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Alternating and combined antipyretics for treatment of fever in children

Wong T, Stang AS, Ganshorn H, Hartling L, Maconochie IK, Thomsen AM, Johnson DW
Published Online: 
30 October 2013

When they are ill with infections, children often develop a fever. The fever with common viral illnesses, such as colds, coughs, sore throats and gastrointestinal illness, usually lasts a few days, makes children feel unwell, and is distressing for the children, their parents, or other caregivers.

Paracetamol (also known as acetaminophen) and ibuprofen lower the child's temperature and relieve their discomfort. This review evaluates whether giving both treatments together, or alternating the two treatments, is more effective than giving paracetamol or ibuprofen alone.

In September 2013, we found six studies, involving 915 children, that evaluated combined or alternating paracetamol and ibuprofen to treat fever in children.

Compared to giving ibuprofen or paracetamol alone, giving both medications together is probably more effective at lowering temperature for the first four hours after treatment (moderate quality evidence). However, only one trial assessed whether combined treatment made children less uncomfortable or distressed and found no difference compared to ibuprofen or paracetamol alone.

In practice, caregivers are often advised to initially give a single agent (paracetamol or ibuprofen), and then give a further dose of the alternative if the child continues to have a fever. Giving alternating treatment in this way may be more effective at lowering temperature for the first three hours after the second dose (low quality evidence), and may also result in less child discomfort (low quality evidence)

Only one small trial compared alternating therapy with combined therapy and found no advantages between the two (very low quality evidence).

This record should be cited as: 
Wong T, Stang AS, Ganshorn H, Hartling L, Maconochie IK, Thomsen AM, Johnson DW. Combined and alternating paracetamol and ibuprofen therapy for febrile children. Cochrane Database of Systematic Reviews 2013, Issue 10. Art. No.: CD009572. DOI: 10.1002/14651858.CD009572.pub2
Assessed as up to date: 
6 September 2013