Antipyretic treatment in young children with fever: acetaminophen, ibuprofen, or both alternating in a randomized, double-blind study

Alternating antipyretics: antipyretic efficacy of acetaminophen versus acetaminophen alternated with ibuprofen in children

Methods A prospective, randomized double-blind placebo control study comparing the efficacy of acetaminophen to acetaminophen alternated with ibuprofen in 38 healthy outpatient children 6 months to 6 years presenting to the outpatient clinic with fever >38 degrees C was conducted. Temperatures were recorded at 0, 3, 4, 5, and 6 hours. Side effect diaries and parental perception of efficacy were filled out hourly by parents.Results There were no significant differences in temperature between the 2 groups at times 0, 3, and 6 hours. The alternating group had significantly lower mean temperatures at both 4 hours (38.0 degrees C vs 37.4 degrees C; P = .05) and 5 hours (37.1 degrees C vs 37.9 degrees C; P = .0032). Parents did not perceive any difference in fever control between the groups.Conclusions An alternating regimen of acetaminophen with ibuprofen significantly decreased fever at 4 and 5 hours compared with acetaminophen alone. However, parents did not perceive a difference in efficacy.

Paracetamol plus ibuprofen for the treatment of fever in children (PITCH): economic evaluation of a randomised controlled trial

OBJECTIVE

To estimate the cost to the NHS and to parents and carers of treating febrile preschool children with paracetamol, ibuprofen, or both, and to compare these costs with the benefits of each treatment regimen.

DESIGN

Cost consequences analysis and cost effectiveness analysis conducted as part of a three arm, randomised controlled trial.

PARTICIPANTS

Children between the ages of 6 months and 6 years recruited from primary care and the community with axillary temperatures >or=37.8 degrees C and <or=41 degrees C.

INTERVENTIONS

Paracetamol, ibuprofen, or both drugs.

MAIN OUTCOME MEASURES

Costs to the NHS and to parents and carers. Cost consequences analysis at 48 hours and 5 days comparing cost with children's temperature, discomfort, activity, appetite, and sleep; cost effectiveness analysis at 48 hours comparing cost with percentage of children "recovered."

RESULTS

Difficulties in recruiting children to the trial lowered the precision of the estimates of cost and some outcomes. At 48 hours, cost to the NHS was pound11.33 for paracetamol, pound8.49 for ibuprofen, and pound8.16 for both drugs. By day 5 these costs rose to pound19.63, pound18.36, and pound13.92 respectively. For parents and carers, the 48 hour costs were pound23.86 for paracetamol, pound20.60 for ibuprofen, and pound25.07 for both, and the day 5 costs were pound26.35, pound29.90, and pound24.02 respectively. Outcomes measured at 48 hours and 5 days were inconclusive because of lack of power; the cost effectiveness analysis at 48 hours provided little evidence that one treatment choice was significantly more cost effective than another. At 4 hours ibuprofen and the combined treatment were superior to paracetamol in terms of the trial primary outcome of time without fever; at 24 hours the combined treatment performed best on this outcome.

CONCLUSIONS

There is no strong evidence of a difference in cost between the treatments, but clinical and cost data together indicate that using both drugs together may be most cost effective over the course of the illness. This treatment option performs best and is no more expensive because of less use of healthcare resources, resulting in lower costs to the NHS and to parents.

Paracetamol plus ibuprofen for the treatment of fever in children (PITCH): randomised controlled trial

OBJECTIVE

To investigate whether paracetamol (acetaminophen) plus ibuprofen are superior to either drug alone for increasing time without fever and the relief of fever associated discomfort in febrile children managed at home.

DESIGN

Individually randomised, blinded, three arm trial.

SETTING

Primary care and households in England.

PARTICIPANTS

Children aged between 6 months and 6 years with axillary temperatures of at least 37.8 degrees C and up to 41.0 degrees C.

INTERVENTION

Advice on physical measures to reduce temperature and the provision of, and advice to give, paracetamol plus ibuprofen, paracetamol alone, or ibuprofen alone.

MAIN OUTCOME MEASURES

Primary outcomes were the time without fever (<37.2 degrees C) in the first four hours after the first dose was given and the proportion of children reported as being normal on the discomfort scale at 48 hours. Secondary outcomes were time to first occurrence of normal temperature (fever clearance), time without fever over 24 hours, fever associated symptoms, and adverse effects.

RESULTS

On an intention to treat basis, paracetamol plus ibuprofen were superior to paracetamol for less time with fever in the first four hours (adjusted difference 55 minutes, 95% confidence interval 33 to 77; P<0.001) and may have been as good as ibuprofen (16 minutes, -7 to 39; P=0.2). For less time with fever over 24 hours, paracetamol plus ibuprofen were superior to paracetamol (4.4 hours, 2.4 to 6.3; P<0.001) and to ibuprofen (2.5 hours, 0.6 to 4.4; P=0.008). Combined therapy cleared fever 23 minutes (2 to 45; P=0.025) faster than paracetamol alone but no faster than ibuprofen alone (-3 minutes, 18 to -24; P=0.8). No benefit was found for discomfort or other symptoms, although power was low for these outcomes. Adverse effects did not differ between groups.

