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Ibuprofen is probably better than Paracetamol in reducing fever in children

Three Part Question

[In a febrile child under the age of 12] is [ Paracetamol more effective than Ibuprofen] at [reducing the child's temperature]

Clinical Scenario

A 6 year old child arrives in the emergency department with a temperature of 39c in order to reduce the child's fever and distress you would like to prescribe an antipyretic

Search Strategy

OVID Medline <1966-June Week 3 2006>
EMBASE <1980 to 2006 week 26>
CINAHL <1982 to June week 5 2006>
Paediatric filter applied
([(high adj temperature).mp OR (high adj fever).mp. OR fever.mp OR exp FEVER/ OR febrile.mp OR temperature.mp OR exp TEMPERATURE/ OR exp HIGH TEMPERATURE/ OR exp TEMPERATURE/ OR exp BODY TEMPERATURE/ OR exp CORE TEMPERATURE/ or hot.mp]) AND (antipyretic.mp OR Antipyretic Agent/ OR acetaminophen.mp OR exp Paracetamol/ OR exp IBUPROFEN/ OR ibuprofen.mp. OR nurofen.mp. OR exp Ibuprofen/) Limit to (human and english language)

Search Outcome

Medline: 502 papers found
EMBAE: 859 papers found
CINAHL: 110 papers found
Cochrane Library: 1 paper found- not relevant
6 relevant papers found 3 from Medline and 3 from EMBASE

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Goldman, R.D. Ko, K. Linett, L.J. & Scolnik, D.
2004
14 studies, 11 of them RCT's.Systematic ReviewAUC of % reduction of temp with respect to time.Efficacy and effectiveness of acetaminophen and ibuprofen in their recommended doses are similar, with slightly more beneficial effects shown with ibuprofen.
Change in temp
Change in temp over time
Duration and extent of temp reduction after single dose of medication
Pursell, E.
2002
UK
8 studies comparing Paracetamol & Ibuprofen as treatments for fever in children. 4mths to 13yrs old.Meta analysisMean difference in temp fall (paracetamol-ibuprofen) at 1 hrMean diff in temp -0.01c cp= 0.22Not extensive info re search strategy provided only reviewed research with data available at 0,1,2,4 and 6 hrs others excluded Different drug dosages used Doesn't say why excluded 5 studies Doesn't look at child discomfort
Mean difference in temp fall (paracetamol-ibuprofen) at 4hrMean diff in temp 0.63c p=0.00003
Mean difference in temp fall (paracetamol-ibuprofen) at 6hrMean diff in temp 0.58c p=0.005
Lesko, S.M. and Mitchell, A.A.
1999
USA
27, 065 febrile children < 2years old practitioner base study with follow up data via hospital records, questionnaires and interviews.RCT Double blindRisk of hospitalisation witg GI bleeding among children randomised to ibubrofen17 per 100 000 no statistical diff from paracetamolOnly one clinician who decided if children required antipyretic or not- bias. Ibuprofen group 2x as large as paracetamol group Includes children < 6mths in analysis age often not known just guessed Different doses not known exactly Only 3 days Rx
Risk of hospitalisation with adverse side effectsno statistical difference
Ibuprofen- number hospitalised261 / 17938
Paracetamol-number hospitalised124 / 9127
Sarrell, E.M. Wielunsky, E. and Cohen, H.A.
2006
Israel
480 patients from 3 primary paediatric community centres consecutive children 6 to 36 months with rectal temp at least 38.4cRandomised double blind studyMean fever of infants in acetaminophen compared to ibuprofenNo statistical significanceGiven different medication as loading dose not necessarily acetaminophen if in acetaminophen group Parents took the temperatures-inter rater reliability affected 3 day safety and efficacy only
Fever recurrence at 5 daysAcetam: 3.3 Ibup: 2.7 P=0.02
Fever recurrence at 10 daysAcetam:18 Ibupr: 19 P= 0.02
Perrott, D.A. Piira, T. Goodenough, B. and Champion, D.
2004
10 blinded RCT's with children (<18yrs)Meta analysisPoint estimates of mean weighted effect sizes 5mg/kg and 10mg/kg0.19 2 hrs 0.31 4 hrs 0.33 6 hrsNo clear table of results for fever reduction results
Point estimates of mean weighted effect 10 mg/kg only0.81 4hrs
Wong, A. Sibbald, A. Ferrero, F. Plager, M. Santolaya, M.E. Exobar, A.M. Campos, S. Barragan, S. Gon
2001
Mexico, Brazil, Argentina, Chile.
628 febrile children 6 mths to 6years 555 completed the study tympanic temperature 38.5 c to 40.5c from inpatient paediatric wards or outpatient emergency clinics (191 in acetaminophen group, 185 in Ibuprofen group)Modified double -blind randomised multinational trialTemp normalisation rate- Ibuprofen78%Children excluded if poor prognosis restricts how representative also very vage exclusion criteria and who decides this isn't mentioned Body temp on admission not in tables
Temp noramlisation rate-Acetaminophen68%
p=0.004
Mean change in tympanic temperatureacet;1hr -1.05 3hr -1.52 6hr -1.2 Ibupr: 1hr -1.0 3hr-1.58 6hr-1.24

Comment(s)

Two of the five studies showed Ibuprofen to be more effective at reducing temperature in children; one study showed Ibuprofen to have a higher percentage of temperature normalisation than Paracetamol but no statistically significant difference was found. Other articles showed no difference in effectiveness at temperature reduction or risk of hospitalisation. Some of the studies only look at the treatment effect over a 3 day period. Some studies recognise the fact that Ibuprofen could be given in 5mg/kg or 10mg/kg doses whilst others do not, so results should be interpreted with caution.

Clinical Bottom Line

Both antipyretics are effective at reducing the temperature of a febrile child. Ibuprofen appears to have a longer duration of action and it's effectiveness in temperature reduction can be increased at higher doses. The differing doses can be confusing to parents and warrant explicit instructions on dosage. No differences in risk of hospitalisation exist between the two treatment groups- there appears to be no statistical significant difference in side effects between the two drugs.

References

  1. Goldman, R.D. Ko, K. Linett, L.J. & Scolnik, D. Antipyretic Efficacy and Safety of Ibuprofen and Acetaminophen in Children. The Annals of Pharmacotherapy. Vol 38 2004, p146-150.
  2. Pursell, E Physical treatment of fever. Arch Dis Child Vol 7 (6) 2000, p238-239.
  3. Lesko, S.M. and Mitchell, A.A. The safety of acetaminophen and Ibuprofen Among Children Younger Than Two Years Old Pediatrics vol 104 (4) Oct 1999, p39-44.
  4. Sarrell, E.M. Wielunsky, E. and Cohen, H.A. Antipyretic Treatment in Young Children With Fever. Acetaminophen, Ibuprofen or both Alternating in a Randomised, Double-blind study Arch Pediatr Adolesc Med Vol 160 Feb 2006, p197-202.
  5. Perrott, D.A. Piira, T. Goodenough, B. and Champion, D. Efficacy and Safety of Acetaminophen vs buprofen for Treating Children's Pain or Fever Arch Pediatr Adolesc Med. Vol 158 June 2004, p321-326.
  6. Wong, A. Sibbald, A. Ferrerro, F. Plager,M. Santolaya, M.E. Escobar, A.M. Campos, S. Barragan, S. Leon Gonzalez, M. & Kesselring, G. Antipyretic Effects of Dipyrone Versus Ibuprofen Versus Acetaminophen in Children: Results of a Multinational, Randomised, Modified Double-Blind Study. Clinical Pediatrics. Vol 40 2001, p313-324.