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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 39°c 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 Review	AUC 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 analysis	Mean difference in temp fall (paracetamol-ibuprofen) at 1 hr	Mean diff in temp -0.01°c cp= 0.22	Not 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 4hr	Mean diff in temp 0.63°c p=0.00003
			Mean difference in temp fall (paracetamol-ibuprofen) at 6hr	Mean diff in temp 0.58°c 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 blind	Risk of hospitalisation witg GI bleeding among children randomised to ibubrofen	17 per 100 000 no statistical diff from paracetamol	Only 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 effects	no statistical difference
			Ibuprofen- number hospitalised	261 / 17938
			Paracetamol-number hospitalised	124 / 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 38.4°c	Randomised double blind study	Mean fever of infants in acetaminophen compared to ibuprofen	No statistical significance	Given 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 days	Acetam: 3.3 Ibup: 2.7 P=0.02
			Fever recurrence at 10 days	Acetam: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 analysis	Point estimates of mean weighted effect sizes 5mg/kg and 10mg/kg	0.19 2 hrs 0.31 4 hrs 0.33 6 hrs	No clear table of results for fever reduction results
			Point estimates of mean weighted effect 10 mg/kg only	0.81 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 40.5°c from inpatient paediatric wards or outpatient emergency clinics (191 in acetaminophen group, 185 in Ibuprofen group)	Modified double -blind randomised multinational trial	Temp normalisation rate- Ibuprofen	78%	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-Acetaminophen	68%
				p=0.004
			Mean change in tympanic temperature	acet;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.