
updated dec 16 2017 by Ricky


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Author(s):

  • G. Michael Allan MD CCFP
  • Yvonne Shevchuk BSP PharmD

1. Perrott DA, Piira T, Goodenough B, et al. Arch Pediatr Adolesc Med. 2004; 158:521-6.

2. Jayawardena S, Kellstein D. Clin Pediatr. 2017; 56:1120-7.

3. Hay AD, Costelloe C, Redmond NM, et al. BMJ. 2008; 337:a13021

4. Wong T, Stang AS, Ganshorn H, et al. Cochrane Database Syst Rev 2013; 10:CD009572.

5. Mackowiak PA. Clin Infect Dis. 2000; 31(Suppl5):S185-9.

6. Duffner PK, Baumann RJ, Berman P, et al. Pediatrics. 2008; 121:1281-6.

7. Offringa M, Newton R, Cozijnsen MA, Nevitt SJ. Cochrane Database System Rev 2017; 2:CD003031

8. Purssell E, While AE. J Pediatr. 2013 Sep; 163(3):822-827.e1-2.

9. Kanabar D, Dale S, Rawat M. Clin Ther. 2007;29:2716–2723.

10. Southey ER, Soares-Weiser K, Kleijnen J. Curr Med Res Opin. 2009; 25(9):2207-22.

11. Lesko SM, Mitchell AA. Pediatrics. 1999; 104(4):e39.

12. Lesko SM, Mitchell AA. JAMA. 1995; 273(12):929-33.

13. Canadian Pediatric Society. Available at: http://www.caringforkids.cps.ca/handouts/fever_and_temperature_taking. Last Accessed: October 24, 2013.

Authors do not have any conflicts of interest to declare.