Does Acetaminophen in Comparison to Ibuprofen Effectively Reduce Fevers in Children Younger than 18 Years of Age?
Fever phobia is a term used to describe parents' unrealistic concerns about fever (Crocetti, Moghbeli, & Serwint, 2001). Schmitt (1980) found that 94% of caregivers thought fever could cause side effects, 63% of caregivers worry a great deal about serious harm resulting from fevers, and 18% of caregivers thought brain damage and other consequences can be caused by fevers of 38.9 C or less. Crocetti et al. (2001) completed a similar study and found that 91% of caregivers believed fever could cause harmful effects, with 21% of caregivers believing brain damage could result from fever.
Both acetaminophen and ibuprofen are effective antipyretic agents in children with history of febrile seizures (Carson, 2003; Goldman, Ko, Linett, & Scolnik, 2004; Hay et al., 2008; Van Esch et al., 1995). For treatment of fever, ibuprofen is more effective than acetaminophen in reducing fever (Goldman et al., 2004; Perrott, Piira, Goodenough, & Champion, 2004; Van Esch et al., 1995; Wahba, 2004; Wong et al., 2001), and ibuprofen provides longer duration of antipyretic effect than acetaminophen – four hours after treatment (Wahba, 2004). Alternating acetaminophen and ibuprofen in febrile children appears to be a common practice among pediatric health care providers (Mayoral, Marino, Rosenfield, & Greensher, 2000) and among parents advised to do so by their health care provider (Wright & Liebelt, 2007).
Studies examining an alternating regimen have not been consistent regarding the dosage of the medications or the schedule of administration. Kramer, Richards, Thompson, Harper, and Fairchok (2008) utilized two groups. Group A received acetaminophen (15 mg/kg/dose) followed by a placebo at hour 3 and a second acetaminophen dose at hour 4. Group B received acetaminophen, followed by ibuprofen (10 mg/kg/dose) at hour 3 and a placebo at hour 4. Nabulsi et al. (2006) also used two groups. Group A received a dose of ibuprofen (10 mg/kg/dose) followed by acetaminophen (15 mg/kg/dose) at hour 4. Group B received a similar dose of ibuprofen followed by a placebo four hours later and acetaminophen, whereas Sarrell, Wielunksy, and Cohen (2006) used six groups to assess medication administration at six and eight-hour dosing intervals for acetaminophen alone (12.5 mg/kg/dose q 6 hour or 25 mg/kg/dose q 8 hour) and ibuprofen alone (10 mg/kg/dose q 6 hour or 5 mg/kg/dose q 8 hour), versus an alternating regimen at four-hour intervals of acetaminophen and ibuprofen. However, these authors consistently found that an alternating regimen of acetaminophen and ibuprofen to reduce fever in children is more effective than either drug alone (Hay et al., 2008; Kramer et al., 2008; Mayoral et al., 2000; Nabulsi et al., 2006; Sarrell et al., 2006).
There is no consistent recommendation regarding the antipyretic schedule to use when alternating medications. The most commonly cited method is giving acetaminophen every four hours and ibuprofen every six hours. However, this timing is problematic in that it exceeds the recommended daily doses of each medication and does not specify which medication should be given at the 12th hour (Carson, 2003; Mayoral et al., 2000). Due to safety concerns, such as potential dosing errors (under dosing and overdosing) and toxicity, monotherapy of antipyretics is recommended (Carson, 2003; Goldman et al., 2004; Hay et al., 2008; Kramer et al., 2008; Mayoral et al., 2000; Sahib & El-Radhi, 2008).
In studies where adverse effects of acetaminophen and ibuprofen were studied, authors reported no significance between the two, and the risk of adverse effects are small (Goldman et al., 2004; Lesko & Mitchell, 1999; Perrott et al., 2004). However, it is recommended to use the lowest therapeutic dose that provides sufficient antipyresis to prevent adverse effects or toxicity related to the medication (American Academy of Pediatrics [AAP], 2001; Carson, 2003). The use of ibuprofen does not exacerbate asthma morbidity and provides a possible therapeutic effect compared with acetaminophen. Acetaminophen use in children may lead to an increased risk for wheezing (Kanabar, Dale, & Rawat, 2007).