Viewpoint: Treatment options for fever in children

Is paracetamol or ibuprofen better at reducing fever in children? Dr Niamh Redmond and Dr Alastair Hay discuss

Many parents are familiar with using paracetamol and/or ibuprofen to treat their child’s fever. Although these are widely used, there is only limited evidence to indicate which medi- cine or combination of medicines is best for controlling a high temperature.

Once a serious cause for the child’s fever has been ruled out, what are the management options? As fever is a natural response to infection and may confer relative advantages to the host, there is an argument for leaving it untreated.

Suppressing fever in otherwise healthy children has been thought to prolong illness, but there is little evidence to support this. There is no evidence to support the idea that leaving fever untreated in children results in their immune systems being stronger.

Argument for treatment
There are arguments for treating fever. If a previously feverish child responds well to antipyretic measures, this can help reassure both clinician and parent that a serious cause is less likely.

Many parents become worried that their child’s high temperature will lead to febrile convulsions or brain damage.

Parents’ knowledge of fever has remained poor over the past two decades with some parents classing mild fevers as serious and fixating on often inaccurate readings of temperature.

Treating the child to reduce their temperature empowers parents to feel they are doing the best for their child.
 
On a practical level, many parents are looking for something to help their child sleep, and improve irritability and misery, so that family and work lives can continue.

Treatment options
Physical methods of reducing temperature are commonly used. Removing excess clothing and encouraging a child to regularly drink fluids can reduce their temperature and keep them hydrated.
 
Tepid sponging is now not recommended because it may cause the peripheral circulation to constrict and inadvertently raise a child’s core temperature further.

There is an overall lack of evidence available comparing the effectiveness of physical methods of reducing fever with monotherapies.

One study showed that treating febrile children with paracetamol was more effective at controlling the temperature than physical methods and was more acceptable to parents.

We are not aware of any studies comparing ibuprofen with physical methods.

One review of studies comparing ibuprofen against paracetamol concluded that ibuprofen is more effective at reducing temperature as well having a prolonged effect at keeping the temperature down.

More recent studies have compared both ibuprofen and paracetamol in combination and singly. At first glance, the studies report some degree of benefit to using an alternating, combined treatment regimen. However, there are limitations to each study that prevent clear conclusions from being drawn.
 
One study looked at whether adding ibuprofen to paracetamol worked best at reducing temperature. A combination of paracetamol and ibuprofen was found to be more effective than paracetamol alone for up to two hours post-treatment but the temperature differences were not statistically significant.

A more recent study looked at whether adding paracetamol to ibuprofen worked best at returning temperature to normal levels. This study found adding a single dose of paracetamol four hours after ibuprofen reduced temperature at six hours.

Neither study investigated children’s discomfort.

Two other studies investigated a combination of paracetamol and ibuprofen compared with either therapy alone.
 
One study found that using both drugs resulted in only half a degree difference in temperature reduction, not a clinically significant difference.
 
The other study was the only one to measure discomfort and it found statistically significant and clinically important differences lasting three days in temperatures and distress scores between the alternating and monotherapy groups.

Drug safety
The safety profiles of the use of paracetamol and ibuprofen in children do not demonstrate significant differences when used on a short-term basis.

Although ibuprofen is not recommended for children with asthma, one large study demonstrated no increased risk of serious asthma exacerbation with short-term use of ibuprofen compared with paracetamol, so we believe these recommendations are open to challenge. Clinicians should be cautious in ibuprofen-naïve children with a history of wheeze.

Although renal failure is a rare adverse effect of ibuprofen, at least three studies have shown no difference in renal function when comparing combined or single use of paracetamol and ibuprofen.

A more widespread issue is that using both medicines alternately may mean that parents lose track of which medicines have been used, leading to an increased risk of unintentional overdosing. There is little evidence to help clinicians know which is the best treatment strategy. This highlights the need for good evidence on which guidelines can be based. 

 

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