Treatment of pediatric fever

Clinical question

Is acetaminophen or ibuprofen superior for the treatment of pediatric fever?

Evidence

A meta-analysis and recent randomized controlled trial provide some guidance.

• Meta-analysis of 10 trials (N = 1078) of ibuprofen (5 to 10 mg/kg) versus acetaminophen (10 to 15 mg/kg)1:

  • -ibuprofen was superior at 2, 4, and 6 hours; and

  • -at 4 to 6 hours, approximately 15% more ibuprofen patients had fever reduction (number needed to treat = 7).

• PITCH randomized controlled trial (N = 156, aged 6 months to 6 years) comparing ibuprofen (10 mg/kg every 6 to 8 hours), acetaminophen (15 mg/kg every 4 to 6 hours), or a combination of both2:

  • -For time without fever in the first 4 hours, the combination was superior to acetaminophen by 55.3 minutes (P < .001) but was not superior to ibuprofen.

  • -Ibuprofen and the combination cleared fever faster.

  • -The combination reduced fever time in the first 24 hours (acetaminophen 4.4 hours more [P < .001], ibuprofen 2.5 hours more [P = .008]).

  • -Overdose was reported in 33 children (21%).

  • -The authors recommended ibuprofen:

    • —ibuprofen was superior to acetaminophen;

    • —the combination was only slightly better on a few outcomes than ibuprofen alone; and

    • —there was a possible risk of excess dosing with the combination.

Context

Some debate surrounds the use of antipyretics:

• There is no evidence that fever itself is harmful (theorized that it might be part of the immune response).3

• Antipyretics do not seem to prevent febrile seizures.4

• There is no evidence that treating fever in mild infections is harmful (unless overdosed).

• If fever is treated, the goal should likely be comfort5 (although no studies have investigated comfort in fever).

Adverse effects of ibuprofen compared with acetaminophen:

• asthma—no increased risk or perhaps slightly lower6 (possible slight increase with acetaminophen2);

• Reye syndrome—no increased risk7,8;

• gastrointestinal and renal effects—no evidence of risk,9 but the Canadian Paediatric Society advises against ibuprofen if a child is not “drinking reasonably well”5; and

• systemic reaction—no evidence of risk.7

Bottom line

The appropriateness of treating pediatric fever is controversial and should be discussed with parents. If clinicians are going to recommend a treatment, they should know that ibuprofen offers superior fever reduction with no increase in adverse events.

Implementation

Providing pamphlets about fever management can reduce parental anxiety and decrease emergency visits.10 Although the evidence for patient information leaflets is generally poor,11 pamphlets about pediatric infections seem to work if they are reviewed during the clinical encounter.12 Therefore, reviewing the Canadian Paediatric Society handout5 with parents to explain fever management might be helpful, but the pamphlet could be altered to encourage ibuprofen use with appropriate dosing regimens.