CONCLUSION

Parents, nurses, pharmacists, and doctors wanting to use medicines to supplement physical measures to maximise the time that children spend without fever should use ibuprofen first and consider the relative benefits and risks of using paracetamol plus ibuprofen over 24 hours.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN26362730.

Fever and hyperthermia: learn to beat the heat

Your interventions depend on an accurate assessment. Here you'll learn to distinguish between these two conditions and take appropriate action.

Fever without apparent source on clinical examination

PURPOSE OF REVIEW

Routine immunization of children with the heptavalent pneumococcal conjugate (PCV7) vaccine and rapid tests for identification of viruses since the last review in 2002 make this review timely and relevant.

RECENT FINDINGS

Since the introduction of the PCV7 vaccine, the incidence of true bacteremia has decreased to 1% and has impacted the epidemiology of fever in the under-3-year-old population, making urinary tract infection the most common cause. Polymerase chain reaction testing for viruses helps in early diagnosis and serves to decrease the unnecessary use of antibiotics. Serious infections are dependent not only on the virulence of the agent, but also on host susceptibility, which has been getting more attention recently. Kawasaki disease in the very young infant is also discussed and awareness is increasing among physicians.

SUMMARY

The decrease in the rate of bacteremia since the PCV7 vaccine was introduced means that the management guidelines for fever in the under-3-year-old population need to be reviewed. In addition, better markers are required to predict serious bacterial infection in this population. Further research into the understanding of the host immune response is also needed.

Over-the-counter medication use for childhood fever: a cross-sectional study of Australian parents

AIM

To report Australian parents' medication (paracetamol, ibuprofen and homeopathic) use in childhood fever management.

METHODS

A cross-sectional survey of 401 Queensland parents of children aged between 6 months and 5 years recruited through advertising (48.4%), face-to-face (26.4%) and snowball (24.4%) methods was conducted. A 17-item instrument was developed; construct and content validity were determined by an expert panel; and item reliability by test-retest with nine parents. Areas targeted were medication use and influences on and barriers to medication use.

RESULTS

Most participants were female, had tertiary education and lived in a major city (mean age 34.6 years). Reducing children's fever with over-the-counter medications was common (91%): 94% of parents reported using paracetamol and 77% reported using ibuprofen. A few (3.7%) used homeopathic remedies. Dosage was determined by weight (86.3%), age (84.3%), temperature (32.4%), illness severity (31.4%) and lethargy (20.9%). Frequency was determined by instructions on the medication label (55.3%), temperature (40.6%) and well-being (27.7%). Ibuprofen was administered too frequently by 31.5% (four hourly by 22.8%), and paracetamol by 3.8%. Fifty-two per cent had alternated medications, 65.8% of these for temperatures below 38.5 degrees C. Decisions to alternate were influenced by information from doctors/hospitals (49.5%) and children remaining febrile post-antipyretic (41.7%). Most parents reported over-the-counter medications as potentially harmful (73.2%), citing liver (38.2%), stomach (26.4%) and kidney (18.6%) damage and overdose (35.7%) as concerns. When medications were refused or spat out (44.0%), parents used force (62.4%), different methods (29.5%) or suppositories (20.8%).

CONCLUSIONS

Most parents used over-the-counter medications to reduce fever, often below 38.5 degrees C. The belief that these medications were harmful was overridden by fears of harmful outcomes from fever.

Managing childhood fever and pain--the comfort loop

Parents can transmit their anxiety to their child, and just as children can pick up on parental anxiety, they can also respond to a parent's ability to stay calm in stressful situations. Therefore, when treating children, it is important to address parental anxiety and to improve their understanding of their child's ailment. Parental understanding and management of both pain and fever - common occurrences in childhood - is of utmost importance, not just in terms of children's health and welfare, but also in terms of reducing the economic burden of unnecessary visits to paediatric emergency departments. Allaying parental anxiety reduces the child's anxiety and creates a positive feedback loop, which ultimately affects both the child and parentIn this review, the integral role of parental perception of the child's condition and the efficacy of treatment in the management of childhood fever and pain will be discussed.

Alternating antipyretics for fever reduction in children: an unfounded practice passed down to parents from pediatricians

A convenience sample of parents/caregivers completed a 10-question survey on their patterns of antipyretic therapy administration to determine if antipyretics were alternated, how often, who advised them to do this, and how they learned to dose the antipyretic. Of the 256 caregivers (93%) who completed the survey, 67% responded that they alternated acetaminophen and/or ibuprofen. The frequency varied: every 2 hours (9%), every 3 hours (16%), every 4 hours (43%), every 6 hours (23%) and other (8%). Of these, 81% stated that their health care provider/pediatrician advised them to alternate acetaminophen and/or ibuprofen; 8% stated that nobody advised them. Only 61% received written instructions on how to dose antipyretics from their health care provider. Most caregivers of young children reported alternating acetaminophen and ibuprofen for fever reduction in their children. There was a wide variability of the dosing interval. Most learned this practice from their pediatrician/health care provider.

Prescribing safely for children

This paper is the second in a series of two and will attempt to highlight important issues in prescribing for children, including principles of safe prescribing, adverse drug reaction assessment and common drugs including paracetamol and ibuprofen. A list of drug information resources is included, which may be useful for clinicians.