Conversations… | with Dr. Greene

If you want to bring down a fever in a child, is it better to use acetaminophen, ibuprofen, a combination of both, or neither? Acetaminophen works by turning down the body’s thermostat; ibuprofen works to reduce inflammation at its source. Given that they each do different things, might they work better together? Some doctors have been recommending this for at least a decade, but there has been scant research about this idea. Now, researchers at the University of Bristol have randomly treated 156 febrile children aged 6 months through 6 years either with a combination of acetaminophen and ibuprofen or with one of the two medicines alone. (This was all disguised: all of the children appeared to receive both of the two medicines, but for some of the children one “medicine” or the other was actually a placebo). What did the researchers learn?

Those who got the combo had their fevers come down an average of 23 minutes faster than those who took acetaminophen alone – but no faster than ibuprofen alone. Similarly, during the four hours after the first dose, those who got the combo had more fever-free-minutes than those who took acetaminophen alone – but no more than those who too ibuprofen alone. In contrast, over 24 hours of taking the medicines the combination kept the children fever-free for 2 ½ hours more than the ibuprofen alone.

The authors suggest using ibuprofen when parents decide to treat a fever, and then adding acetaminophen if the child still has a fever. This strategy makes sense – if bringing down a fever is the only consideration.

But why treat a fever in the first place? Fevers are usually part of the body’s way of fighting an illness. A fever is a friend, not a foe. Treating a fever does nothing to prevent febrile seizures. Treating a fever does not give additional protection to the brain. Treating a fever does not prevent the temperature from going too high (in otherwise normal children, the body does this by itself, unless something short circuits this mechanism, such as being trapped in a hot car. Treating a fever does not make an illness go away more quickly – in fact in a number of diseases, treating the fever makes the illness last longer.

The main reason to treat a fever is to make a sick child more comfortable. This might also make it easier for a child to get needed sleep and to drink needed fluids. If these are the goals, then perhaps the least amount of medicine that makes a child comfortable is the best, along with dressing the child in cool, comfortable, loose clothing and providing cool liquids to drink.

In this study, there was no advantage of combination therapy in reducing discomfort for children over either medicine alone. Nor was there any advantage of ibuprofen over acetaminophen, although the study may have been too small to detect a real difference.

To me the most striking finding of this small study was that 31 children were given too much of one “medicine” or the other, even under research study conditions, with clear instructions given to the parents. In the real world, with different concentrations of medicines available, different durations, different dosages, different timing schedules, different brand names, and overlapping ingredients in multi-symptom cold medicines, I suspect that over-dosing is even more common. While these medicines are safe at recommended doses, taking too much can pose additional risks to the child.

I favor making sick children comfortable using the gentlest and simplest approach that really works for them. In my experience some children seem to respond better to acetaminophen and others to ibuprofen. Also, some illnesses seem to respond better to ibuprofen (especially inflammatory illnesses, with redness, swelling, and pain in the throat or ear, for instance).

If you are going to treat a fever, I suggest using comfort and sleep as your yardstick of success, rather than the thermometer. Start with loose clothing, cool liquids, and whichever medicine you prefer. Only add another medicine if important for comfort, sleep, or the willingness to drink plenty of fluids.

Alan Greene, MD, FAAP

Hay AD, Costelloe C, Redmond NM, Montgomery AA, Fletcher M, Hollinghurst S, and Peters TJ. Paracetamol plus ibuprofen for the treatment of fever in children (PITCH): randomized controlled trial. BMJ 2008;337;a1302.

Harnden A. Antipyretic treatment for feverish young children in primary care: No persuasive evidence shows benefit of combining paracetemol and ibuprofen. BMJ 2008;337:a1409.