A5V4d

Antipyretic interventions
There was limited evidence showing that improvement in quality of life and temperature reduction was
greater when paracetamol was alternated with ibuprofen compared with either treatment alone. The
GDG recognises an alternating regimen of paracetamol and ibuprofen is sometimes used by
healthcare professionals and carers. However, although there was some evidence showing the
efficacy of this approach, there was a lack of data on safety outside research settings. The GDG
concluded that it would not be unreasonable for healthcare professionals to advise alternating the two
agents if they had both been ineffective as standalone treatments.
Healthcare professionals and others involved in the supply of these drugs should ensure that parents
understand how to administer them safely, and explain that they are intended for short-term use only.
Healthcare professionals should also check whether the child is receiving any other drugs to avoid the
risk of drug interactions or inadvertent overdose.
Consideration of health benefits and resource uses
The clinical review reported no evidence of any difference between ibuprofen and paracetamol and
some limited evidence of improvement when the regimens were alternated. The benefit of antipyretics
lasts a few hours, and the impact on quality of life of the child can be described qualitatively but has
not been translated into a meaningful quality of life health state that can be translated into quality
adjusted life years (QALYs). There is no evidence that there is a long-term benefit or harm from
reducing fever or that it changes the course of serious bacterial illness. For these reasons a cost
effectiveness analysis was not considered to be feasible for this question.
Paracetamol is less expensive than ibuprofen (£1.05 per 200 mL for the oral suspension compared
with £2.71 per 200 mL for ibuprofen oral suspension, August 2012). However, the GDG recognised
that, in reality, parents and carers have often given their child one antipyretic or the other before
seeking medical advice. There is no evidence that switching to the cheaper alternative once a child is
on ibuprofen is a cost-effective strategy.
The GDG noted that healthcare professionals routinely advise using paracetamol when discharging
children from hospital because it is cheaper than ibuprofen. Parents and carers may have a
preference for one preparation over the other based on their past experience with these agents and
they may decide to buy their own preferred preparation. The advice to parents not to alternate
treatments should dissuade healthcare professionals from offering both paracetamol and ibuprofen on
discharge from hospital. It should also reduce the doubling up of NHS prescriptions of both
antipyretics where this remains routine practice.
Quality of evidence
A large number of relevant studies were identified for this review. The evidence varied from high to
very low in quality depending on the study design and outcome being measured. There was
considerable heterogeneity in the treatment regimens used between studies in terms of dosage and
timing of administration. In addition, the included populations varied, especially in relation to age and
the underlying condition. For a number of studies data had to be extracted from graphs and this is
liable to measurement error; this was counted as an imprecision and the quality of the evidence was
downgraded in these circumstances. It was for these reasons that meta-analysis was not undertaken.
Other considerations
No inequalities issues were raised in relation to this question.
The GDG was aware that a Cochrane review examining the effectiveness of antipyretics on fever in
children was undertaken at the same time as this guideline was under development, but it was
unpublished at the time of submission. Discussions with the authors of this review have shown that
the same studies have been selected for inclusion.
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2013 Update